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Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Heal...
Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Heal...
Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Heal...
Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Heal...
Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Heal...
Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Heal...
Pathways to Partnerships | Bridging Connections For Value edifecs confidential
Value Based Care
Maturity model
Consume Tra...
Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Heal...
Pathways to Partnerships | Bridging Connections For Value edifecs confidential
Provider
EMR
Billing
Practice Management
Co...
Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Heal...
Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Heal...
Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Heal...
Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Heal...
Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Heal...
Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Heal...
Pathways to Partnerships | Bridging Connections For Value edifecs confidential
Intervention Gateway
Learning Engine Studio...
Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Heal...
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Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Heal...
Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Heal...
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4. walsteijn.edifecs enabling value based healthcare 2015 04 09 v3

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4. walsteijn.edifecs enabling value based healthcare 2015 04 09 v3

  1. 1. Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Healthcare Michiel Walsteijn, Executive Vice President - International Enabling Value Based Health Care April 9, 2015
  2. 2. Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Healthcare Software Innovator in Healthcare IT Edifecs is the first Partnership Platform for the healthcare industry Serving more than 215 Million lives through our 100+ Health Plan customers Worldwide 700+ Employees Leaders In Configurable Healthcare Data Interchange & Compliance 70+ Provider Customers Multiple Federal Agencies incl. CMS 8/9 National Health Plans 25/37 Blue Plans 24/52 State Medicaid Programs Pre-integrated Business Applications, e.g. Value Based Healthcare Enterprise Testing & Compliance Configurable Healthcare Data Interchange Partnership Platform 1996 2015 Since 1996, Edifecs technology has been helping healthcare insurers, providers, pharmacy benefit management companies, and other healthcare entities address key challenges to scaling partnerships.
  3. 3. Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Healthcare Some Definitions Quality (in medicine): The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge (Institute of Medicine, 1990) Value: Outcomes Achieved divided by Resources Expended Health Cost
  4. 4. Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Healthcare Understanding the Shift from Fee-for- Volume to Fee-for-Value Fee-for-Volume (Old World) Fee-for-Value (New World) Providers make money by negotiating higher rates and performing as many services as possible Providers make money by not only providing services, but other results valued by the industry, such as quality, efficiency, wellness, care coordination, and prevention Providers see every touch as revenue Providers see every touch as an expense to be managed Payers primarily pay providers based on claims Payers pay providers based on claims plus many other inputs (few of which are automated) Most providers have little regard for evidence-based medicine. Providers care a great deal about evidence based medicine Payers see providers as vendors Payers begin to see providers as partners
  5. 5. Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Healthcare Value Based Reimbursement A Continuum of Provider Risk Fee for Service Fee for Service Plus P4P or Shared Savings Episode of Care / Payment Bundling Partial Capitation Global Capitation Provider Sophistication ProviderRisk
  6. 6. Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Healthcare Scaling Healthcare Partnerships? Addressing 3 challenges is emerging as the key to scaling. Information Exchange and Integration Process Automation Community Collaboration Is information flow between partners flow seamlessly ? Does it comply with industry & partner standards? Is it timely, trusted and visible ? Are there any changes to core process or workflow ? Does the partnership model need new analytics? Can core systems adapt to support the changes? Is there a need for shared intelligence between partners? Do the workflows of the partners need to be linked ? How can best practices be harvested and propagated
  7. 7. Pathways to Partnerships | Bridging Connections For Value edifecs confidential Value Based Care Maturity model Consume Transactional Data Value-Based Reimbursement Agreements Align Financial Incentives with Clinical Outcomes Combine Clinical and Claim Data into Member-centric and Population Views. Monitor the Population, Create Clinical Intelligence, and Drive Effective Interventions Share Intelligence and Processes Across Multiple Payers and Providers Consume & Interpret Integrate & Share Intervene: Change Care Delivery Expand to Other Partners Support Payment Reform
  8. 8. Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Healthcare Value-Based Care Solution
  9. 9. Pathways to Partnerships | Bridging Connections For Value edifecs confidential Provider EMR Billing Practice Management Core Systems EDI Gateway Claim adjudication Membership administration Other applications Core Systems Payer EDI Gateway Partnership Enablement Future Enterprise Apps Business Applications for Providers Liquid Transaction Data Liquid Transaction Data Community Shared Intelligence and Workflow Transaction Workflow Transaction Workflow Edge-based innovation for supporting the industry initiatives. Natural advantage of timeliness and completeness of information. Filter out transactions that add downstream costs. Edge Transaction Hub Admin/ Clinical Transactions Admin/ Clinical Transactions Healthcare Information Pipe EdgeSmart Trading (All Initiatives) EDI Gateway Business Applications for Health Insurers
  10. 10. Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Healthcare Enabling Value Based Healthcare Integrated Member Record Workflow PrioritizationReporting Trigger Inventions Set Monitoring/Intervention Rules Monitor Populations Health Information Exchange Intervention Platform Authorized Care Team Clinical Analysts Population Analysis Program Targeting Member Attribution Savings Modeling Model Population and Plan Value-Based Agreement Business/ Executive Manager Partnership Platform Population Payment Administrator Business/ Executive Manager Payment Calculations Reporting Program Automation Program Optimization Tasks Target Populations Design Contracts Assemble Integrated Patient Records Coordinate Care Measure Outcomes Pay for ValueTarget Interventions
  11. 11. Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Healthcare Population Payment
  12. 12. Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Healthcare Financial Management Edifecs’ Approach Easily define, edit and re-use patient and provider sets Examine costs & stratify risks, drill down by any number of variables Asses impact of alternative reimbursement models Perform targeted budget calculations Leverage pre-defined templates and risk adjustment models Compare historical and projected budgets Design dashboards and reports for internal/provider use Enable reporting transparency to all stakeholders Automate program savings calculations Reduce actuarial and regulatory risk Employ advanced data analyses Gauge utilization and assess saving opportunities Provide multi-layer views of program measures TARGET Improve targeting DESIGN Scale ADMINISTER Minimize risk, improve experience OPTIMIZE Optimize Shared savings and other VBR initiatives
  13. 13. Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Healthcare
  14. 14. Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Healthcare How are PMPM Costs changing? What is your budget to date performance? What savings might you anticipate? How is your attribution changing? What is your leakage? How is your quality performance so far? What is your performance against KPIs? What is driving your costs?
  15. 15. Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Healthcare Population Health Monitoring
  16. 16. Pathways to Partnerships | Bridging Connections For Value edifecs confidential Intervention Gateway Learning Engine Studio Observation Agent Learning Engine Design-timeRuntime 1 2 3  Enables clinical analysts to define monitoring and intervention rules  Visual toolkit to model and test interventions  Collaborate and share concepts and rules across communities.  Inspect incoming data streams and extract real-time data to trigger interventions  Execute Intervention Rules against streaming data and historical data  Surface the intervention in payer and provider systems Intervention Rules List of Data Elements to Extract Message Streams Intervention Data Alerts, Inferences Intervention platform for early detection of changes to risk thresholds, quality thresholds, morbidity patterns, behavioral patterns and protocol compliance
  17. 17. Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Healthcare Story of George’s Father  January, 1991 – PCP  “Need to lose some weight – BMI 38, waist circumference 41 inches, and you need to stop smoking”  February, 1991 – Routine lab work  Triglyceride 160 mg/dL  HDL 30 mg/dL  Glucose 100 mg/dL  Total cholesterol 250 mg/dL  March, 1992 – To ER, “not feel well”  “Every is ok except a bit stressed and blood pressure borderline (145/95)”  November, 1993  Massive heart attack  EHR CCD  SNOMED 162864005  LOINC 9844-2 = 41  ICD-9 278.02  ICD-9 305.1  Lab Claims  LOINC 2571-8 = 160  LOINC 2085-9 = 30  LOINC 1558-6 = 100  LOINC 2093-3 = 250  ER ADT + EHR CCD  ADT-A04  ICD-9 308.9  LOINC 8480-6 = 145  LOINC 8462-4 = 95  Real life  Digital life  Edifecs logic Metabolic syndrome Framingham Risk 28% clipboard insurance Physician- supervised weight loss program Health and wellness program1 point of intervention 1 Baicker et al. Workplace wellness programs can generate savings. Health Affairs. 2010 Feb 2 HCUP/AHRQ 2009 data. Accessed http://hcup-us.ahrq.gov/reports/factsandfigures/2009/exhibit4_1.jsp 2014 Sep 3 Ford et al. Prevalence and correlates of metabolic syndrome based on a harmonious definition among adults in the US. J Diabetes 2010;2(2):180-93 “Start Statin”
  18. 18. 100 Fastest Growing Companies in WA Washington’s 100 Best Places to Work For Inc. 5000 Fastest- Growing Private Companies in the US Deloitte Technology Fast500 North America Puget Sound Business Journal WA Best Workplaces Seattle Business Magazine’s Tech Impact Award
  19. 19. Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Healthcare Appendix
  20. 20. Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Healthcare 1990s All-at-once shift to full provider capitation 1998 Physician Profiling (used for public reporting and contract rates) 2000 Leading California effort for third party to collect and calculate quality-based payment 2001 Provider owned insurance companies 2003 Bonus payment for submitting quality data 2004 Bonus payment based on quality 2009 Payment based on episode of care 2011 Shared Savings based on total cost of care 2015 New forms of partial capitation Progression of Payment Reform in US

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