RowdMap Health Datapalooza Payer Provider Risk Readiness

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HEALTHDATAPALOOZASummary

LearnmoreabouthowbothpayersandprovidersareusingHHSdatatoidentify,quantifyandreduce low-valueservicesastheymovefromFeeforServicetoPayforValuearrangements.

RowdMap’s Risk-Readiness®benchmarkshelphealthplans,physiciangroups,andhospitalsystemsidentify,quantify,andreducedeliveryofno-valuecare—acentraltenetofsuccessfulpay-for-valueprograms.

RowdMapusespublicdataincludingPartB,DandAandreferralsaswellasBRFSSandotherCDCdata,viewedinlightoftheDartmouthAtlasforUnwarrantedVariationtodeterminewhichgeographiesandproviderswilllikelysucceedinthemovementfromFeeforServicetoPayforValueandRiskArrangements.

RowdMapisusingHHSdatawithclients in48statesandtheDistrictofColumbiacoveringover100MMmembersandpatients,withPayersacrossalllinesofbusinessincludingMA,Medicaid,Exchange/Marketplace,LargeGroup&SmallGrouppopulationsandwithProvidersincludingSpecialtyGroups,PCPgroups,CINs,ACOsandHospital-basedsystems.

PayersletRowdMaphelpthemuseHHSdatatomovetovaluebasedarrangementsbybuildingandoptimizingnetworksthengrowingthrough thebestproviders;ProvidersletRowdMaphelpthemuseHHSdatatocalculatetheirrealimpactoftheirpracticepatternsforwhoeverownstherisk,usingadifferentapproach thantraditionalutilizationoractuarialunitcostanalysis. Providersthenpickvalue-basedprograms,negotiatewithPayers,andmakechangestoindividualproviders andtheir deliverytosucceedintheshiftfromFFStoRisk.

ForhelpingbothPayersandProvidersinhealthcaremarketuseHHSdatatomovefromFeeforServicetoPayforValuearrangements,RowdMaphasbeennamedErnstandYoungEYEntrepreneursoftheYear®. RowdMaphasalsopartneredwithUSNEWStohelpconsumersmakemoreinformeddecisionsandavoidlowvalueservicesbyusingHHSdata.



HEALTHDATAPALOOZAWhatWe’reNotInterestedin

LearnmoreabouthowbothpayersandprovidersareusingHHSdatatoidentify, quantify andreducelow-valueservices astheymovefromFeeforServicetoPayforValuearrangements.

Notadvocatingforpolicy/programsNotsellingyouanything

Notexploitingmodels/mechanics forshort termgain

Bundle-O-MaticACOs-R’-USData/ClaimSystems



HEALTHDATAPALOOZAWhatWeAreInterestedin


Wanttosharewhereyourdataisbeingusedbypayersandproviders tomoveoutofFFSandtakeonsharedrisk,sometimesworking togetherwithHHSdataascommonbasisforpartnershipsandsharedriskarrangements.

Usedtodesignnetworks, changepracticepatternsandmanagecare,selectgovernmentprogramsorriskarrangements,pickpartnersandnegotiaterisk,design financiallyviableproductsandasevaluatecriteriatoforsuccessvaluebasedarrangements.

Wanttoshareyourdataholdsupextendstoprovidersandpayersinmarketplace/exchange,commerciallarge/smallgroup, etc.

Wanttoadvocateforcontinued datareleases.

Basically,encourageHHS&themarkettokeeprockingthemike!



HEALTHDATAPALOOZAWhoUsesHHSDataforRealStrategy&Ops?


Healthplansandprovidersin48statesandtheDistrictofColumbiauseRowdMapandHHSdatatoreducethedeliveryofno-valuecare.

TheclientsRowdMapservescollectivelycoverthelivesofmorethan100millionAmericans.

Here’swhereHHSDataisbeingusedtomovefromFFStoValueBaseArrangements(not ‘pilot’or‘innovation’ programs)butactiveoperationalprograms.

ClientsusingHHSdataincludeNational,Regional&BoutiquePayersinMarketplace/Exchange,MA,Medicaid,

CommercialandGovernmentProgramsaswellasProviders includingPCP&SpecialtyGroups,CINs&Systems,

ACOs,Bundles &other CMMIProgramParticipants.



HEALTHDATAPALOOZALow-ValueServices:WhyYouShouldGiveaDarn

RowdMap’s Risk-Readiness® benchmarks helphealthplans,physician groups, andhospital systemsidentify,quantify, andreducedelivery ofno-value care—acentraltenetofsuccessful pay-for-valueprograms.

Over$9BinOrangeCounty, CA

$850BillionUnnecessarySpendin2014(InstituteofMedicine)

InstituteofMedicine(IOM)report,“BestCareatLowerCost,”(Sept.2012)estimatesthattheUnitedStateslost$750billionin2012.(Adjustedin2013at$800BB,2014at$850BB.)Thisisabout3%ofGDP.

No-ValueCare(30%)

NecessaryUtilization(70%)

“It’sgenerallyagreedthatabout30percentofwhatwespendonhealthcareisunnecessary.Ifweeliminatetheunneededcare,therearemorethanenoughresourcesinoursystemtocovereverybody.”

-Dr.ElliottFisher,DartmouthInstitutefor

HealthPolicy

“Biggerthanhigherprices,administrativeexpenses,and

fraud,however,wastheamountspentonunnecessaryhealth-care

services.”Injustasingleyear,upto42%ofpatientsreceive

“NoValue”Care.

- Dr.AtulGawande,DepartmentofHealthPolicyand

ManagementattheHarvardSchoolofPublicHealth&DepartmentofSurgeryatHarvardMedicalSchool



HEALTHDATAPALOOZALow-ValueServices:Broad,IncreasingInterest


Research EvaluatingCMS&PrivatePlanPrograms:“DotheyreduceLowValuecare?”

PopularPressReportingandProviderRankings:“Consumers are/shouldavoidLowvaluecare.”

CritiqueofFeeforService:“FFShastoomuchLowValuecare.”

RowdMappartner

Recommendedevaluationcriteriaforvaluebasedplansfrompayers/providers



HEALTHDATAPALOOZALowValueServices:PaymentModel-Driven


Askingadifferentquestion:We’renottryingtochangeproviderbehavior,butrathercreateavirtuouseconomiccyclewheredocswhomitigatelow-valueservicesgetpaidmoreandpull inmorepatients/members

Okay,explainwhatwe’retryingtodo



HEALTHDATAPALOOZALowValueServices:PracticeVariation


Theestimated30%ofmedicalexpensethatgoestono-valuecare.

Unnecessary spending drivesbilling inafee-for-serveeconomicmodel, butsuccessinpay-for-valuecomesfrommanagingandmitigatingthesepocketsofvariation.

Variation:UnwarrantedorUnexplained?Everyphysicianhasauniquefingerprint

EconomicDrillDown:ExampleUtilizationReviewandActuarialUnitCostAnalysisagainstCareIntensityCurveacrossTotalBasketofCare

Variationacrossgeographiesandwithinpracticesacrossphysicians.“Physician-Level PracticeVariation:WhoYouSeeIsWhatYouGet”BrianPowers,Sachin Jain,DavidCutler,&Ziad ObermeyerHealthAffairs,09.23.15

Definitions,researchandgeocodingbyHospitalReferralRegionalavailableviatheDartmouthAtlasforUnwarrantedVariation:www.dartmouthatlas.org

NB:Unwarranted variationrefers topractice patterns, which holdupacrosspopulations butpricing variationmayalsobeunwarranted andmarkedfluctuatesacrossinsuranceproduct andlinesandgeography.“ThePriceAin’t Right.”Cooper, Craig, GaynorandVanReenen, 2015.

10

HEALTHDATAPALOOZARowdMap’sRisk-Readiness®Benchmarks


ProvidersinaMarketGroups

IndividualPhysicians

Whatisdrivingaprovider’sRisk-Readiness®?Isitprocedures,prescriptions,referralsorvisits?

Howbigisaprovider’spanel?

Howreadyisaprovidertosucceedinrisk

comparedtopeers?Byspecialty?

Withinaregion?

Fingerprintwithpracticepatternsthatmitigateno-valuecare=GreenDot

Fingerprintwithpracticepatternsthatcreateno-valuecare=RedDot

Risk-Readiness®Benchmarks



HEALTHDATAPALOOZADataSources&Uses

RowdMapuses publicdataincluding PartB,DandAandreferralsaswellasBRFSSandotherCDCdata,viewedinlightoftheDartmouthAtlasforUnwarrantedVariationtodeterminewhichgeographiesandproviderswilllikely succeedinthemovementfromFeeforServicetoPayforValueandRiskArrangements.

Happy togothroughdeepmethodsinalternativeformat;essentiallywe’retakingadifferentapproach.

Ratherthanatypicaldiagnosis/risk/spendassociationmodel,we’refollowingapopulation-based,top-downapproachtohotspotanddrillintounexplainedvariation,thenattempttoexplainitthroughfinancial/contractingandclinical/populationdrivers.

Inspecificcases,wedo runclientclaimsdataandhavetheirfinancials(MLR,actualprofitability,providercontracts,etc.)but tovalidate/calibratebenchmarksandto“explain”thevariation.

Wearenotgroupingepisodictreatmentstoseewhatspendingbelongswhichevent,norarewelookingatindividualpatientswithabottomup totalcostofcaremodel,butratherwearetakingapopulation-basedapproach,comparingpracticepatternsacrossprocedures,prescriptions,visitsandgroupingphysicianswithsimilarprofilesandaskinghowtotheyspend theirtimeandonwhatcomparedtotheirpeerswithinaregion.

WeessentiallybinprovidersusingtheHHSbenchmarksthenadjustandmeasurethemindifferentways,sometimeswithaclient’sparticularmethodology. Sometimesprofilingthesameproviders fromtwoseparatevantagepoints,onbehalfofapayerandaproviderwithinthesamemarket,oraPCPgroupsandspecialtygroupinthesamemarket.

Inotherwords,wearelookingatratiosaroundunexplainedvariationandwithinanepisodeoracrossatotalbasket/bundleofcareistheretoomuch/littlelow-valueservicegiventhepatterns.Forinstance,istheretoolittlepainmanagementgivethevolumeandintensityofspecificsurgeries,whichleadstoexcessreadmissions.Sometimethevariationisunwarranted;sometimesitisexplainedviafinancialsandcontractincentives.





MedicareDocGraphReferralfile(PatientflowsbetweenPCPS,specialists,hospitalsandpostacutecenters)

DartmouthAtlasofHealthCare&Choosing Wisely(Decadesofresearchanddataonunwarrantedvariationbyconditionandgeographytokeepthingsapples-to-applesforcomparisons)

CMSFFSDataSets,CDCDataSets(MEDPAR,PartB,PartD,BRFSS)(Individualproviders,groups,hospitalsandpostacutecenters)

ProviderPatternIntensityProfilesandRiskReadinessforeveryprovider,hospital,postacutecenterintheUS.Allpreloaded withno IT.

AffordableCareActdatatodetermineRisk-ReadinessofProviders/Networks





Behaviors –BroaderDefinitions ofHealthwithBehaviors

Utilization – UtilizationandCosts ofProceduresandDrugs

Prevalence – MajorDiseasesandConditions

Supply – NumberofPrimaryCarePhysicians andSpecialists

Socio-demographics – Income,Environment, etc.

BRFSSetc.tominimizeobservation

intensitybias(HCCs) andmatchstrategiestoa

population tosucceed invalue-basedprograms

DavidWennberg,MDRowdMapAdvisoryBoard





Over/UnderCodingCounty&ZipCode

UnderCoding OverCoding

Under-codingJacksonville

Overs-codingMiami

HealthFactors

AverageRiskScores

Watcha2minute videoonthemethod&concept:www.bmj.com/content/348/bmj.g2392



HEALTHDATAPALOOZAMarketAdoption

RowdMapisusingHHSdatawithclients in48statesandtheDistrictofColumbia coveringover100MMmembersandpatients,withPayersacrossalllinesofbusiness includingMA,Medicaid,Exchange/Marketplace,LargeGroup&SmallGrouppopulations andwithProviders includingSpecialtyGroups, PCPgroups,CINs, ACOsandHospital-based systems.

Facilitatingstructuredconversationbetweenpayersandproviders totakeonsharedriskusingHHSbenchmarkdataasacommon foundation.

Goalisvirtuouscycleofbestdocsgettingpaidmorewithmoremembers(30centsper$allowsmuchmoretoplaywith).

Removescontentionasattheendofthedayifthepartiesdon’tagree,theycanwriteriskcontractstoaddressanyissuesofdisagreement.

SummaryofAdoption:



HEALTHDATAPALOOZAMarketExamples– CompensatingProviders

PayersletRowdMaphelpthemuseHHSdatatomovetovaluebasedarrangementsbybuilding andoptimizingnetworksthengrowingthroughthebestproviders;Providers letRowdMaphelpthemuseHHSdatatocalculatetheirrealimpactoftheirpracticepatternsforwhoeverownstherisk, usingadifferentapproachthantraditionalutilizationoractuarialunitcostanalysis. Providers thenpickvalue-basedprograms,negotiatewithPayers,andmakechangestoindividual providers andtheir deliverytosucceedintheshiftfromFFStoRisk.



HEALTHDATAPALOOZAMarketExamples– NetworkOptimization




HEALTHDATAPALOOZAMarketExamples– Value-BasedCareChains




HEALTHDATAPALOOZAMarketExamples– VirtuousGrowthCycle




HEALTHDATAPALOOZAMarketExamples– EnsureFinancialViability




HEALTHDATAPALOOZAMarketExamples– DesignProfitableProducts




HEALTHDATAPALOOZAMarketExamples– AchieveFinancialViability




HEALTHDATAPALOOZAYouRock

ForhelpingbothPayersandProviders inhealthcaremarketuseHHSdatatomovefromFeeforServicetoPayforValuearrangements,RowdMaphasbeennamedErnstandYoungEYEntrepreneursoftheYear®. RowdMaphasalsopartneredwithUSNEWStohelpconsumersmakemoreinformeddecisionsandavoidlowvalueservices byusingHHSdata.

Thisisawinfromestablishmentoutside healthcarerecognizing

thepowerofHHSdatatopositivelytransformthemarket&economy

Thisisconsumers demandingtomakeinformeddecisionsusingHHSdataandprovidersinternalizingimpact

ThisisstartupsmakingrealimpactandtraditionalmarketpowersadoptingHHSdatato

movefromFFStoPayforValue



HEALTHDATAPALOOZAYouRock

ForhelpingbothPayersandProviders inhealthcaremarketuseHHSdatatomovefromFeeforServicetoPayforValuearrangements,RowdMaphasbeennamedErnstandYoungEYEntrepreneursoftheYear®. RowdMaphasalsopartneredwithUSNEWStohelpconsumersmakemoreinformeddecisionsandavoidlowvalueservices byusingHHSdata.

Told‘ya

MarketIncentive

OpenData

PositiveDisruptioninaComplexSystem



No-ValueCare(30%)

NecessaryUtilization(70%)

CareThatDoesn’tProduceBetterOutcomes$850BillionUnnecessarySpendin2014

(InstituteofMedicine)

No-ValueCare:.30/Each$IsWasted

LowValueCareDrivesBillinginFeeforService“#1Weakness ofFFSPaymentSystemIs

ExcessUseofLowValueServices”Dr.PatrickConway,

ChiefMedicalOfficer,CMS

Allcontentsareproprietary toRowdMap,Inc.andarebeingprovidedonaconfidential basis.Anyuse,reproduction ordistribution ofthisinformation, inwholeorinpart,orthedisclosure ofanyofitscontents

without theprior written consent oftheCompany,isprohibited.

No-ValueCare:CMSIsPayingonIt

2016 World Economic ForumAnnual Meeting in Switzerland

Ontracktosunset50%ofFFS



“Millions of people are receiving drugs that aren’t helping them, operations that aren’t going to make

them better, and scans and tests that do nothing beneficial for them, and often cause harm.”

Dr. Atul Gawande, Professor, Department of Health Policy and Management at the Harvard School of Public Health & the Department of Surgery at Harvard Medical School.

No-ValueCare:MediaIsReportingonIt



"It'snosecretthatpatientsoftenundergounnecessaryproceduresthatcanbedangerousandcostly."Throughourcollaboration withRowdMap,weareprovidingpatientswithmeaningful informationabouttheseno- orlow-valuetreatments,allowingthemtomakebetter,moreinformeddecisionsabouttheirdoctors,hospitalsandmedicalcare.”

No-ValueCare:ConsumersDemandIt



RowdMaphasno-valuecareandpopulationhealthbenchmarks for…

everyphysician

everyhospital

everyzipcode

…intheUnitedStates. Whatifyouknewwhichproviderswould

driveyoursuccess?

No-ValueCare:RowdMapHasIt



ABOUTROWDMAPWhatWeDo

RowdMap’sRisk-Readiness®benchmarkshelphealthplans,physiciangroups,andhospitalsystemsidentify,quantify,andreducedeliveryofno-valuecare— acentraltenetofsuccessful

pay-for-valueprograms.

31AllcontentsareproprietarytoRowdMap,Inc.andarebeingprovidedonaconfidentialbasis.

Anyuse,reproductionordistributionofthisinformation,inwholeorinpart,orthedisclosureofanyofitscontentswithoutthepriorwrittenconsentoftheCompany,isprohibited.

Leadingtheway…

USCTOonRowdMap:“VisionaryGenius”

ABOUTROWDMAPMarket&MediaResponse

…intheshiftfromfee-forservicetopay-for-value.

Andfeaturedin…RowdMapPartner



CMS:50%ofFFSwillbegoneby2018

Whatifyouknewwhichproviderswould

driveyoursuccess?

Whatifyouknewwhichproviderswouldsinkyou? WHATWOULDYOUDOIFYOUKNEW

whowillwinandwhowillloseinvaluebasedarrangements

Date post:	13-Feb-2017
Category:	Health & Medicine
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RowdMap Health Datapalooza Payer Provider Risk Readiness

Health & Medicine