March 02, 2018
Value-based health care is one of the most pressing topics in health care finance and policy today. Value-based payment structures are widely touted as critical to controlling runaway health care costs, but are often difficult for health care entities to incorporate into their existing infrastructures. Because value-based health care initiatives have bipartisan support, it is likely that these programs will continue to play a major role in both the public and private health insurance systems. As such, there is a pressing need to evaluate the implementation of these initiatives thus far and to discuss the direction that American health care financing will take in the coming years.
To explore this important issue, the Petrie-Flom Center for Health Law Policy, Biotechnology, and Bioethics at Harvard Law School collaborated with Ropes & Gray LLP to host a one-day conference on value-based health care. This event brought together scholars, health law practitioners, and health care entities to evaluate the impact of value-based health care on the American health care system.
For more information, visit our website at: http://petrieflom.law.harvard.edu/events/details/will-value-based-care-save-the-health-care-system
Population health management real time state-of-health analysispscisolutions
To lower health costs, physician networks and medical homes must employ a closed loop population management program that focus on patient SOH stratification, chronic disease management, care coordination and incentive management. This approach will enable them to consistently reduce ER and inpatient admissions, which are the greatest expenditures in health care today.
April 28, 2017
Transparency is a relatively new concept to the world of health and health care, considering that just a few short decades ago we were still in the throes of a “doctor-knows-best” model. Today, however, transparency is found on almost every short list of solutions to a variety of health policy problems, ranging from conflicts of interest to rising drug costs to promoting efficient use of health care resources, and more. Doctors are now expected to be transparent about patient diagnoses and treatment options, hospitals are expected to be transparent about error rates, insurers about policy limitations, companies about prices, researchers about data, and policymakers about priorities and rationales for health policy intervention. But a number of important legal and ethical questions remain. For example, what exactly does transparency mean in the context of health, who has a responsibility to be transparent and to whom, what legal mechanisms are there to promote transparency, and what legal protections are needed for things like privacy, intellectual property, and the like? More specifically, when can transparency improve health and health care, and when is it likely to be nothing more than platitude?
This conference aimed to: (1) identify the various thematic roles transparency has been called on to play in American health policy, and why it has emerged in these spaces; (2) understand when, where, how, and why transparency may be a useful policy tool in relation to health and health care, what it can realistically be expected to achieve, and when it is unlikely to be successful, including limits on how patients and consumers utilize information even when we have transparency; (3) assess the legal and ethical issues raised by transparency in health and health care, including obstacles and opportunities; (4) learn from comparative examples of transparency, both in other sectors and outside the United States. In sum, we hope to reach better understandings of this health policy buzzword so that transparency can be utilized as a solution to pressing health policy issues where appropriate, while recognizing its true limitations.
Learn more on our website: http://petrieflom.law.harvard.edu/events/details/2017-annual-conference
March 02, 2018
Value-based health care is one of the most pressing topics in health care finance and policy today. Value-based payment structures are widely touted as critical to controlling runaway health care costs, but are often difficult for health care entities to incorporate into their existing infrastructures. Because value-based health care initiatives have bipartisan support, it is likely that these programs will continue to play a major role in both the public and private health insurance systems. As such, there is a pressing need to evaluate the implementation of these initiatives thus far and to discuss the direction that American health care financing will take in the coming years.
To explore this important issue, the Petrie-Flom Center for Health Law Policy, Biotechnology, and Bioethics at Harvard Law School collaborated with Ropes & Gray LLP to host a one-day conference on value-based health care. This event brought together scholars, health law practitioners, and health care entities to evaluate the impact of value-based health care on the American health care system.
For more information, visit our website at: http://petrieflom.law.harvard.edu/events/details/will-value-based-care-save-the-health-care-system
Population health management real time state-of-health analysispscisolutions
To lower health costs, physician networks and medical homes must employ a closed loop population management program that focus on patient SOH stratification, chronic disease management, care coordination and incentive management. This approach will enable them to consistently reduce ER and inpatient admissions, which are the greatest expenditures in health care today.
April 28, 2017
Transparency is a relatively new concept to the world of health and health care, considering that just a few short decades ago we were still in the throes of a “doctor-knows-best” model. Today, however, transparency is found on almost every short list of solutions to a variety of health policy problems, ranging from conflicts of interest to rising drug costs to promoting efficient use of health care resources, and more. Doctors are now expected to be transparent about patient diagnoses and treatment options, hospitals are expected to be transparent about error rates, insurers about policy limitations, companies about prices, researchers about data, and policymakers about priorities and rationales for health policy intervention. But a number of important legal and ethical questions remain. For example, what exactly does transparency mean in the context of health, who has a responsibility to be transparent and to whom, what legal mechanisms are there to promote transparency, and what legal protections are needed for things like privacy, intellectual property, and the like? More specifically, when can transparency improve health and health care, and when is it likely to be nothing more than platitude?
This conference aimed to: (1) identify the various thematic roles transparency has been called on to play in American health policy, and why it has emerged in these spaces; (2) understand when, where, how, and why transparency may be a useful policy tool in relation to health and health care, what it can realistically be expected to achieve, and when it is unlikely to be successful, including limits on how patients and consumers utilize information even when we have transparency; (3) assess the legal and ethical issues raised by transparency in health and health care, including obstacles and opportunities; (4) learn from comparative examples of transparency, both in other sectors and outside the United States. In sum, we hope to reach better understandings of this health policy buzzword so that transparency can be utilized as a solution to pressing health policy issues where appropriate, while recognizing its true limitations.
Learn more on our website: http://petrieflom.law.harvard.edu/events/details/2017-annual-conference
March 02, 2018
Value-based health care is one of the most pressing topics in health care finance and policy today. Value-based payment structures are widely touted as critical to controlling runaway health care costs, but are often difficult for health care entities to incorporate into their existing infrastructures. Because value-based health care initiatives have bipartisan support, it is likely that these programs will continue to play a major role in both the public and private health insurance systems. As such, there is a pressing need to evaluate the implementation of these initiatives thus far and to discuss the direction that American health care financing will take in the coming years.
To explore this important issue, the Petrie-Flom Center for Health Law Policy, Biotechnology, and Bioethics at Harvard Law School collaborated with Ropes & Gray LLP to host a one-day conference on value-based health care. This event brought together scholars, health law practitioners, and health care entities to evaluate the impact of value-based health care on the American health care system.
For more information, visit our website at: http://petrieflom.law.harvard.edu/events/details/will-value-based-care-save-the-health-care-system
Value Based Care is a framework that helps healthcare ecosystem collaborate to provide value to patient for entire care-cycle. It also enables providers to iterate by measuring outcome and cost to maximise value over time.
Better Life Insurance Risk Assessment by Leveraging Medical InnovationsCognizant
Insurance companies must adopt medical technology innovations such as evidence-based underwriting, wearable fitness devices, bio-monitors and gene tests to elevate insurance underwriting efficiency and accuracy
the paradigm is changing; the dominant focus for the next decade at least will be value, or to be precise triple value
The Aim is triple value & greater equity
• Allocative value, determined by how the assets are distributed to different sub groups in the population
• Technical value, determined by how well resources are used for all the people in need in the population
• Personalised value, determined by how well the decisions relate to the values of each individual
If you want to see more please look at http://bettervaluehealthcare.weebly.com
At the Heart of the Matter: Medical NecessityPYA, P.C.
PYA Principal Denise Hall and Michael Spake, Vice President of External Affairs and Chief Compliance & Integrity Officer at Lakeland Regional Health System, co-presented “At the Heart of the Matter: Medical Necessity,” at the AHLA Institute on Medicare and Medicaid Payment Issues. They discussed:
Recent cases and legal actions
Impact of medical necessity when interpreting the regulations and guidelines for:
-Stents
-Pacemakers
-Automatic Implantable Cardiac Defibrillators (AICD)
-Electrophysiology Studies (EPS) and Ablations
Common areas of risk in applying local coverage determination (LCD)/national coverage determination (NCD) guidance to cardiac procedures: how to identify your risks and avoid vulnerability
Best practices for ensuring compliance with regulations
Rethinking Value Based Healthcare
Around the world healthcare providers are busy exploring how value-based healthcare can both improve the efficiency and effectiveness of healthcare delivery and seed new opportunities for innovation. Continuing our collaboration with Denmark, we are very pleased to release a new perspective on how VBHC can have greater impact in practice. Based on insights from a recent event hosted by DTU Executive Business Education and undertaken in partnership with Rethink Value, this point of view looks at the key issues for patients, physicals, providers and payers.
It explores some of the associated implications for healthcare systems worldwide, highlights several leading early examples of VBHC in practice and looks at how it can have impact at scale. Recommendations focus on the structure of care, key metrics, moving beyond pilots, changes in reimbursement models and the need for greater insight sharing and deeper collaboration.
For related Future Agenda research see www.futureofpatientdata.org
Panel D: Reimagining Innovative Access to Innovative Therapies, including Rare Disease Drugs
Moderator: Bill Dempster, 3Sixty Public Affairs
Panelists: Brent Fraser, CADTH; Aidan Hollis, University of Calgary; Fred Horne, Horne & Associates; Dylan Lamb-Palmer, PDCI Market Access; Andrea Souchen; Sobi, John Moore, AdamEzra Corporation
March 02, 2018
Value-based health care is one of the most pressing topics in health care finance and policy today. Value-based payment structures are widely touted as critical to controlling runaway health care costs, but are often difficult for health care entities to incorporate into their existing infrastructures. Because value-based health care initiatives have bipartisan support, it is likely that these programs will continue to play a major role in both the public and private health insurance systems. As such, there is a pressing need to evaluate the implementation of these initiatives thus far and to discuss the direction that American health care financing will take in the coming years.
To explore this important issue, the Petrie-Flom Center for Health Law Policy, Biotechnology, and Bioethics at Harvard Law School collaborated with Ropes & Gray LLP to host a one-day conference on value-based health care. This event brought together scholars, health law practitioners, and health care entities to evaluate the impact of value-based health care on the American health care system.
For more information, visit our website at: http://petrieflom.law.harvard.edu/events/details/will-value-based-care-save-the-health-care-system
Value Based Care is a framework that helps healthcare ecosystem collaborate to provide value to patient for entire care-cycle. It also enables providers to iterate by measuring outcome and cost to maximise value over time.
Better Life Insurance Risk Assessment by Leveraging Medical InnovationsCognizant
Insurance companies must adopt medical technology innovations such as evidence-based underwriting, wearable fitness devices, bio-monitors and gene tests to elevate insurance underwriting efficiency and accuracy
the paradigm is changing; the dominant focus for the next decade at least will be value, or to be precise triple value
The Aim is triple value & greater equity
• Allocative value, determined by how the assets are distributed to different sub groups in the population
• Technical value, determined by how well resources are used for all the people in need in the population
• Personalised value, determined by how well the decisions relate to the values of each individual
If you want to see more please look at http://bettervaluehealthcare.weebly.com
At the Heart of the Matter: Medical NecessityPYA, P.C.
PYA Principal Denise Hall and Michael Spake, Vice President of External Affairs and Chief Compliance & Integrity Officer at Lakeland Regional Health System, co-presented “At the Heart of the Matter: Medical Necessity,” at the AHLA Institute on Medicare and Medicaid Payment Issues. They discussed:
Recent cases and legal actions
Impact of medical necessity when interpreting the regulations and guidelines for:
-Stents
-Pacemakers
-Automatic Implantable Cardiac Defibrillators (AICD)
-Electrophysiology Studies (EPS) and Ablations
Common areas of risk in applying local coverage determination (LCD)/national coverage determination (NCD) guidance to cardiac procedures: how to identify your risks and avoid vulnerability
Best practices for ensuring compliance with regulations
Rethinking Value Based Healthcare
Around the world healthcare providers are busy exploring how value-based healthcare can both improve the efficiency and effectiveness of healthcare delivery and seed new opportunities for innovation. Continuing our collaboration with Denmark, we are very pleased to release a new perspective on how VBHC can have greater impact in practice. Based on insights from a recent event hosted by DTU Executive Business Education and undertaken in partnership with Rethink Value, this point of view looks at the key issues for patients, physicals, providers and payers.
It explores some of the associated implications for healthcare systems worldwide, highlights several leading early examples of VBHC in practice and looks at how it can have impact at scale. Recommendations focus on the structure of care, key metrics, moving beyond pilots, changes in reimbursement models and the need for greater insight sharing and deeper collaboration.
For related Future Agenda research see www.futureofpatientdata.org
Panel D: Reimagining Innovative Access to Innovative Therapies, including Rare Disease Drugs
Moderator: Bill Dempster, 3Sixty Public Affairs
Panelists: Brent Fraser, CADTH; Aidan Hollis, University of Calgary; Fred Horne, Horne & Associates; Dylan Lamb-Palmer, PDCI Market Access; Andrea Souchen; Sobi, John Moore, AdamEzra Corporation
Treat EDPS as a Risk Adjustment program…not an IT function. This Episource presentation walks you through the 3 phases of EDPS, and key aspects to keep in mind to run a successful risk adjustment program.
Edifecs- How to ensure RAPS and EDPS submissions equal revenue successEdifecs Inc
The RAPS to EDPS transition for Medicare Advantage plans (MAOs) has now taken on a role of greater importance. CMS has called for an acceleration of the transition with payment determinations in 2017 split 75/25 between RAPS and EDPS.
In this webinar viewers will learn the following:
The RAPS to EDPS transition challenges facing MAOs (some not so obvious)
The cost of the status quo. What you lose by attempting to address encounter submission with a “legacy” approach
How one plan is solving the submission/reconciliation puzzle and experiencing revenue success
What a revenue success checklist for MAOs would contain and how to get started
Surviving the Healthcare World of Risk AdjustmentPYA, P.C.
PYA Principal Bob Paskowski and Senior Staff Consultant Carine Leslie presented a webinar for the Georgia chapter of the Healthcare Financial Management Association Friday, December 16, 2016.
The presentation is tailored for coders in ambulatory/Medicare Advantage settings, providers participating in Medicare Advantage or other risk-based healthcare plans, and leaders in providers’ managed care contracting departments. The webinar is titled “Surviving the Healthcare World of Risk Adjustment.”
The webinar addresses:
• Principles of the Medicare Advantage risk-adjustment model from Medicare Advantage Hierarchical Condition Categories and other risk-based healthcare plans;
• Strategies for reducing compliance risks;
• Methods for accurately, completely, and consistently capturing and documenting a patient’s disease burden to promote effective care management and to reflect the proper risk score.
Why Clinical Quality Should Be Your Core Business StrategyHealth Catalyst
Over 100 years ago, healing professionals and healthcare itself went through a massive transformation that led us to the models of care delivery that we use today. Dr. Brent James argues that we are now, again, at a once-in-a-century inflection point to change the course of healthcare. Change takes real effort, but provides massive opportunity.
Those changes include a move away from the highly-profitable fee-for-service payment to fee-for-value. An IOM report, published in 2010, substantiated that more than a third of healthcare spending is waste. Pay-for-value aligns financial returns for those who invest in waste elimination. It also requires that clinicians move away from the craft of medicine to the science of medicine, using data and evidence to drive better clinical care.
As the vice president and chief quality officer at Intermountain Healthcare, Dr. James led much of the change that produced Intermountain’s recognized operational and clinical excellence. In this webinar Dr. James educates and inspires all of us to do great work by sharing practical stories of how data has become the critical tool to help healthcare shift from revenue enhancement to clinical quality, which produces the most affordable care.
Learn how to:
- Use data to find variations in both cost and quality of care.
- Standardize care without demotivating underperforming outliers.
- Build a culture of data-driven care providers.
- Develop an improvement strategy that you can start today.
Sought the world over, Dr. James is a recognized expert in this outcomes improvements area. He has championed the standardization of clinical care through data collection and analysis on a wide variety of treatment protocols and complex care processes for more than 20 years.
The Future of Personalized Health Care: Predictive Analytics by @Rock_HealthRock Health
View the archived webinar here: https://www.youtube.com/watch?v=UJak41hIDWc
How can we use new and existing sources of data to deliver better, personalized care? Predictive analytics underlies what has always been conducted by doctors through their training, experience, and decision-making. Dozens of new digital products have hit the market and $1.9B has flowed into the space since 2011—but what does it take for an algorithm to accurately and reliably impact care?
Purchase the report here: https://gumroad.com/l/gzbzV
A Vision for U.S. Healthcare's Radical MakeoverCognizant
The healthcare industry is on the verge of a disruptive change that will significantly reshape our experiences and reorient our expectations across the provider and payer value chain.
Predictive Risk Stratification: Using Analytics to Empower Change with Action...Health Catalyst
Effective population health initiatives are challenging to implement for a variety of reasons. Care teams are already overburdened, and healthcare data is challenging to aggregate and analyze. These factors make it difficult to accurately identify patients who are high-risk or have rising risk for poor outcomes and provide appropriate intervention. To manage patient populations effectively and efficiently, healthcare organizations must be able to automate predictive risk stratification based on claims data, clinical data, and social determinants of health. When care teams know which patients need the most help, which patients have rising risk, and which patients are healthy, they can focus their valuable time where it’s needed most. In this webinar, Dr. Welch shares best practice strategies for utilizing analytics that empower change with actionable workflows, like patient engagement, to ensure that clinically integrated entities can manage high-risk populations appropriately, while also caring for those with rising risk, and engaging with healthy populations mapped to the right targeted interventions.
Presentation on transparency of doctor performance at Health Datapalooza 2015 by Josh Rosenthal, PhD
Applications of Transparency: From Visibility to Action
As transparency in health care has emerged as a crucial enabler towards achieving the Triple Aim, myriad sources and types of information have become available in the last few years. Join this session to learn new ways of understanding the behaviors of patients and providers, and novel approaches to payment and delivery already underway.
Moderator: Ben Harder, U.S. News & World Report
Panelists: Elizabeth Mitchell, NRHI; Jeanne Pinder, ClearHealthCosts; Josh Rosenthal, PhD, RowdMap, Inc.
What eHealth strategies work and do not work, and what should be implemented to effectively meet these healthcare “transformational” imperatives?. Crawford J. eHealth week 2010 (Barcelona: CCIB Convention Centre; 2010)
Analytics-Driven Healthcare: Improving Care, Compliance and CostCognizant
In the face of skyrocketing costs, the healthcare industry is addressing inefficiencies by improving data sharing and collaboration across the industry value chain and applying analytics to improve operations and patient outcomes.
How Pharma Can Use Digital Health to Drive Value | A Medullan WebinarMedullan
With the shift to value, healthcare payers are insisting that pharmaceutical manufacturers deliver real world evidence of their drug’s efficacy before being allowed on formulary. The cost of new specialty treatments has forced companies to bolster and go beyond clinical trial, proving that their drugs improve health outcomes and reduce the cost of care with real world evidence.
So how do pharmaceutical companies gather these data points and what kind of digital tools should they use?
James G. Kahn, MD, MPH
Pharmacy Leadership Institute
Kaiser Permanente Development Program
Debate on Health Care Reform
Youtube: http://youtu.be/2ed0qRXMRBE
Similar to World Health Congress 2009 Europe Market Insight (20)
1. Predictive Modeling and Risk Adjustment
Applications in the U.S. and I t
A li ti i th U S d International M k t
ti l Markets
Dr. Rong Yi, Vice President, Consulting
Dr. Thomas Zahn, General Manager, DxCG Gesundheitsanalytik GmbH
World Health Congress, European Conference
Brussels, May, 2009
3. Setting up the Stage -
Healthcare Dichotomy
Healthcare
Financing Delivery
Feasibility
Cost, Quality,
andd
and Efficacy
sustainability
4. Healthcare Financing Challenges
For all decision-makers from governments down
to individual consumers:
How much?
How many years?
Whom to cover?
What services to offer?
…
Need to understand and predict acc ratel
nderstand accurately:
• Risk selection
• Aging and disease burden
g g
• Benefit design and outcomes
5. Healthcare Delivery Challenges
Resource planning
Health d
H lth and wellness management
ll t
• Population
• g
Disease and case management
• Wellness and productivity
• Patient education and outreach
• …
Need to:
• Stratify the population and prioritize management efforts
• Measure outcomes (cost, quality and efficacy)
• …
7. How are Models Built?
Claims Data +
Clinical Classification +
Econometric/Statistical Modeling
8. Data used as input
Enrollment information:
• age, sex, eligible months, basis of eligibility (e.g., disabled)
Claims information
• Diagnosis
• Procedures
P d
• Pharmacy
• Long term care
• Spending – timing, categories, patterns
p g g, g ,p
• Utilization – hospital, ED, specialty
Not everything is used for prediction!
• D
Depends on client needs, available d t model’s i t d d
d li t d il bl data, d l’ intended
use, and the tradeoff between easy of use and added
predictive accuracy
9. Risk Prediction using Medical
Diagnosis only
John Smith
Age: 45
Sex: M
Hypertension
essential hypertension
Type II Diabetes Mellitus
type II diabetes w/ renal manifestation
Congestive Heart Failure
g
hypertension heart disease, w/ heart failure
6.35x sicker than Drug/Alcohol Dependence
average alcohol dependence
Relative Risk Score: 6.35
10. Clinical Classification Systems
Example – DCG/HCC Diag Grouping
Why Grouping?
Distill massive amount of data to create useful analytic units
y
Most Common Classification Systems:
DCG/HCC - Grouping of Diagnosis Codes
RxGroups - Grouping of Drug Codes
BETOS - Grouping of Procedure Codes
Example: The DCG/HCC Classification System
ICD-9 or ICD-10 Diagnosis Codes
DxGroups (DxGs)
(784 groups)
Hierarchical C diti
Hi hi l Condition
Categories (HCCs)
(184 groups)
11. What Can be Predicted?
… almost anything as long as data supports
y g g pp
Individual level prediction. Can be g p up by
p grouped p y
age/gender, medical conditions, geography, benefit
design, etc.
Predicts within a year, across years and for multiple
y , y p
years,
Examples of predicted outcomes:
• Total healthcare cost or a subset, e.g., drug cost
g g
• Distribution of risk, e.g., probability of cost more than
$100,000
• Healthcare utilization, e.g., future hospitalization, avoidable
ER visits, total length of stay use of advanced imaging tests
visits stay,
• Disease progression and spending persistence
• Duration of injury
15. Healthcare Reform Example
Massachusetts Universal Healthcare
2006 Massachusetts landmark legislation
g
Procurement of healthcare for the previously
uninsured
• Capitation based on age/sex/geography/benefit design
p g g g p y g
• Structured bids to incentivize lower bidders
Challenge: risk selection. Healthier members cluster in
lower-priced p
p plans
Need to establish a fairer and more sustainable procurement
process
Solution:
• Fairer – account for disease burden
• Sustainable – prospective risk adjustment to ensure financial
stability
16. Risk-based Capitation Illustration
Systemwide
Monthly Payment/Capita
$420
Health Plan A Health Plan B Health Plan C
Relative Risk Score 1.16 Relative Risk Score 0.61 Relative Risk Score 1.52
Budget: $420 x 1.16 Budget $420 x 0.61 Budget: $420 x 1.52
= $488 = $256 = $640
Implementation:
• Budget Neutral
• Further Adjustments on benefit design, geographic factor,
new/partial enrollees
/ ti l ll
• Quarterly adjustments to smooth cash flow
