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Using Newly-Released HHS Benchmark Data to Negotiate and Succeed in Value and Capitation

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Presentation mat at CAPG 2015 Colloquium.
Thirty cents of every dollar goes to no and low value care. While that drove billing in FFS service, success in value based arrangements comes from mitigating it by matching your practice patters with the right arrangements and payer partners. Often providers delivering the best care have hidden value that traditional utilization reviews and unit cost analysis don’t uncover. Fortunately, the newly-released HHS government benchmark data allow providers to pick the right risk arrangements and identify their exact contributions to payers.
Attend this session to learn what public government data is available to help providers move to risk, how payers and providers are using it to successful negotiate and manage capitation.

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Using Newly-Released HHS Benchmark Data to Negotiate and Succeed in Value and Capitation

  1. 1. All contents are proprietary to RowdMap, Inc. and are being provided on a confidential basis. Any use, reproduction or distribution of this information, in whole or in part, or the disclosure of any of its contents without the prior written consent of the Company, is prohibited.
  2. 2. 2 All contents are proprietary to RowdMap, Inc. and are being provided on a confidential basis. Any use, reproduction or distribution of this information, in whole or in part, or the disclosure of any of its contents without the prior written consent of the Company, is prohibited. CAPG Risk-Readiness SM What Is Happening: A – Public Data: CMS releasing benchmark data on geographies and docs B – CMS Policy: Sun-setting Fee for Service to mitigate Unnecessary Spend C – Market Trends: Payers rolling through with narrowing networks What This Means for CAPG: 1 – Provider profiles for CAPG with CMS benchmarks for Unnecessary Spend 2 – Provider & market profiles showing the best arrangements for CAPG members 3 – Payer report cards using CMS benchmarks to negotiate more effectively
  3. 3. 3 All contents are proprietary to RowdMap, Inc. and are being provided on a confidential basis. Any use, reproduction or distribution of this information, in whole or in part, or the disclosure of any of its contents without the prior written consent of the Company, is prohibited. CAPG Risk-Readiness SM What Is Happening: A – Public Data: CMS releasing benchmark data on geographies, payers and docs New powerful data on every provider, market and health plan in the US When combined with Dartmouth, allows national benchmarks on providers Providers often perform better against these metrics than traditional payer- driven evaluations such as unit cost and utilization The data also shows every health plan’s expected profits, strengths and weakness and which providers are contributing to them Data is public, does not require IT or integration, up the next day
  4. 4. 4 All contents are proprietary to RowdMap, Inc. and are being provided on a confidential basis. Any use, reproduction or distribution of this information, in whole or in part, or the disclosure of any of its contents without the prior written consent of the Company, is prohibited. CMS: 50% of FFS will be gone by 2018 CMS is releasing new, powerful data to support their goals of transitioning providers in to Pay for Value New Powerful Data on Every Provider, Market and Health Plan in the US
  5. 5. 5 All contents are proprietary to RowdMap, Inc. and are being provided on a confidential basis. Any use, reproduction or distribution of this information, in whole or in part, or the disclosure of any of its contents without the prior written consent of the Company, is prohibited. Medicare DocGraph Referral file (Patient flows between PCPS, specialists, hospitals and post acute centers) Dartmouth Atlas of Health Care & Choosing Wisely (Decades of research and data on unwarranted variation by condition and geography to keep things apples-to-apples for comparisons) CMS FFS Data Sets, CDC Data Sets (MEDPAR, Part B, Part D, BRFSS) (Individual providers, groups, hospitals and post acute centers) Provider Pattern Intensity Profiles and Risk Readiness for every provider, hospital, post acute center in the US. All preloaded with no IT. New Government Benchmark Data Particularly powerful when pulled together Affordable Care Act data to determine Risk-Readiness SM of Providers / Networks When Combined with Dartmouth, Allows National and Regional Provider Benchmarks
  6. 6. 6 All contents are proprietary to RowdMap, Inc. and are being provided on a confidential basis. Any use, reproduction or distribution of this information, in whole or in part, or the disclosure of any of its contents without the prior written consent of the Company, is prohibited. At the core of Risk-Readiness SM is Unwarranted Variation: Every provider has a unique practice pattern that informs Risk-Readiness SM Providers often Perform Better against These Metrics than Traditional Payer Evaluations Apply the Dartmouth Atlas for Unwarranted Variation methodologies to the newly released CMS data. This research has been repeatedly validated over the last 30 years and we now have a national data set to apply the methodologies at a large scale. This doctor has lower utilization and unit costs But this doctor is making money for whoever owns the risk Often, physicians with practice patterns that make money for whoever owns risk do not receive the right compensation because traditional payer utilization review and actuarial analysis
  7. 7. All contents are proprietary to RowdMap, Inc. and are being provided on a confidential basis. Any use, reproduction or distribution of this information, in whole or in part, or the disclosure of any of its contents without the prior written consent of the Company, is prohibited. 7 Data on Every Health Plan’s Expected Pro Forma, Strengths, Weakness and Provider Contribution Payer Profiles and Report Cards California Determine which payers have acute needs and where and how you help them. For a payer with low reimbursement, poor population health scores, poor overall clinical metrics and a small population, negotiate less from your medical performance and more from your coding and panel size. Blue = Volume Every Payer in your market
  8. 8. 8 All contents are proprietary to RowdMap, Inc. and are being provided on a confidential basis. Any use, reproduction or distribution of this information, in whole or in part, or the disclosure of any of its contents without the prior written consent of the Company, is prohibited. Parent Org %Parent Org % Layer on your state and self-reported data sources and get the benefit of external and internal perspectives side by side Explore and track based on an integrated view of your data and gov benchmarks (including Cal-Index and/or IHA Data, etc.) Start with Government Benchmarks, then Layer on Internal Sources Data Is Public, Does Not Require IT or Integration, up the Next Day
  9. 9. 9 All contents are proprietary to RowdMap, Inc. and are being provided on a confidential basis. Any use, reproduction or distribution of this information, in whole or in part, or the disclosure of any of its contents without the prior written consent of the Company, is prohibited. CAPG Risk-Readiness SM What Is Happening: B – CMS Policy: Sun-setting Fee for Service to mitigate Unnecessary Spend Burwell’s announcement on sun-setting FFS is real and the CMS ortho bundled payments is the tip of iceberg Goal is to get rid of unnecessary spend – the 30 cents of every dollar that goes to no value care drove billing in Fee for Service Concern is providers will not be able to successfully transition (cf. AMA/RAND study) and CMS is making multiple bets on payers & providers across programs Win is to create a virtuous cycle where providers who mitigate unnecessary spend are paid more and have more membership from plans
  10. 10. 10 All contents are proprietary to RowdMap, Inc. and are being provided on a confidential basis. Any use, reproduction or distribution of this information, in whole or in part, or the disclosure of any of its contents without the prior written consent of the Company, is prohibited. Burwell on Sun-Setting FFS Is Real; CMS Ortho Bundles Is the Tip of Iceberg CMS: 50% of FFS will be gone by 2018 No, Really, CMS Means Business! These are just the first pieces to move and transforming payment across the system!
  11. 11. 11 All contents are proprietary to RowdMap, Inc. and are being provided on a confidential basis. Any use, reproduction or distribution of this information, in whole or in part, or the disclosure of any of its contents without the prior written consent of the Company, is prohibited. Risk-Readiness℠ looks at a different category of spending Goal Is to Get Rid of Unnecessary Spend, the 30 Cents of Every Dollar of No-Value Care Clinically Appropriate, but Unnecessary Care (30% of spend) Claims Spend for a Health Plan / Government Program Necessary Utilization (70%) “Bigger than higher prices, administrative expenses, and fraud, however, was the amount spent on unnecessary health-care services. Now a far more detailed study confirmed that such waste was pervasive.” In just a single year, up to 42% of patients receive “No Value” Care. Dr. Atul Gawande, Professor, Department of Health Policy and Management at the Harvard School of Public Health & the Department of Surgery at Harvard Medical School. “It’s generally agreed that About 30 percent of what we spend on health care is unnecessary. If we eliminate the unneeded care, there are more than enough resources in our system to cover everybody.” -Dr. Elliott Fisher, Dartmouth Institute for Health Policy
  12. 12. 12 All contents are proprietary to RowdMap, Inc. and are being provided on a confidential basis. Any use, reproduction or distribution of this information, in whole or in part, or the disclosure of any of its contents without the prior written consent of the Company, is prohibited. Magnitude of Problem Means Darwinian Approach 30% of the U.S. health care spend goes to no value care and unnecessary spending driven by FFS Incentives Over $9B in Orange County, CA Over $66B in Florida $850 Billion Unnecessary Spend* in 2014 30% of U.S. health care spend that goes to clinically appropriate, but unnecessary care. Newly released data and historic models can identify the cost-savings opportunities in a geography based on the collective intensity of care delivered by doctors in that area. * Unnecessary Spend = (Dartmouth Avg cost) * (Population) * (Network Opportunity Index) Concern Is Providers Won’t Successfully Transition; CMS Is Making Multiple Bets across Programs RAND/AMA study confirms providers face challenges, especially on data, and may not be able to achieve success. CMS A/B testing payers and providers across a wide variety of programs and ratcheting economics to find winners.
  13. 13. 13 All contents are proprietary to RowdMap, Inc. and are being provided on a confidential basis. Any use, reproduction or distribution of this information, in whole or in part, or the disclosure of any of its contents without the prior written consent of the Company, is prohibited. Hospital Marketshare by Major Clinical Categories Provider Group Marketshare by Major Clinical Categories Physician Marketshare by Major Clinical Categories Decrease market share of this group for ortho Circulatory Respiratory Unnecessary Spend in Miami By condition across hospitals, groups and physicians Win Is a Virtuous Cycle where Providers with Less Unnecessary Spend Have More Membership System goal is virtuous cycle where providers with lower rates of unnecessary care have higher market share. Fastest path may come from payers, employers and new network design and optimization. Increase market share of this group for ortho
  14. 14. 14 All contents are proprietary to RowdMap, Inc. and are being provided on a confidential basis. Any use, reproduction or distribution of this information, in whole or in part, or the disclosure of any of its contents without the prior written consent of the Company, is prohibited. CAPG Risk-Readiness SM What Is Happening: C – Market Trends: Payers rolling through with narrowing networks Narrow networks pay off for payers and employers. [E.g. High/Med/Low scenario in unnecessary spending via network construction.] Market is consolidating around narrow networks with payers buying providers who mitigate unnecessary spend and private equity accelerating groups to this Providers often not aware of the valuation impact tied to ability to mitigate unnecessary spend and transition to pay for value Providers who do not create and articulate value may be ‘designed around’
  15. 15. 15 All contents are proprietary to RowdMap, Inc. and are being provided on a confidential basis. Any use, reproduction or distribution of this information, in whole or in part, or the disclosure of any of its contents without the prior written consent of the Company, is prohibited. All physicians in Winston-Salem, NC generate $1.37 BB of Unnecessary Spending / No-Value Care Winston-Salem, NC Diamond Network (95% of PCPs) Emerald Network (65% of PCPS) Amethyst Network (50% of PCPs) Cut Bottom 5% of physicians, save $303 MM each Year Cut Bottom 35% of physicians, save $615 MM each Year Cut Bottom 50% of physicians, save $790 MM each Year Possible Network Savings in Winston-Salem, NC Curated and Narrow Networks Pay off for Payers and Employers Network optimization creates large, disproportionate gains as metrically with the very bottom of physicians accounting for large gains. Networks can be optimized by excluding specific doctors or shifting members/patients within a network.
  16. 16. 16 All contents are proprietary to RowdMap, Inc. and are being provided on a confidential basis. Any use, reproduction or distribution of this information, in whole or in part, or the disclosure of any of its contents without the prior written consent of the Company, is prohibited. Market Is Consolidating around Narrow Networks often Using This Data Payers buying providers who mitigate unnecessary spending and private equity groups accelerating groups to this. The newly released data can identify hidden value in providers.
  17. 17. 17 All contents are proprietary to RowdMap, Inc. and are being provided on a confidential basis. Any use, reproduction or distribution of this information, in whole or in part, or the disclosure of any of its contents without the prior written consent of the Company, is prohibited. Risk-Readiness SM Provider Ranking Tool Providers Often Not Aware of the Valuation Impact Tied to Unnecessary Spending Mitigating unnecessary spending seen as indicating ability to successfully transition to Pay for Value and often has large impact on overall valuation of providers. Hidden value also drives negotiations from payers. Blue = Volume Shape = Practice Patterns on Key Ratios Blue = Volume Purple = Unnecessary Spend Red = $ Lost Green = $ Gained
  18. 18. 18 All contents are proprietary to RowdMap, Inc. and are being provided on a confidential basis. Any use, reproduction or distribution of this information, in whole or in part, or the disclosure of any of its contents without the prior written consent of the Company, is prohibited. Payers Activity Use This Data You have heard payers describe market goals We actively help payers use this data to: Risk Adjust all P&Ls (commercial & exchange) without Claims Design Curated Networks around Risk-Readiness SM Grow Membership into Risk-Ready SM Providers Design Products based on Risk-Ready SM Providers Identify and Purchase Risk-Ready SM Providers Design Risk Arrangements for Providers Negotiate with Providers Based on Risk-Readiness SM Often providers are not aware of their own hidden value We prefer payers interested in creating a virtuous cycle and partnership with providers, but some will use this data aggressively Where we’ve done it… Providers Who Do Not take ‘Value-Poor’ Deals May Be ‘Designed around’
  19. 19. 19 All contents are proprietary to RowdMap, Inc. and are being provided on a confidential basis. Any use, reproduction or distribution of this information, in whole or in part, or the disclosure of any of its contents without the prior written consent of the Company, is prohibited. CAPG Risk-Readiness SM What This Means for CAPG: 1 – Provider profiles for CAPG with CMS benchmarks for Unnecessary Spend New public data shows how risk ready each group is, what is driving that readiness and where their individual physicians fall along that continuum This can be used identify opportunities to mitigate unnecessary spend and gain profitability from risk arrangements
  20. 20. 20 All contents are proprietary to RowdMap, Inc. and are being provided on a confidential basis. Any use, reproduction or distribution of this information, in whole or in part, or the disclosure of any of its contents without the prior written consent of the Company, is prohibited. New Public Data Shows Risk-Readiness SM and Drivers for Groups, Individual Physicians Practice patterns for unnecessary spending and no-value care benchmarked nationally and regionally inform government programs and payer-based risk arrangements Great profile for aggressive risk Tread carefully on path to risk Match appropriate risk arrangements based on provider practice patterns and Population characteristics within a geography
  21. 21. 21 All contents are proprietary to RowdMap, Inc. and are being provided on a confidential basis. Any use, reproduction or distribution of this information, in whole or in part, or the disclosure of any of its contents without the prior written consent of the Company, is prohibited. EXAMPLE Risk-Readiness SM Practice Risk-Readiness SM Report IPA (Chinese American IPA) Staff Model (Advocate Health Partners) Clinically Integrated Network (Geisinger Health System) Academic Center (Tufts Medical Center) Choose National or Regional Benchmarks All four candidates well positioned with current practice patterns for risk with Tufts the highest on overall benchmark. Chinese IPA should focus on prescription patterns and visit intensity to improve position for risk and payer perception but has potential best practices in managing referral intensity. Blue = Volume
  22. 22. 22 All contents are proprietary to RowdMap, Inc. and are being provided on a confidential basis. Any use, reproduction or distribution of this information, in whole or in part, or the disclosure of any of its contents without the prior written consent of the Company, is prohibited. EXAMPLE Risk-Readiness SM Risk-Readiness SM by Provider Type * CMS Anomalies Choose National or Regional Benchmarks Chinese IPA issues with PCP care and cardiology should be explored, explained for negotiating with payers on risk. Geisinger here is well positioned for risk with a strong negotiating position with payers around PCP care and cardiology. Blue = Volume
  23. 23. 23 All contents are proprietary to RowdMap, Inc. and are being provided on a confidential basis. Any use, reproduction or distribution of this information, in whole or in part, or the disclosure of any of its contents without the prior written consent of the Company, is prohibited. EXAMPLE Risk-Readiness SM Chinese American IPA Top 5 Largest Providers by Specialty Choose National or Regional Benchmarks Chinese IPA prescription patterns in cardiology driven by three physicians and in PCP care driven by four physicians Blue = Volume
  24. 24. 24 All contents are proprietary to RowdMap, Inc. and are being provided on a confidential basis. Any use, reproduction or distribution of this information, in whole or in part, or the disclosure of any of its contents without the prior written consent of the Company, is prohibited. EXAMPLE Risk-Readiness SM Geisinger Clinic Top 5 Largest Providers by Specialty Choose National or Regional Benchmarks Geisinger particular pattern of PCP care driven by visit intensity. For Cardiology risk readiness is largely driven by one physician. Blue = Volume
  25. 25. 25 All contents are proprietary to RowdMap, Inc. and are being provided on a confidential basis. Any use, reproduction or distribution of this information, in whole or in part, or the disclosure of any of its contents without the prior written consent of the Company, is prohibited. EXAMPLE Risk-Readiness SM Advocate Health and Hospital Top 5 Largest Providers by Specialty Choose National or Regional Benchmarks Advocate is particularly well-positioned for risk in PCP care with largest physician generating profit for whoever owns the risk Blue = Volume
  26. 26. 26 All contents are proprietary to RowdMap, Inc. and are being provided on a confidential basis. Any use, reproduction or distribution of this information, in whole or in part, or the disclosure of any of its contents without the prior written consent of the Company, is prohibited. EXAMPLE Risk-Readiness SM Tufts Medical Center Top 5 Largest Providers by Specialty Choose National or Regional Benchmarks Tufts is particularly well-positioned for risk in both PCP and Cardiology arrangements. On PCP, there is one physician with an outlying pattern different from other top Tufts PCPs that will raise payer eyebrows and is worth exploration. Blue = Volume
  27. 27. 27 All contents are proprietary to RowdMap, Inc. and are being provided on a confidential basis. Any use, reproduction or distribution of this information, in whole or in part, or the disclosure of any of its contents without the prior written consent of the Company, is prohibited. CAPG Risk-Readiness SM What This Means for CAPG: 2 – Provider & market profiles showing the best arrangements for CAPG members New public data shows what government programs or payer-based risk arrangements will yield the best results short term and long term profitability This can be used pick the risk government programs and risk arrangements with payers to maximize strategic value today and over time
  28. 28. 28 All contents are proprietary to RowdMap, Inc. and are being provided on a confidential basis. Any use, reproduction or distribution of this information, in whole or in part, or the disclosure of any of its contents without the prior written consent of the Company, is prohibited. New Public Data Shows Best Programs and Payer-Based Risk Arrangements New public data shows what programs or payer-based risk arrangements will yield the best results short term and long term profitability and allows negotiating around financial impact of mitigating unnecessary spending and no value care using government benchmarks High performers with practice patterns out- performing unit cost and utilization analysis due to case mix and population factors. Looking to grow. Negotiate from Government Benchmarks for Unnecessary Spend and Economic Impact
  29. 29. 29 All contents are proprietary to RowdMap, Inc. and are being provided on a confidential basis. Any use, reproduction or distribution of this information, in whole or in part, or the disclosure of any of its contents without the prior written consent of the Company, is prohibited. CAPG Risk-Readiness SM What This Means for CAPG: 3 – Payer report cards using CMS benchmarks to negotiate more effectively New public data shows payer attributes including strengths and weaknesses based on CMS finances, populations, and network impact This can be used to negotiate with payers based on real provider value, specific payer need and impact and alternative government provider options
  30. 30. 30 All contents are proprietary to RowdMap, Inc. and are being provided on a confidential basis. Any use, reproduction or distribution of this information, in whole or in part, or the disclosure of any of its contents without the prior written consent of the Company, is prohibited. New Public Data Shows Payer Attributes, Strengths and Weaknesses Determine which payers have acute needs and where and how you help them. Walk in not only with your contribute to payer profit through risk but also with the profile of the payer with whom you are negotiating highlighting their needs and your value in solving them. Washington Payer Report Card Blue = Volume Red = Members Lost Green = Members Gained Every Payer in your market
  31. 31. 31 All contents are proprietary to RowdMap, Inc. and are being provided on a confidential basis. Any use, reproduction or distribution of this information, in whole or in part, or the disclosure of any of its contents without the prior written consent of the Company, is prohibited. CAPG Risk-Readiness SM What Is Happening: A – Public Data: CMS releasing benchmark data on geographies and docs B – CMS Policy: Sun-setting Fee for Service to mitigate Unnecessary Spend C – Market Trends: Payers steamrolling through narrowing networks What This Means for CAPG: 1 – Provider profiles for CAPG with CMS benchmarks for Unnecessary Spend 2 – Provider & market profiles showing the best arrangements for CAPG members 3 – Payer report cards using CMS benchmarks to negotiate more effectively
  32. 32. 32 All contents are proprietary to RowdMap, Inc. and are being provided on a confidential basis. Any use, reproduction or distribution of this information, in whole or in part, or the disclosure of any of its contents without the prior written consent of the Company, is prohibited. CAPG Risk-Readiness SM US CTO on using this public data: “Visionary Genius” This Is Real, a National Trend Payers are using public data for risk and design Risk-bearing providers are getting in the game
  33. 33. 33 All contents are proprietary to RowdMap, Inc. and are being provided on a confidential basis. Any use, reproduction or distribution of this information, in whole or in part, or the disclosure of any of its contents without the prior written consent of the Company, is prohibited. CAPG Risk-Readiness SM Jump on in! [Referrals: http://1.usa.gov/1FzoEOV] [Variation: http://go.cms.gov/1D8j7LE] [Shared Savings: http://go.cms.gov/1Hh8vx0] [Medicare FFS Part B: http://go.cms.gov/OCmyoy] [Medicare FFS Part D: http://bit.ly/1mGyBxk] [Medicaid: http://go.cms.gov/1z7b5ic] [Dartmouth: http://bit.ly/1GXvlJp] [Behaviors: http://1.usa.gov/1PzcisT] [Health Data All Stars: http://bit.ly/1GAsVC3]

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