Payment reform and emphasis on value-based care is forcing payers, ACOs, and Integrated Delivery Networks to look for ways through which physician performance can be evaluated and measured over time with the goal of creating highly efficient and effective physician networks. With more pressure and risk moving to physicians – they will expect fair measurement of quality against their peers. Join this webinar to understand the implications of value-based care as it relates to physician performance analysis and why the ability to effectively monitor physicians with less than acceptable cost performance and those with high-quality performance will be non-negotiable.

1. Moving to Value Based Care – Leveraging advanced analytics
to measure physician performance
Webinar
February 25, 2016
This presentation cannot be duplicated or reproduced in part or in whole without written consent
from LexisNexis. Copyright © 2016 LexisNexis. All rights reserved.

2. Today’s Speakers
Lizzy Feliciano
Sr. Director, Marketing
Kathy Mosbaugh
VP, Clinical Solutions
Gordon Giffen
Director Product Development
2

3. Agenda
• Market drivers and recent trends
• Implications of value based care for network design
• Leveraging analytics to meet new market demands
• Q&A
3

4. Polling Question: What type of organization do you represent?
• Health Plan
• Hospital System/Integrated Delivery Network
• Physician or Physician Practice
• Pharmaceutical Manufacturer
• Life Sciences Company (i.e.. Durable medical equipment, etc.)
• Pharmacy Benefit Manager
• Other
4

5. Performance Use Cases
5
Planning
Forecasting
Targeting
Identify Eligible Participants
Improve Compliance Reporting
Optimize Provider Networks
Treatment Patterns
Pay for Performance
Care Management
Care Coordination

6. 6
“Instead of payment that asks, How much did you do?, the Affordable Care Act
clearly moves us toward payment that asks, How well did you do?, and more
importantly, How well did the patient do?”
Dr. Donald Berwick, April 2011
“...it is the glory of science to become ever more and more precise in its
measurements, and it is the agony of the scientist to discover that when his
measurements are really precise, what he has measured is just to one side of
what he is after.”
F. Fremont-Smith, 1956

7. 7
Payment Reform
is driving the
creation of
physician networks
that provide
HIGH-QUALITY
care for a fair
price.
Payment Model
is moving from
“volume” of care to
“value” of care.
Physicians expect
fair measurement
of quality against
their peers and
payers expect to
pay physicians a
fair price.
Effective
monitoring
of physician
efficiency and
quality to identify
drivers for behavior
change.
Market Drivers are Increasing the Demand for Measuring Physician
Cost AND Quality Performance

8. Balancing Costs with Increased Access, New and Unknown Health
Risks, Provider Network Adequacy, and Quality Performance
8

9. The Aging of America
9
According to the Centers for Disease
Control and Prevention (CDC): 1
• Chronic illness affects one of every
two adults in the U.S.
• They are responsible for 75 percent
of health-care costs
• In 2008, those costs were 16.8
percent of GDP
• By 2022 they are projected to be
just shy of 20 percent
Source:
1 Milken Institute
2 U.S. Department of Housing and Urban Development
Needless to say, the demand for
health care services will be
increasing significantly.
2

10. 10
Worsening Physician Shortage

11. Ever Increasing Risk Adjustment
PROGRAM POPULATION STATES METHODOLOGY
Part C-Medicare Advantage ALL CMS- HCC's (Hierarchical Condition Categories)
Part D- Perscription Drug Plans ALL CMS-RxHCC's
17 CDPS (Chronic Disease Management System)
4 ACG's (Adjusted Clinical Groups)
3 Other (i.e. CRG's-Clinical Risk Groups
ACA
Non-grandfathered Individual
and Small Group market
on and off exchange
ALL CMS-Modified HCC's
Medicaid Managed CareMedicaid
Medicare
• The trend is all in the direction of MORE risk adjustment
• Different processes and methodologies by program
• Significant administrative burden
11

12. 12
 Align quality measures among all payers
 Identify more actionable, meaningful
measures
 Achieve greater consistency and rigor with
consumer information
 Leverage new technology and big data to
identify and assess quality metrics
 Make sure measures reflect actual clinical
quality, not factors like socioeconomic status
that are out of health systems' control
 Attribute results to specific providers
 Improve consumer engagement
Risk Adjustment for Socioeconomic
Status or Other Sociodemographic
Indicators
TECHNICALREPORT
National Quality Forum is Discussing Risk Adjustment for
Socioeconomic Indicators

13. Revenue
Enhancement
Focus on risk adjustment that is
used to determine payment
Cost & Quality
Improvement
Focus on the right members and the
right providers for outreach and impact
Revenue vs. Cost Strategies – Lots of Confusion
RISK: Missed revenue opportunity,
Increases in premiums
RISK: Poor Health Outcomes and Missed
Cost Savings
13

14. Narrow Networks Create Both Advantages and Challenges
According to the Robert Wood Johnson study, "insurers generally did not
report any efforts to design a network built on providers' performance,
quality metrics or patient outcomes." Instead, the primary reason for
including or excluding a provider was largely based on price.
14
Advantages
• Contains costs for plan
• Affords lower premiums
• Maintains benefits and
lower out of pocket costs
for members
Challenges
• Restricts consumer choice
• Reduces network adequacy
• Increases provider
administrative burden

15. Polling Question: Where are analytics used most often within your
organization?
• Revenue Enhancement
• Cost Containment
• Quality Improvement
• Marketing
15

16. Risk Stratification &
Care Coordination
Opportunity
Identification
Risk, Financial, &
Trend Analysis
Provider
Performance
Measurement
Information
Sharing &
Physician
Engagement
Analysis around
Evidence-based
Medicine
Compliance
EMR DATA
MEDICAL &
PHARMACY
CLAIMS
PATIENT HRAs
Multiple Sources and Uses of Data for Cost and Quality Improvement
LAB DATA
Patient Centric
Analytics
SOCIOECONOMIC DATA
16

17. Polling Question: What data sources do you access and apply
effectively today?
• Claims Data (medical and/or pharmacy)
• Clinical/EHR Data
• Socioeconomic Data
• Health Risk Assessment Data
• Lab Data
17

18. Use analytics as a differentiated
advantage for delivering better care
Create High-Value Networks Leveraging Analytics
18
Narrow
Networks
Optimized
Networks
Utilize the most efficient physicians to manage health
outcomes
Build a relationship of trust with physicians
Concurrently manage provider and patient quality
compliance
Value-
Based
Care
Fee for
Service
Broad
Networks

19. Polling Question: When will you concurrently measure provider
efficiency and quality to design optimized networks?
• Doing so today
• Within 6 months
• Within 1 year
• Within 2 years
• No plans. Not a priority.
19

20. Are You Building a Relationship of Trust with Physicians?
• Ensure severity adjustment
• Evaluate case complexity
• Measure illness burden
Fair Measurement
20

21. Are You Building a Relationship of Trust with Physicians?
• External Industry benchmarks
• Internal Client specific benchmarks
• Peer Groups By Specialty, Disease Condition,
and/or Geographic Location
Fair Comparison
• Ensure severity adjustment
• Evaluate case complexity
• Measure illness burden
Fair Measurement
20

22. Are You Building a Relationship of Trust with Physicians?
• External Industry benchmarks
• Internal Client specific benchmarks
• Peer Groups By Specialty, Disease Condition,
and/or Geographic Location
Fair Comparison
• Ensure severity adjustment
• Evaluate case complexity
• Measure illness burden
Fair Measurement
• Closer alignment to optimal performance
• Evaluate and monitor cost drivers and practice
patterns
• Avoid immediate excess resource consumption
and future healthcare costs
Effective Monitoring
20

23. Are you Concurrently Managing Provider and Patient Quality
Compliance?
• Optimal compliance versus outliers
• Patient gaps in care
Identify Drivers
• Coaching and mentoring providers
• Spreading best practices
• Provider incentive and disincentives
Implement
Improvement
Strategies
• By Measure Category and Measure
• Compliance rates by provider
• Compliance rates by patient
Understand
Compliance
23

24. Are You Utilizing the Most Efficient Provider to Manage Patient Health
Risk?
Referring provider is:
• Motivated to reduce costs and improve efficiency
• Willing to refer to efficient specialists in network
• Willing to match right specialist to the right patient
Influence Toward
Best Practices
• Identify providers who are not following best
practices
• Identify providers to mentor or manage out of
networks
Implement
Improvement
Strategies
• Providers and specialists most aligned to benchmarks
• Referrals to providers within the same network
• Out of network referrals by exception only
Follow Best
Practices
24

25. Summary: To remain competitive, at-risk organizations must leverage
advanced analytics. Both fair measurement and flexible comparisons
are necessary to design optimized networks both for efficiency and
quality.
25
Optimize provider
networks to deliver
high quality care for
a fair price
Compare provider
performance
against customized
peer groups and
benchmarks
Fairly measure
PCP and Specialty
performance
using severity
adjusted scores

26. LexisNexis® Clinical
Analytics Suite
A portfolio of risk stratification
tools, predictive analytics, unique severity-
adjustment methodology, member
engagement resources and clinical expertise.
Provider
Performance
Monitor
Facilitate transition to
value-based care with
robust physician
performance analysis.
Population Health
Monitor
Improve care management
efforts, risk stratification
initiatives and the health of
member populations.
Socioeconomic
Health Score
Improve health risk
predictions for new enrollees
and augment existing
analytics with a unique score
based on socioeconomic data
derived from public records.
Socioeconomic
Health Attributes
Improve accuracy of
predictive models and
analytics with tested
socioeconomic attributes.
MemberPoint™
Improve member engagement
by populating member profiles
with the most current and
comprehensive contact and
demographic data.
Public record identity data-based products
Socioeconomic data-based products
Claims-based products
26
LexisNexis® Health Care
Summary:
Advanced analytics using
medical claims and
pharmacy/PBM data can
standardize how maturing
organizations can measure and
monitor provider performance –
both for efficiency and quality.
Future Topics:
• Member engagement
strategies
• Provider Network Adequacy

27. Q&A
Linkedin.com/company/lexisnexis-risk-solutions
Youtube.com/user/lexisnexisnetwork
Twitter.com/lexisnexisrisk
Facebook.com/lexisnexisrisk
27
This presentation cannot be duplicated or reproduced in part or in whole without written consent
from LexisNexis. Copyright © 2016 LexisNexis. All rights reserved.
Contact information: Kim Eifrid
Kimberly.Eifrid@lexisnexis.com
813.838.0033