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Data & Strategy from an Managed Care Organization’s Perspective 1
Data & Strategyfrom an Managed Care Organization’s Perspective
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Disclaimer
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This training is an educational initiative designed to
improve providers’ knowledge of New York State’s Value-
Based Payment Roadmap initiatives. Any contracting
and/or reimbursement decisions are to be made by the
provider and their respective MCOs.
Agenda
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Fidelis Overview
NYS VBP Roadmap
Fidelis Contracting Approach
Fidelis Data Strategy
Blinded Case Study
Data Sharing Challenges
About Fidelis
Founded as New York State Catholic Health Plan in 1993
Became Centene’s New York plan in July 2018
Over 1.7 million members enrolled in 11 products
Operational in all 62 counties of New York
Regional offices located in New York City, Albany, Syracuse, Rochester, and Buffalo
Satellite offices in Suffern and Poughkeepsie & more than 20 community offices
throughout the State
4,569 employees statewide
2018 projected revenue of approximately $10.6 billion
Network of 77,300 Providers including:
15,000 PCP’s
59,000 Specialists
206 Hospitals
23 VBP signed arrangements
30+ additional providers engaged
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About Fidelis
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Sources: Internal Reporting, Enrollment to Budget Report
Product Distribution
New York State VBP Roadmap
New York State VBP Roadmap
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• Key document authored by the
State Department of Health
establishing principles,
guidelines, and standards for
VBP within NYS
• Updated periodically throughout
the DSRIP waiver period
• Defines types and levels of VBP
arrangements
• Specific to Medicaid
* Released 7/17/2018
NYS VBP Roadmap Guidance: Types of VBP Arrangements
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Ep
iso
dic
Arra
ng
em
en
ts
To
tal
Co
st
of
Care
Arr
an
gem
en
ts
Total Cost for
General Population
Total Cost for
Subpopulation(HARP, MLTC, HIV, IDD)
Integrated Primary
Care +
Chronic Bundles
Maternity Bundles
• Focus of Fidelis models
• All Medical, Dental, Vision, Pharmacy costs
included in measurement
• Follows Prometheus Grouper methodology
• Categorizes all related costs of an event
across a measurement year (IPC & Chronic)
or across a pregnancy (Maternity)
NYS VBP Roadmap Guidance: Levels of VBP
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Level 1: Shared Savings (and FFS)
• Underlying Fee contract remains in place; VBP model sits on top of current contract
• Shared savings model (Upside only): If performance beats target, savings are generated and shared
• Provider quality score impacts percentage of savings shared with Provider
Level 2: Shared Savings + Risk (and FFS)
• Underlying Fee Contract remains in place; VBP model sits on top of current contract
• Shared savings + Shared Risk (Upside / Downside): If performance beats target, savings are generated
and shared; if performance is worse than target, losses are generated and shared
• Due to the inclusion of downside risk, a larger percentage of upside savings are shared
Level 3: Global Capitation
• Upfront payment / percent of premium, with quality-based component
• Some providers may apply to be designated with Innovator Status• MCOs are expected to contract with Providers with Innovator Status for a Level 3 VBP arrangement
• Provider is eligible for up to 95% premium payment
• MCOs must delegate services to Provider – fully or partially, depending on the service
• Greater number of delegated functions = Greater percentage premium shared
NYS VBP Milestones
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SFY 2017-18
• 10% in VBP Level 1 or higher
• 1% penalty applied to the delta between the State milestone and MCO expenditure tied to VBP arrangements
SFY 2018-19
• 50% in VBP Level 1 or higher
• At least 15% in Level 2 or higher
• 2% penalty applied to the delta between the State milestone and MCO expenditure tied to VBP arrangements
• If MCO performance is under target for both milestones, the greater of the two penalties will be incurred
SFY 2019-20
• 80% in VBP Level 1 or higher
• At least 35% in Level 2 or higher
• 2% penalty applied to the delta between the State milestone and MCO expenditure tied to VBP arrangements
• If MCO performance is under target for both milestones, both penalties will be incurred
Fidelis VBP Approach
Fidelis Models
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Level 1 TCGP
• Large-sized Provider Group Model: >10,000 attributed lives
• No downside risk
• Shared Savings
• Concurrent Risk Adjustment
• No cap
• Mid-sized Provider Group Model: 5,000 – 9,999 attributed lives
• No downside risk
• Shared Savings
• Concurrent Risk Adjustment
• “Symmetrical” cap
Level 2 TCGP
•Downside Risk
•Shared Savings/(Losses): Potential for greater percentage of savings
•Concurrent Risk Adjustment
•State Requirement: Minimum 3% symmetrical cap in first year, 5% in subsequent years
•State Requirement: If applicable, minimum 20% of losses must be passed to provider
MLTC Level 1
•LHCSA, CHHA, SNF contractors only
•Single State-calculated Quality Measure: Potentially Avoidable Hospitalizations
•Not Risk Adjusted
•Characteristics of a Level 0 VBP model, but considered Level 1 for MLTC
Facility Based Model
•Not dependent on attribution
•Developed to assist distressed hospitals retain State bonus funding
•Focuses on improvement of Potentially Preventable Event rates
•Considered “approved off menu”
Large-sized Provider
Group Model
Mid-sized Provider
Group Model
Attribution Size ≥10,000 lives 5,000 - 9,999 lives
Reconciliation Shared Savings Only Shared Savings Only
Risk Adjustment Concurrent Concurrent
State RequirementHigh quality = 40% of
savings, if generated
High quality = 40% of
savings, if generated
Fidelis Requirement No Cap “Symmetrical Cap”
Progression of a VBP Relationship
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• Understand provider quality
initiatives and collaborate to
improve
• Discuss ad hoc data
requests that offer insights
into Provider initiatives
• Review MCO’s quality
initiatives and collaborate to
improve
• Social Determinants of
Health opportunities with
local Community Based
Organizations
• Connect MCO resources
with Provider VBP Leaders
• Provider Network Attestation
• 3M Provisioning
• Dashboard Training
• Reoccurring Meetings
Scheduled
• sFTP Setup
• Review VBP Readiness
• Discuss Provider Network
Structure
• Model Presentation
• Discussion of Risk
Adjustment and Risk
Mitigation Strategies
• Quality Measure Overview
• Data Presentation
• Signature
Negotiation Phase Onboarding Ongoing Relationship
Fidelis Data Strategy
VBP Data Strategy & Approach
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Ad Hoc Reporting
Raw Claims Data Extract
3M Data Platform
• Advanced Analytics
Platform
• Allows Providers to track
their performance for both
quality and cost
• Rolling-12 month views
• YTD views
• VBP Data Analytics team
dedicated to ongoing
review and analysis of
VBP partners
performance
• Avenue for Providers to
send in data requests
focused on specific areas
not highlighted in 3M
dashboards
• Providers can choose to receive claims data feed from Fidelis on a regular basis
• Allows Providers to use the data in their own data warehouses and population health platforms / EMRs
• Full utilization views, including “leakage” utilization
• Some detailed cost data
3M Data Platform
Fidelis sends over 20 files to 3M on a monthly basis containing data on our entire Medicaid Population
• All Medical, Pharmacy, Dental and Vision Claims
• All member/eligibility information
• All provider/network data
• All relevant non-claims cost data
• All member-level revenue data
• Select HEDIS measure numerator and denominator data
3M processes our data and applies groupers and calculations to provide the following:
• Member-Level CRG risk scores calculated with Fidelis weights
• All inpatient claims are flagged by APDRG/Category
• All outpatient claims are flagged by EAPG/Category
• Claims are flagged as Potentially Preventable Events using 3M’s proprietary methodology
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3M Clinical Risk Groups (CRGs)
• Population classification system that stratifies patient acuity
based on the amount and type of health care services that
individuals use
• Using standard demographics, diagnostic, and procedural
data, all individuals are assigned to one of seven population
health segments:
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1: Non User
2: Healthy 3: Stable 4: At Risk
5: Simple Chronic
6: Complex Chronic
7: Critical
Cost by Population Health Segment
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Why Risk Adjustment Matters
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Provider ARisk Score: 1.07
Provider BRisk Score: 0.99
Potentially Preventable Events
• Risk Adjustment is used to determine expected values for
the following outcome measures:
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Potentially Preventable Admissions
(PPA)
Potentially Preventable
Readmissions (PPR)
Potentially Preventable
ER Visits (PPV)
Score =
Observed Events
Risk Adjusted
Expected Events
Care Management Dashboard
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3M, Risk Scores, & Patient Lists
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• Lists patients who were identified as having a chronic, catastrophic, or malignant condition in a prior 12-month data set and are no longer flagged as such in the current data set
Chronic Fallout Report
• Identifies patients whose Clinical Risk Grouper (CRG) score has jumped significantly in status
• A significant jump in status could entail moving from having one chronic condition to having multiple conditions or showing an increase in the severity of an existing condition
Jumper Report
• Identifies patients that are now considered chronically ill but were previously not considered chronic
• These could be previously healthy members, non-users, or newly attributed/enrolled members
• The data in this report can be used to generate lists for outreach initiatives
Newly Chronic
• HEDIS Gaps in Care reports
• Member lists of Potentially Preventable Events
Quality Measure Specific Patient Lists
Ad Hoc Reporting
Informed Analytics (IA):
• The ability to build interactive reports that can be exported
and shared
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Customizable Reports
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Case Study
Patient Populations Driving Costs
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CategoryPerson Count % Total
Aggregate Allowed
% Total Allowed
Healthy 4,736 54.85% $ 216,245.76 6.62%
Significant Acute 486 5.63% $ 159,558.66 4.88%
Single Minor 506 5.86% $ 96,939.48 2.97%
Multiple Minor 111 1.29% $ 34,216.86 1.05%
Single Dominant or Moderate Chronic 1,379 15.97% $ 432,909.47 13.25%
Pairs - Multiple Dominant and/or Moderate Chronic 1,117 12.94% $ 1,121,043.54 34.30%
Triples - Multiple Dominant Chronic 111 1.29% $ 472,830.03 14.47%
Malignancies - Metastatic, Complicated, or Dominant 29 0.34% $ 236,412.64 7.23%
Catastrophic 159 1.84% $ 498,229.68 15.24%
8,634 100.00% $ 3,268,386.12 100.00%
Patient Populations Driving Costs
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54.9%
5.6%
5.9%1.3%
16.0%
12.9%
1.3% 0.3%1.8%
PERSON COUNT
6.6%
4.9% 3.0%
1.0%
13.2%
34.3%
14.5%
7.2%
15.2%
% TOTAL ALLOWED
Pairs
Pairs
Healthy
Healthy
Cost by Category
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24%
1%
19%
20%
26%
3%3%
4%
Category% Total
AllowedAllowed
PMPM
IP Non-Preventable Allowed PMPM 24% $ 97.05
OP ER Non-Preventable Allowed PMPM 1% $ 5.66
OP Other PMPM 19% $ 75.15
PR Allowed PMPM 20% $ 79.74
Rx Allowed PMPM 26% $ 106.39
Preventable IP PPR Allowed PMPM 3% $ 12.09
Preventable IP PPA Allowed PMPM 3% $ 13.38
Preventable OP PPV Allowed PMPM 4% $ 14.57
Total PPE Allowed PMPM 10% $ 40.04
PPE Trending
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IP PPA Allowed Amount by APDRG Service Line (Top 10)
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IP PPA Visits: Pulmonary
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Data Challenges
• Virtual IPA Network composition poses unit price
sharing challenges
Solution: Aggregate financial reports and utilization
drilldown report capabilities
Data Challenges
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• Dependence on claims data
causes delays in sharing
Solution: No runout in Care
Management dashboard
Virtual
Provider
Networks
• When exchanging numerous files & return extracts
with vendors technical issues are bound to arise
Solution: Maintain close relationship with vendor and
internal IT team; reoccurring status meetings
Timing of
Data Sharing
Data Sharing
Infrastructure
Contact Us
http://www.nyhq.org/dsrippps
Amanda Simmons
(713) 859-9683
Sarah Schauman
(505) 231-5591
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http://www.nyp.org/pps
Paula N. Richter
(646) 317-2092
Rachel Naiukow
(347) 880-1707
