Joshua Rosenthal, PhD and Elizabeth Young

Government Data and You:

Using Public Use Files to Guide Value-Based Care

Decisions and Deliver High-Value Care

How Medicare Public Use Files, along with a variety of

additional Public Use Files, can be used to provide strategic

insights for health plans, physician groups, and hospital

systems looking to provide high-value care.

Background on the currently available datasets and their

strengths and limitations with the goal of inspiring new

avenues of workforce research.

Government Data and You:

Using Public Use Files to Guide

Value-Based Care Decisions

and Deliver High-Value Care

Joshua Rosenthal, PhD and Elizabeth Young

Context: Public Data, Public-Good Goals

Overview: Uses and Examples

Trying Your Hand: Sources and Samples

Government Data and You:

Using Public Use Files to Guide

Value-Based Care Decisions

and Deliver High-Value Care

Joshua Rosenthal, PhD and Elizabeth Young

Context: Public Data, Public-Good Goals

Overview: Uses and Examples

Trying Your Hand: Sources and Samples

Government Data and You:

Using Public Use Files to Guide

Value-Based Care Decisions

and Deliver High-Value Care

Joshua Rosenthal, PhD and Elizabeth Young

Government is releasing lots of data*

Government Data and You:

Using Public Use Files to Guide

Value-Based Care Decisions

and Deliver High-Value Care

Joshua Rosenthal, PhD and Elizabeth Young

Need market to adopt – use to create value

Cf. Weather & Geo-Location data

Government Data and You:

Using Public Use Files to Guide

Value-Based Care Decisions

and Deliver High-Value Care

Joshua Rosenthal, PhD and Elizabeth Young

Context

Exit

Exit w/ Good Multiple

Idea

Prototype

Funded

1 %*

1 %*

1 %*

1 %*

*Health Care Start Ups fail at astounding,

disproportionate rates

Government Data and You:

Using Public Use Files to Guide

Value-Based Care Decisions

and Deliver High-Value Care

Joshua Rosenthal, PhD and Elizabeth Young

Most ‘Successes’, Aren’t

Measuring Value Creation

Government Data and You:

Using Public Use Files to Guide

Value-Based Care Decisions

and Deliver High-Value Care

Joshua Rosenthal, PhD and Elizabeth Young

Measuring Value Creation

Government Data and You:

Using Public Use Files to Guide

Value-Based Care Decisions

and Deliver High-Value Care

User Guide (ALT)

Consultants /Professional Services,

Providers

SaaS-baseddata / analytic

platforms

Measuring Value Creation

Joshua Rosenthal, PhD and Elizabeth Young

Government Data and You:

Using Public Use Files to Guide

Value-Based Care Decisions

and Deliver High-Value Care

Joshua Rosenthal, PhD and Elizabeth Young

Health care has not done so well

“Just wait ‘till next year Financial Services & Energy!”

In this race vs. other verticals

Government Data and You:

Using Public Use Files to Guide

Value-Based Care Decisions

and Deliver High-Value Care

Joshua Rosenthal, PhD and Elizabeth Young

*Direct-to-Consumer Note: People don’t like to pay out of pocket for something they don’t like to do or don’t want to know about

Challenge: Direct to Consumer Apps

Government Data and You:

Using Public Use Files to Guide

Value-Based Care Decisions

and Deliver High-Value Care

Joshua Rosenthal, PhD and Elizabeth Young

Speaking at a major health care conference near you

Challenge: Fluff in nice suits

Government Data and You:

Using Public Use Files to Guide

Value-Based Care Decisions

and Deliver High-Value Care

Joshua Rosenthal, PhD and Elizabeth Young

I have better engineering / architecture

Hmm, ‘fixing the pipes’was not the answer

Challenge: Noise from Tech

Government Data and You:

Using Public Use Files to Guide

Value-Based Care Decisions

and Deliver High-Value Care

Joshua Rosenthal, PhD and Elizabeth Young

I have better design & experience

Hmm, the pretty colors on my social app didn’t stop me

Challenge: Bubbles (design)

Government Data and You:

Using Public Use Files to Guide

Value-Based Care Decisions

and Deliver High-Value Care

Joshua Rosenthal, PhD and Elizabeth Young

My data is bigger than yours

Challenge: Buzz (cf. big data)

Government Data and You:

Using Public Use Files to Guide

Value-Based Care Decisions

and Deliver High-Value Care

Joshua Rosenthal, PhD and Elizabeth Young

* Source: Dartmouth Atlas for Unwarranted Variation

Challenge: Perverse Incentives

Government Data and You:

Using Public Use Files to Guide

Value-Based Care Decisions

and Deliver High-Value Care

Joshua Rosenthal, PhD and Elizabeth Young

Perverse Incentives: Fee for Service

Payers aggregate –but some have not historically been “health care”

“Actually, I make more money off of bad drivers.”*

(Read w/ accent)

Government Data and You:

Using Public Use Files to Guide

Value-Based Care Decisions

and Deliver High-Value Care

Joshua Rosenthal, PhD and Elizabeth Young

Some Hospitals/Providers may historically generated revenueby filling rooms* Keep patients away?!?

I was trying to book you for an extra night!

Perverse Incentives: Fee for Service

Government Data and You:

Using Public Use Files to Guide

Value-Based Care Decisions

and Deliver High-Value Care

Joshua Rosenthal, PhD and Elizabeth Young

Perverse Incentives: Disrupting Status Quos

David Wennberg, MDRowdMap Advisory Board

Open Health Data Outperforms Claims and Electronic / Personal Health Records, & Devices for Risk & Cost

Government Data and You:

Using Public Use Files to Guide

Value-Based Care Decisions

and Deliver High-Value Care

Joshua Rosenthal, PhD and Elizabeth Young

Challenge: Interpretation of Data

Government Data and You:

Using Public Use Files to Guide

Value-Based Care Decisions

and Deliver High-Value Care

Joshua Rosenthal, PhD and Elizabeth Young

Causal?

Then again… Maybe there’s something to it?

Government Data and You:

Using Public Use Files to Guide

Value-Based Care Decisions

and Deliver High-Value Care

Joshua Rosenthal, PhD and Elizabeth Young

Review

Health Care Start Ups fail at astounding,

disproportionate rates

FAIL

Government Data and You:

Using Public Use Files to Guide

Value-Based Care Decisions

and Deliver High-Value Care

Joshua Rosenthal, PhD and Elizabeth Young

Solution: NEW INCENTIVESGovernment Announces Sun-setting of Fee for Services

Government Announces New Pay-for-Value Models

Government Data and You:

Using Public Use Files to Guide

Value-Based Care Decisions

and Deliver High-Value Care

Joshua Rosenthal, PhD and Elizabeth Young

New Government Released Referral Data(Patient flows between PCPS, specialists, hospitals and post acute centers)

Dartmouth Atlas for Unwarranted Variation(Decades of research and data on unwarranted variation by condition and geography to keep things apples-to-apples for comparisons, hence “Unwarranted” in the name)

New Government Released Performance Data (Individual providers, groups, hospitals and post acute centers including the new part B&D)

Provider Pattern Intensity Profiles and Risk Readiness for every provider, hospital, post acute center in the US. All preloaded with no IT.

Solution: NEW DATA

Government Data and You:

Using Public Use Files to Guide

Value-Based Care Decisions

and Deliver High-Value Care

Joshua Rosenthal, PhD and Elizabeth Young

Answering the Open Challenge:Connecting Open Data to an Meaningful Business Model

DIY it!

Guide: http://tinyurl.com/l2nxvw9

Sources: http://tinyurl.com/ko7jnfa

Game: http://tinyurl.com/kspxr4e

Government Data and You:

Using Public Use Files to Guide

Value-Based Care Decisions

and Deliver High-Value Care

Joshua Rosenthal, PhD and Elizabeth Young

Context: Public Data, Public-Good Goals

Overview: Uses and Examples

Trying Your Hand: Sources and Samples

Government Data and You:

Using Public Use Files to Guide

Value-Based Care Decisions

and Deliver High-Value Care

Joshua Rosenthal, PhD and Elizabeth Young

CMS: 50% of FFS will be gone by 2018

The business context has changed. Health plans, government payers, providers, and hospital systems need

to develop Risk-Readiness strategies to excel as they transition from fee-for-service to pay-for value.

Government Data and You:

Using Public Use Files to Guide

Value-Based Care Decisions

and Deliver High-Value Care

Joshua Rosenthal, PhD and Elizabeth Young

PUF Files Featured NationallyUS CTO on RowdMap: “Visionary

Genius”

What you can do [without a PhD]With mashups of gov’t data (CMS HHS, Gov, CDC)

Chronic prevalence & physician supplyPopulation Health ReportPopulation Report Card

Match practice patterns to the right risk arrangements – PFV ReadinessGroup Risk-Readiness SM ReportPhysician Risk-Readiness SM ReportHospital Risk-Readiness SM ReportPost Acute Center Risk-Readiness SM ReportRisk-Readiness SM Arrangement Match-Maker

Manage clinical care and costs –Remove No Value CareGroup Unnecessary Cost ReportPhysician Unnecessary Cost ReportHospital Unnecessary Cost ReportPost Acute Center Unnecessary Cost ReportUnnecessary Cost Referral and Value Chain Report

What you can do [without a PhD]With mashups of gov’t data (CMS HHS, Gov, CDC)

Chronic Prevalence &Physician Supply

Match Practice Patterns to the right Risk Arrangements – PFV Readiness

Manage Clinical Care and Costs –Remove No Value Care

Diabetes Prevalence -Westchester

Use this data to allocate providers and care management resources around condition-specific population needs by zip.

Locate clinics, health fairs, etc. based on chronic needs.

Income

Obesity

Depression

Health Opportunity Index

Demand and Supply

What type of populations?

Medicare FFS Geo. Variation: http://go.cms.gov/1D8j7LECDC Behavioral Risk Factor Surveillance: http://1.usa.gov/1PzcisTMedicare FFS Part B: http://go.cms.gov/OCmyoyMedicare FFS Part D: http://bit.ly/1mGyBxk

Lots of diabetics but few PCPs

Lots of diabetics and lots of PCPs

PCP Density –Westchester

32

Demand and Supply

County ProfilesLargest Counties In Ohio

People use this data to calibrate expectations for profitability by incorporating population health and provider performance into

product strategy. Use excess to subsidize operations in counties with fewer high-performing resources

Risk ScoresTotal Cost

PMPM Reimbursement Overall Star

Chronic Star

Health Rank

MA Profit Opportunity -

MA

Profit Opportunity -

Exchange

MA Eligibles

MA Enrolled

Exchange Subsidized

ExchangeEnrolled

Compare to National and Regional Benchmarks

Medicare FFS Geo. Variation: http://go.cms.gov/1D8j7LECDC Behavioral Risk Factor Surveillance: http://1.usa.gov/1PzcisTMedicare FFS Part B: http://go.cms.gov/OCmyoyMedicare FFS Part D: http://bit.ly/1mGyBxk

What you can do [without a PhD]With mashups of gov’t data (CMS HHS, Gov, CDC)

Chronic Prevalence &Physician Supply

Match Practice Patterns to the right Risk Arrangements – PFV Readiness

Manage Clinical Care and Costs –Remove No Value Care

At the core of Risk-Readiness SM is

Unwarranted Variation:

RowdMap applies the Dartmouth Atlas for Unwarranted Variation methodologies to data on Medicare Parts B & D. This research has been repeatedly validated over the last 30 years and we now have a national data set to apply the methodologies at a large scale.

The estimated 30% of medical expense that goes to unnecessary care. This unnecessary spend drives billing in a fee-for-serve economic model, but success in pay-for-value comes from managing and mitigating these pockets of variation.

Every provider has a unique practice pattern that informs Risk-Readiness SM

Pay for Value Readiness

Los Angeles, CA

Compare to National or Regional Benchmarks

Pay for Value Readiness

Provider Profiles

Identify highly efficient, Risk-Ready practices and physicians to profitably grow into. Improve profitability of lower performing practices with large panel sizes through modified arrangements

or performance improvement plans.

Medicare FFS Part B: http://go.cms.gov/OCmyoyMedicare FFS Part D: http://bit.ly/1mGyBxkReferrals: http://1.usa.gov/1FzoEOV

Identify high and low performing hospitals and post-acute facilities— are there post acute facilities that hospitals with poor chronic

readmits are routing members to?

Pay for Value Readiness

Dartmouth Atlas: http://bit.ly/1GXvlJpCMS Hospital Compare: https://goo.gl/p8MtoICMS Hospital Readmissions: http://goo.gl/02KnQdCMS Nursing Home Compare: https://goo.gl/3DpT8m

EOL Hosp Days: Which hospitals fewer end-of-life days than their peers?

Chronic Admits: Which hospitals see their most chronic population repeatedly/ with the most frequency?

Cardiac Imaging: Which hospitals are more likely to over-utilize cardiac imaging compared to their peers?

Pay for Value Readiness

Great profile for aggressive risk

Tread carefully for some risk

Match appropriate risk arrangements based on provider practice patterns and Population characteristics within a geography.

What you can do [without a PhD]With mashups of gov’t data (CMS HHS, Gov, CDC)

Chronic Prevalence &Physician Supply

Match Practice Patterns to the right Risk Arrangements – PFV Readiness

Manage Clinical Care and Costs –Remove No Value Care

Low-Value Care looks at a different category of spending

Shift focus from clinical edits, audits, and recovery efforts to identifying care that is clinically appropriate, but unnecessary. Historical efforts have shown returns, but they only look at a fraction of total spending. Unnecessary care can account for up to 30% of total spending and provides significantly larger opportunities for cost containment and quality improvement.

Clinically Appropriate, but Unnecessary Care

(30% of spend)

Claims Spend for a Health Plan

Necessary Utilization(70%)

“It’s generally agreed that about 30 percent of what we spend on health care is unnecessary. If we

eliminate the unneeded care, there are more than enough resources in

our system to cover everybody.”

-Dr. Elliott Fisher,Dartmouth Institute for Health Policy

Remove Low-Value CareManage Unnecessary Spend

Remove Low-Value CareManage Unnecessary Spend

RowdMap tackles the 30% of the U.S. health care spend that goes to clinically appropriate, but unnecessary care

Over $9B in Orange County, CA

How much unnecessary spend is in your market?

Over $66B in Florida

$850 Billion Unnecessary Spend* in 2014

Least Unnecessary Spend

Most Unnecessary Spend

RowdMap tackles the 30% of U.S. health care spend that goes to clinically appropriate, but unnecessary care. RowdMap’s models identify the cost-savings opportunities in a geography based on the collective intensity of care delivered by doctors in that area.

* Unnecessary Spend =

(Dartmouth Avg cost) * (Population) * (RowdMap Network Opportunity Index)

Unnecessary Spend in Florida

In Broward Co. alone, there is over $7.6B in unnecessary spend.

Let’s look at which hospitals, groups and physicians account for this and for what conditions

Remove Low-Value CareManage Unnecessary Spend

Physician Marketshare by Major Clinical Categories

Match appropriate risk arrangements based on provider practice patterns and Population characteristics within a geography.

Hospital Marketshareby Major Clinical Categories

Provider Group Marketshareby Major Clinical Categories

Unnecessary Spend in BrowardBy condition across hospitals, groups and physicians

This Physician.Let’s start here

This GroupThis Hospital

Circulatory

Muscular-skeletal

Respiratory

Remove Low-Value CareManage Unnecessary Spend

Physicians Driving Unnecessary Care in Broward

Musculoskeletal care is major contributor to unnecessary spend in Broward. Let’s take a physician who is not an outlier but in the middle of the pack such as Dr. Spend*. Let’s walk through what his clinically acceptable, but medically unnecessary, practice pattern creates

in unnecessary spend.

Remove Low-Value CareManage Unnecessary Spend

Referral Patterns and Physician Value Chains

Identify high performing providers and downstream referral patterns. Encourage referrals to

high-performing specialists.

Remove Low-Value CareManage Unnecessary Spend

Least Unnecessary Spend

Most Unnecessary Spend

Option 2: Reinforce highest-performing referral

and care pathways. Increase the number of patient interactions

with green dot doctors.

Option 1: Change provider behavior. Requires lots of provider education. Requires

payer to make up a significant portion of a provider’s revenue. Increase the number of

green dot doctors.

Zoom to zip

Remove Low-Value CareManage Unnecessary Spend

If had same ratio as :

• His decompression rate would drop from 6.01 to 0.436 per patient.

• Which translates to 2,608 fewer decompressions per year.

• At an average cost of $332 per decompression, this represents potential savings of over $850K

If decompression to fusion rate were average for orthopedic surgeons:

• He would have 1629 fewer decompressions for a potential savings of $540K.

*Actual physician names have been changed.

For every 10 back fusions, does 103 decompressions

For every 10 back fusions, does 2 decompressions.

Dr. Save*

Dr. Spend’s

Dr. Spend*

Dr. Save*

That’s one physician, with one procedure, in one clinical condition. This savings would not be picked up in unit cost or utilization analysis,

but cumulatively dwarfs fraud, waste and abuse outliers. Intense practice patterns like this power FFS arrangements

but success in Pay for Value comes from identifying Risk-Ready providers.

Dr. Spend*

Remove Low-Value CareManage Unnecessary Spend

Government Data and You:

Using Public Use Files to Guide

Value-Based Care Decisions

and Deliver High-Value Care

Joshua Rosenthal, PhD and Elizabeth Young

Context: Public Data, Public-Good Goals

Overview: Uses and Examples

Trying Your Hand: Sources and Samples

TRY YOUR HAND AT GOV DATA

Before data products, tools, widgets, benchmarks, APIs, systems…

Before access and security; before interoperability, standards…

Before automation and efficiency…

Taxonomy

… basis for moving to new paradigm from fee-for-service to pay for value

… bridges business & technology/data… bridges internal & external users

... across CMS… identifiable beneficiary databases and non-beneficiary files

Helps to get started:

TRY YOUR HAND AT GOV DATA

http://www.medicare.gov/download/downloaddb.asp

Example Taxonomy

TRY YOUR HAND AT GOV DATA

Sample record from the downloaded file

What is this? How can I use it to answer business questions?

Example Taxonomy

TRY YOUR HAND AT GOV DATA

Example Taxonomy

In order to get insight, I need the data in a meaningful business structure!

TRY YOUR HAND AT GOV DATA

Taxonomy defines business entities and the relationships among them

TRY YOUR HAND AT GOV DATA

Taxonomy defines attributes for business entities

TRY YOUR HAND AT GOV DATA

Taxonomy at the center of any system

If you want to do something meaningful with the data, go through taxonomy

TRY YOUR HAND AT GOV DATA

[Referrals: http://1.usa.gov/1FzoEOV ]

[Variation: http://go.cms.gov/1D8j7LE ]

[Shared Savings: http://go.cms.gov/1Hh8vx0 ]

[Medicare FFS Part B: http://go.cms.gov/OCmyoy ]

[Medicare FFS Part D: http://bit.ly/1mGyBxk ]

[Medicaid: http://go.cms.gov/1z7b5ic ]

[Dartmouth: http://bit.ly/1GXvlJp ]

[Behaviors: http://1.usa.gov/1PzcisT ]

[Health Data All Stars: http://bit.ly/1GAsVC3 ]

Places to Start: