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PROVIDER-LED HEALTH PLANS 202: A Roadmap to Ensuring Financial and Clinical Stability

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This presentation throws light on:
• Managing Risk and Revenue
• Network and Operational Optimization
• Improving Quality and Compliance

For more information on our Care Optimization & Network Optimization solutions, please
http://www.sciohealthanalytics.com/offerings/solutions/care-optimization
http://www.sciohealthanalytics.com/offerings/solutions/network-optimization

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PROVIDER-LED HEALTH PLANS 202: A Roadmap to Ensuring Financial and Clinical Stability

  1. 1. |1 ©2017 SCIO Health Analytics®. Confidential and Proprietary. All rights reserved.©2017 SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. PROVIDER LED HEALTH PLANS 202 A Roadmap to Ensuring Financial and Clinical Stability September 21, 2017
  2. 2. |2 ©2017 SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. THE PROMISE OF A PROVIDER LED HEALTH PLAN The Opportunity for Strategic and Economic Advantages • Four Positive Market Conditions Solidified Since the 1990s: Movement Toward Value- Based Outcomes Data and Technology Access Consumer Acceptance of Narrow Networks Expanded Consumer Segments ~The Payoff~ Leverage the combined power of integrated claims and clinical data to: • Better identify opportunities • Act sooner • Deliver better informed medical management • Improve outcomes
  3. 3. |3 ©2017 SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. SIGNIFICANT CHALLENGES EXIST – PART 1 The Inherent Push and Pull of Payer and Provider Value Creation • Fundamental to success is the need to have deep collaboration or synergy between the payer and provider groups to reconcile these differences and think of the organization as a whole Where are we in the shift to value-based care?
  4. 4. |4 ©2017 SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. THE JOURNEY TOWARDS VALUE-BASED CARE Where Is Your Organization Along This Path? • Tipping point around 2020 • Value-based models are transitional on a path to capitation • Estimated 25% of healthcare dollars are currently in true “value-based” models • MACRA/MIPS transitions provider reimbursement to a Quality Payment Program – Push toward alternate payment models (APMs) Degree of Population Risk Transferred to Provider by Payment System Fee for Service Pay for Coordination Pay for Performance Episodic Payments Shared Savings Capitation Paid for each unit of service without constraint on spending Additional per capita payment based on ability to manage care Payments tied to objective measures of performance Payment based on delivery of services within a given timeframe Shared savings from better care coordination and disease management Providers share savings from better care coordination and disease management Low High
  5. 5. |5 ©2017 SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. Financial Risk Management • Cost and utilization analytics • Financial risk accounting/reporting • Contract management • Documentation and accurate coding Care Management • Care Coordination, including post-acute and supportive care • Case management • Utilization management • Chronic disease management • Wellness and prevention • Clinical analytics for risk segmentation and provider reporting Clinical Integration • Governance, strategy, and alignment across the network • Clinical-quality best-practice dissemination clinical pathways • Clinical-operations improvement to optimize quality and cost • Practice transformation • IT tools that enable integration (eg, EHR interoperability) Patient Engagement • Patient navigation tools, including transparency • Tools to manage own health/engagement • Superior patient experience and customer service SIGNIFICANT CHALLENGES EXIST – PART 2 Critical Considerations in Health Plan Success Identifying market target segments (Medicaid, MA, Individual, Small Group, Large Group, ASO) Build or buy a plan? Are provider and operational leader incentives aligned? Is there a volume v. value barrier to overcome? What is the potential payer friction? What is the readiness for the operational, financial and population health requirements of a plan? This is where we’ll focus today. Source: McKinsey Healthcare Systems and Services Practice in the Americas Population Health Readiness
  6. 6. |6 ©2017 SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. MANAGING RISK & REVENUE
  7. 7. |7 ©2017 SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. MANAGING RISK & REVENUE Key Aligned Need: Ensure Quality Care & Appropriate Documentation No matter which LOB, health plans need to ensure they are providing quality care to their populations AND documenting care to high risk members to ensure their achievements in improving cost and quality are recognized: Line of Business (LOB) Impact of Risk Documentation to Revenue Medicare Advantage Reimbursement from CMS is directly tied to HCC-derived risk adjustment factor (RAF) scores Medicaid Transfers from Health plans with healthier populations to plans with riskier populations Commercial Exchange (ACA) MSSP ACOs Savings rate calculated by comparing expected spend vs. actual spend • Expected spend based upon riskiness of members Have a chronic condition Missing document- tation of treatment High Priority Member flagged for management
  8. 8. |8 ©2017 SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. FOSTERING AN INTEGRATED APPROACH Key Need: Actionable information to proactively enhance patient care and improve revenue through accurate risk scores and higher quality ratings Accurate Risk Scores Ensure that Reimbursement is Commensurate With the Expected Costs Improved Quality Measures Ensure that Conditions are Identified and Treated Each Year
  9. 9. |9 ©2017 SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. THE THREE “RIGHTS” Engaging the RIGHT PERSON (member or provider) with the RIGHT INFORMATION at the RIGHT TIMES Before Visit During Visit After Visit Challenges Member Needs to Visit PCP PCP Needs to Manage Member Conditions, and Document Management Ensure Coding / Billing Robust & Accurate Submit all Data / Dxs to Measuring Authority Solutions Member Suspect Lists Patient Engagement In Home Visits Visit Support Tools Provider Education Sessions Financial Incentives Chart Review Data Flow Analysis Quality Initiatives
  10. 10. |10 ©2017 SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. PROVIDER COLLABORATION & MEMBER OUTREACH • Coordination is critical to ensure optimal results: – Prioritize key Areas of Opportunity within plan – Identify providers/groups that need outreach – Lists of gaps for patients, prioritized – Patient-specific reports to support providers office visits – Review physician’s progress notes for accuracy – Data entry of the additional and/or corrected data • Reconcile data to ensure accuracy of information used by governing entity • Trend and forecast risk and revenue using most current model • Monitor program progress with user-defined reporting Improve evaluation of chronic conditions to close member care gaps and document member acuity
  11. 11. |11 ©2017 SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. TOP 15 HCC CONDITIONS *The book of business benchmark is nationwide data of + 2.5 Million Medicare members for a closed CMS performance year` 21.5% 16.3% 14.8% 13.1% 10.1% 10.4% 9.1% 5.7% 4.4% 3.8% 3.2% 3.1% 2.6% 3.0% 3.3% 23.0% 18.2% 17.6% 16.0% 11.6% 11.5% 10.2% 6.9% 5.8% 4.6% 3.9% 3.8% 3.8% 3.5% 3.5% 20.8% 22.1% 8.9% 20.1% 10.5% 13.0% 4.4% 5.9% 13.8% 6.2% 5.2% 2.5% 6.9% 1.5% 1.7% 0% 5% 10% 15% 20% 25% Diabetes without Complication Vascular Disease Specified Heart Arrhythmias Diabetes with Chronic Complications Congestive Heart Failure Breast, Prostate, and Other Cancers and Tumors Chronic Obstructive Pulmonary Disease Rheumatoid Arthritis and Inflammatory Connective Tissue Disease Major Depressive, Bipolar, and Paranoid Disorders Coagulation Defects and Other Specified Hematological Disorders Other Significant Endocrine and Metabolic Disorders Acute Renal Failure Morbid Obesity Colorectal, Bladder, and Other Cancers Ischemic or Unspecified Stroke NEMG Service Year 2015 NEMG Service Year 2016 Book of Business Benchmark Diabetes with complication, Obesity, Vascular disease, Major Depressive disorder have lower prevalence compared to benchmark indicating opportunities for further improvement. 2016 HCC Prevalence higher than 2015 for all conditions suggesting improved coding practice. • Benchmark top conditions to prioritize areas of focus for health plan • Monitor changes over time to ensure efforts are working and improvement continues • Can provide flag for areas where processes may be breaking down
  12. 12. |12 ©2017 SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. ANALYZE HEDIS GAPS AS WELL
  13. 13. |13 ©2017 SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. AND STARS RATINGS…
  14. 14. |14 ©2017 SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. CONDITION PREVALENCE CODING COMPARED TO BENCHMARK Chronic conditions - with prevalence lower than benchmark Plan 2015 Plan 2016 Book of Business Benchmark Attaining Benchmark # No HCC Members needed to attain benchmark levels # Member Weight Opportunity Vascular Disease 16.30% 18.19% 22.11% 3.92% 900 4,177 0.298 $227,607 Diabetes with Chronic Complications 13.10% 15.96% 20.12% 4.16% 955 3,664 0.318 $257,688 Major Depressive, Bipolar, and Paranoid Disorders 4.40% 5.80% 13.00% 7.24% 1,663 1,323 0.395 $557,346 Morbid Obesity 2.60% 3.80% 6.88% 3.13% 718 860 0.273 $166,275 $981,309 Comparison to Benchmarks show Low prevalence for conditions like Diabetes w/o complication, Vascular disease, Major Depression and Morbid Obesity
  15. 15. |15 ©2017 SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. TOP 15 CHRONIC CONDITIONS WITH COC GAP 2016 HCC Condition $ Opportunity at best HCC gap levels $ Opportunity meeting NEMG average $ Opportunity with No gap COC gap weight as % of Condition Vascular Disease $1,780,160 $392,298 $3,108,850 24.5% Congestive Heart Failure $1,092,804 $130,518 $2,014,013 22.9% Acute Renal Failure $1,517,557 $1,106,323 $1,911,609 50.9% Chronic Obstructive Pulmonary Disease $779,712 - $1,599,579 20.5% Rheumatoid Arthritis and Inflammatory Connective $762,899 $14,886 $1,478,950 21.7% Diabetes with Chronic Complications - - $1,243,139 10.5% Coagulation Defects and Other Specified Hematology $703,988 $443,780 $953,234 40.1% Atherosclerosis of the Extremities with Ulceration o $742,396 $561,580 $915,685 55.5% Major Depressive, Bipolar, and Paranoid Disorders $319,156 - $876,832 16.5% Vascular Disease with Complications $598,201 $329,269 $855,757 34.8% Other Significant Endocrine and Metabolic Disorders $482,799 $254,260 $701,661 33.6% Breast, Prostate, and Other Cancers and Tumors $215,435 - $628,152 16.0% Myasthenia Gravis/Myoneural Disorders and Guillain-Barre Syndrome/Inflammatory and Toxic $485,757 $359,900 $606,363 52.8% Morbid Obesity $341,291 $79,517 $591,906 24.8% Continuity of Care Gap specific HCC $9,822,156 $3,672,330 $20,805,212 21.4% Diabetes and Major Depressive conditions are coded more consistently than other chronic conditions such as Acute Renal Failure
  16. 16. |16 ©2017 SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. ANALYSIS OF CHRONIC CONDITION CARE & CODING GAPS 0 5 10 15 20 25 0.00 0.05 0.10 0.15 0.20 0.25 Density COC gap Location H Mean12.96% Location F Location L Location N Provider Missed HCC Weight Total HCC Weight 2016 % COC gap $ Opportunity at No gap $ Opportunity at Best HCC Gap Level Location A 549.5 4,072 13.50% $ 5,594,934 $ 2,979,748 Location B 151.0 1,144 13.20% $ 1,537,717 $ 878,938 Location C 142.4 1,001 14.23% $ 1,450,300 $ 1,036,662 Location D 113.5 965 11.75% $ 1,155,212 $ 840,506 Location E 112.8 825 13.67% $ 1,148,625 $ 812,387 Location F 91.1 769 11.85% $ 927,291 $ 834,478 Location G 71.0 568 12.49% $ 722,462 $ 389,832 Location H 70.5 688 10.25% $ 717,544 $ 429,916 Location I 67.5 536 12.61% $ 687,407 $ 331,443 Location J 55.2 374 14.78% $ 562,410 $ 427,329 Location K 53.9 408 13.21% $ 548,543 $ 331,642 Location L 35.4 201 17.61% $ 360,238 $ 206,331 Location M 32.7 283 11.58% $ 333,196 $ 239,233 Location N 28.7 175 16.43% $ 292,298 $ 240,961 Overall 2,043.5 15,764 12.96% $ 20,805,691 $ 12,973,227 The weighted distribution of HCC risk is skewed indicating providers with double the average gap levels. $ amounts are annual • Analyze group practices that have more Care Gaps than peers • Size opportunity if Gaps are closed Members at Locations J and L of similar demographics have 40% lower risk weights than Location H.
  17. 17. |17 ©2017 SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. IDENTIFY PROVIDER OUTLIERS • Drill down to specific providers within health plan in need of coaching / assistance • Monitor changes over time to ensure efforts are working and improvement continues
  18. 18. |18 ©2017 SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. GET DOWN TO THE MEMBER LEVEL - CARE GAPS Chronic Condition Documentation Gaps and Their Financial Impact • Ultimately, results are achieved at the member level • Knowing the financial impact can help motivate team to ensure items are addressed
  19. 19. |19 ©2017 SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. INCLUDING HEDIS… • Some items are easier to address than others, but you need to know about a gap, to increase chance of closing it…
  20. 20. |20 ©2017 SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. MEMBER SPECIFIC FORMS TO CLOSE GAPS Chronic Conditions Previously Documented Now Missing For This Member Quality Gaps For This Member
  21. 21. |21 ©2017 SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. OTHER KEY CONCERNS • Root Cause Analysis – What is causing the top issues/need? • Data Drop Off – Even if providers are doing a great job of managing care, data might not be getting into measurement system • Coding Accuracy – Increased focus by regulators on OVER coding – Need to audit for coding accuracy and educate providers Root Cause Analysis Coding Accuracy Dropped Data
  22. 22. |22 ©2017 SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. OPERATIONAL & NETWORK OPTIMIZATION
  23. 23. |23 ©2017 SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. STRIKING THE BALANCE BETWEEN A PROVIDER AND A HEALTH PLAN Benefits of a Balanced Approach: Complete Claims Data is Necessary for Reporting to Governing Entities (e.g., CMS, NCQA) Accurate Utilization and Cost Information Improves Pricing Analysis and Decisions Robust Data is Critical to Insightful Analytics (e.g., Population Health, Network Performance) Health Plan Only Pays Actual Cost of Care Health Plan Processes Provider Claims and Corrects Payment Inaccuracies via Audits and Education Health Plan Pays Providers Without Any Discounts Provider- Centric Payer- Centric Health Plan Narrows Network to Only System Providers Health Plan Requires Pre- Authorization Across Wide Network Health Plan Leverages System Providers While Ensuring Member Access, No Pre-Authorization, Provider and Patient Education
  24. 24. |24 ©2017 SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. Considerations Despite Growth of Value-Based Care, Most Reimbursement is Still Based on Volume (Fee For Service) The “Left Pocket/Right Pocket” Question Shift from Managing Care to Managing Care AND Utilization Unique Challenges Large fixed costs in facilities, etc. New to “payer” thinking about controlling utilization or unit cost Balancing the Loss of Inpatient Volume. Developing Strategies to Transition Toward Outpatient and Related Services ENSURING CLAIMS ACCURACY 6-10% of Spending is Inappropriate (Overutilization, Billing/Payment Errors, or Fraud)
  25. 25. |25 ©2017 SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. A PHILOSOPHY FOR PAYMENT INTEGRITY Select Right Use a complete understanding of specific coverage guidelines & billing rules with analytic tools to optimize claims selected for audit Audit Right Ensure staff performs comprehensive reviews of each claim they receive, and do not focus just on initial concern identified, to ensure most effective process. Make It Stick Communicate audit findings clearly, with detailed reasons errors were found. This maximizes change in behavior.
  26. 26. |26 ©2017 SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. PRECISE SELECTION REDUCES FALSE POSITIVES Use New Data Sources & Novel Analytic Models to Precisely Select Claims Goal PROVIDER ANALYTICS / PROFILES Based on Claims, Member Risk, Demographics, Linkage, Quality and Efficiency, benchmarks MEMBER ANALYTICS / PROFILES Conditions, Utilization, Cost, Risk Based on Clinical and Payment history, Co- Morbidity, Propensity, Socio- Demographics, Lifestyle Preferences PAYER ANALYTICS / PROFILES Payment Lifecycle, Bundled Payments, Quality and Compliance, benchmarks CLAIM ANALYTICS / PROFILES An extensive library of queries that is continually curated by subject matter experts. FOUR FACTORS IN SELECTION: BENEFITS: Feedback from Results to Refine Selection Reduces Appeals / Overturns & False Positives Identifies Root Causes of Widespread Issues Addresses Emerging Trends Maximizes Error Avoidance
  27. 27. |27 ©2017 SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. CLINICAL REVIEW AREAS: INPATIENT & OUTPATIENT Concept Key Highlights Typical Results Inpatient Hospital Bill Audit • Onsite review compares itemized bills to medical records for high cost percent of charge reimbursement claims to validate proper billing • Review of >8,000 claims with $1.5 billion in billed charges • Results: 95% had errors | $60 million Total billing errors • Errors average 3-5% of billed charges DRG Validation • Onsite or desk audits validate coding, discharge disposition, etc. • >30% of reviews result in findings • Average overpayment of $4,000 DRG Short Stay • Clinical review of whether level of care was appropriate (inpatient v. outpatient, etc.) • >60% of situations were more appropriate at lower level of care • Typical overpaid amount per audit is $4,200 NICU/ICU • Verify diagnoses billed are accurate based upon clinical review of medical documentation and medical necessity of level of care • Errors found in ~30% of claims audited • Average overpayment of $4,000+ per claim Outpatient Outpatient (APC, etc.) • Review of records for outpatient claims for coding accuracy and reasonableness of services. • Recent project found errors on 72% of claims • 39% of total was paid in error
  28. 28. |28 ©2017 SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. CLINICAL REVIEW AREAS: ANCILLARY Concept Key Highlights Typical Results Skilled Nursing (Per Diem) • Validates that services provided are consistent with the acuity level billed • Errors identified in 40+% of claims audited • Average overpayment range $900-1,200 Skilled Nursing (RUG) • Experienced clinical auditors apply the Medicare Assessment Schedule, MDS 3.0 / RAI User’s Manual to the Minimum Data Set • Errors identified in 25+% of claims audited • Average overpayment near $2,000 Home Health • Data analysis and record review by clinical auditors assess compliance with Medicare assessment schedule, number of visits, HIPPS score, and clinical need for care • 35+% of reviews show unsupported HIPPS score • Typical overpaid amount per audit is $2,600 High Cost Drug / Home Infusion • Audits of key provider and treatment types (eg, physician, specialty pharmacy, home infusion) and review records for: • Pricing methodology • Billing (dosage, method of administration, size, etc.) • Adjudication issues & billing errors / abuse • Overpayments of 8% of paid amount on audited claims • 40-50% of overpayments based on medical record review • Average overpayment of $750 / claim Durable Medical Equipment • Identify duplicate billing of services • Verify coding accuracy and obsolete codes • Overpayments of 10-20% of paid amount on audited claims • Average overpayment of $100-$150 / claim
  29. 29. |29 ©2017 SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. 1. Evaluate • Utilization • Leakage • Efficiency • Provider Groups and PCPs 2. Act on Insights • Provider Education • Network Strengths/ Weaknesses • Incentive Design NETWORK OPTIMIZATION PLHPs: Uniquely Positioned to Achieve the Long-Sought Provider-Health Plan Collaboration
  30. 30. |30 ©2017 SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. NETWORK AT A GLANCE
  31. 31. |31 ©2017 SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. MONITOR PROVIDER REFERRAL PATTERNS & LEAKAGE Who are the providers with the highest out of network utilization & costs? Detailed information on that leakage.
  32. 32. |32 ©2017 SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. IMPROVE QUALITY & COMPLIANCE 24 30 26 27 2827 43 29 27 25 1 2 3 4 5 6 7 8 9 10 Quality Rating Distribution Based on Quality Network Average Quality Score 0.49 $500 .8 3 2 1 3 3 50 $500 $475 .8 .8 View side-by-side comparison of provider groups’ performance
  33. 33. |33 ©2017 SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. EVALUATE NETWORK EFFICIENCY
  34. 34. |34 ©2017 SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. IMPROVING QUALITY AND COMPLIANCE
  35. 35. |35 ©2017 SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. POPULATION HEALTH Directing Interventions to Improve Quality & Compliance Maximize Resources by Prioritizing Member Interventions • Identify members who have the potential for the greatest impact • Isolate members who are most likely to comply with prescribed interventions • Avoid high-cost, low-value procedures (preference sensitive treatments) • Segment members for improved engagement • Evaluate the impact of care management programs – ROI analysis
  36. 36. |36 ©2017 SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. BEYOND TRADITIONAL RISK ANALYSIS Where can I have the greatest impact?1 Who is at risk to undergo an avoidable surgery?3 What conditions and subsequent interventions represent the highest opportunity value? 2 Which consumer types comprise my membership? How do they compare? Which programs are best? 4 Intervene at phases 1 and 2 to reduce likelihood of a patient needing invasive surgery
  37. 37. |37 ©2017 SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. 9 LEVERS OF POPULATION MANAGEMENT Provider Measurement & Incentives Patient Education (with or without incentive) Inpatient Management Outreach for Case and Condition Management Prior Authorization Claims Audit Unit Cost, Network Selection (i.e. contracting with providers) Capitation Benefit Design
  38. 38. |38 ©2017 SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. IDENTIFY & QUANTIFY IMPACTABLE OPPORTUNITY Where can I have the greatest impact?1 What is the cost and overall savings opportunity by condition? 3 What is the potential savings by open and closed gaps in care? 2 Can I drill down to the member level details?4
  39. 39. |39 ©2017 SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. PREFERENCE SENSITIVE TREATMENT (PST) MODEL CHALLENGE: Patients with preference sensitive conditions often display a selection bias towards surgery based on the assumption that it provides the highest quality of care. These invasive surgeries are expensive and in many cases the less-invasive treatment provides equal or greater outcomes with less complications. PREFERENCE SENSITIVE CONDITIONS: Ailments in which there are no definitive clinical guidelines and multiple treatment options exist THE PST MODEL IDENTIFIES AND STRATIFIES MEMBERS WITH PREFERENCE SENSITIVE CONDITIONS ACCORDING TO THEIR: • Risk of avoidable surgery in the next 12 months • Episode cost • Remaining time to utilize a less invasive option Identifying members in phases 1 or 2 and informing them and their providers of other treatment options reduces the likelihood of a member progressing to a high cost phase 3 procedure EXAMPLE TREATMENT PHASES FOR KNEE - OSTEOARTHRITIS Phase 1 – Severity 1 Selected Procedures Phase 2 – Severity 2 Selected Procedures Phase 3 – Severity 3 Selected Procedures • X-ray of the Knee • CAT Scan of the Knee • MRI of the Knee • Physical Therapy • Knee Brace … • Diagnostic knee Arthroscopy • Arthroscopic Drainage of knee • Arthroscopic knee Surgery – Chondroplasty • Arthroscopic knee Surgery – Synovectomy … • Partial knee Replacement • Total knee Replacement • Total knee Replacement Revision … Reduce Invasive Surgeries and Deliver Valuable Care
  40. 40. |40 ©2017 SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. PREFERENCE SENSITIVE TREATMENT (PST) MODEL CHALLENGE: Patients with preference sensitive conditions often display a selection bias towards surgery based on the assumption that it provides the highest quality of care. These invasive surgeries are expensive and in many cases the less-invasive treatment provides equal or greater outcomes with less complications. PREFERENCE SENSITIVE CONDITIONS: Ailments in which there are no definitive clinical guidelines and multiple treatment options exist THE PST MODEL IDENTIFIES AND STRATIFIES MEMBERS WITH PREFERENCE SENSITIVE CONDITIONS ACCORDING TO THEIR: • Risk of avoidable surgery in the next 12 months • Episode cost • Remaining time to utilize a less invasive option Identifying members in phases 1 or 2 and informing them and their providers of other treatment options reduces the likelihood of a member progressing to a high cost phase 3 procedure EXAMPLE TREATMENT PHASES FOR KNEE - OSTEOARTHRITIS Phase 1 – Severity 1 Selected Procedures Phase 2 – Severity 2 Selected Procedures Phase 3 – Severity 3 Selected Procedures • X-ray of the Knee • CAT Scan of the Knee • MRI of the Knee • Physical Therapy • Knee Brace … • Diagnostic knee Arthroscopy • Arthroscopic Drainage of knee • Arthroscopic knee Surgery – Chondroplasty • Arthroscopic knee Surgery – Synovectomy … • Partial knee Replacement • Total knee Replacement • Total knee Replacement Revision … Reduce Invasive Surgeries and Deliver Valuable Care OUTCOMES Organizations using the PST Model to inform and guide their engagement with members have generated high quality care at lower costs: • 20% reduction in invasive treatments • ~25% reduction in healthcare expenditure • Up to 1.5% reduction in overall population costs • 97% of participants rate the service “Excellent” or “Very Good”
  41. 41. |41 ©2017 SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. CONSUMER SEGMENTATION ANALYTICS CHALLENGE: Predictive analytical models require robust data set to yield accurate insights. Common issues from relying on medical and pharmacy claims data alone: • Using less than 12 months of claims data (e.g., new members) • Missing claim data (e.g., members who receive out-of-network care) • Insufficient volume of claims data (e.g., members with low utilization rates) A Quicker Path to Accurate Insights SCIO’s consumer segmentation analytics blends client data with supplemental data from SCIO to map and analyze members according to seven distinct consumer types.* CONSUMER TYPES • Healthy and Affluent • Balanced Adults • High Utilizers • Quality Driven • Cost Conscious • Chronic Older Adults • High Cost Baby Boomers Viewing membership this way helps organizations develop, evaluate, and market care management programs to the most appropriate members. * Data from SCIO can also be used by clients on its own, with client data added at a later date.
  42. 42. |42 ©2017 SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. EXAMPLE OF PERSONAS – CLINICAL
  43. 43. |43 ©2017 SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. EXAMPLE SEGMENT PROFILE: HIGH UTILIZERS
  44. 44. |44 ©2017 SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. DEMONSTRATING VALUE Analyze program outcomes for continual improvement and client reporting • Build a statistically robust model that allows measurement and tracking of the overall outcomes of care management programs and the value – internally and externally • Measure the clinical, utilization, and financial impact of the programs • Consider if you will build the model internally or leverage third party • If working with a third party, look for flexibility to run models in or out of your systems Why? • Increasingly, buyers – commercial and government – want to understand the impact of programs. • Continual evaluation enables care management program adjustments/improvements. • Gather insights about who participated to direct member outreaches and program recruitment.
  45. 45. |45 ©2017 SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. KEY TAKEAWAYS Managing Risk & Revenue • Combine quality and risk adjustment approaches to maximize revenue opportunities and reduce risk • Three Levels: Overall, Provider, and Member Network & Operational Optimization • Leverage your unique position to create true provider-health plan collaboration Improving Quality & Compliance • Segment the population beyond risk to prioritize members/resources for increased impact • Engage members in the channels they prefer • Measure impact for continuous internal improvement and client reporting

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