All contents are proprietary to RowdMap, Inc. and are being provided on a confidential basis.Any use, reproduction or distribution of this information, in whole or in part, or the disclosure of any of its contents
without the prior written consent of the Company, is prohibited.
Are you Risk-Ready?Using Government Benchmarks to Identify, Quantify and
Reduce Low and No-Value Care to Succeed in Risk
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CMS: 50% of FFS will be gone by 2018
CMS Means Business!
These are just the first pieces to move and transforming
payment across the system!
Current payment models aren’t changing provider behavior. Providers need help.
Effects of Health Care Payment Models on Physician Practice in the United States, May 2015.
CMS and The End of FFSGoals for Value
3
Paid more to perform more & higher intensity services
Investment in capital for higher intensity services to attract profitable service lines
Sicker population may be more profitable
Paid the same regardless of service volume & intensity
Investment in efficient and valuable providers & services
Healthier population is more profitable
FFSStatus Quo
BPCIVoluntary
ValueMandatory
System incentivized to keep people healthy and out of the operating room
and physician office
CJRMandatory
PCMHVoluntary
MSSPVoluntary
Next-Gen
Voluntary
This is only the beginning. CMS is getting more aggressive in pushing providers towards risk with the goal of value/capitation
FFS Reimbursement Experimentation/Bridge the Gap Value-Based
System incentivized to do stuff –Visits, procedures, scripts
System incentivized meet quality outcomes and reduce cost
incrementally
The Future
CMS and The End of FFSGoals for Value
4All contents are proprietary to RowdMap, Inc. and are being provided on a confidential basis.
Any use, reproduction or distribution of this information, in whole or in part, or the disclosure of any of its contents without the prior written consent of the Company, is prohibited.
Value-Based ReimbursementFFS Reimbursement
Perc
ent o
f Rev
enue
Time
Identify & Quantity
Value
Population Health as Social
Investment
Profit through bonuses or savings against a flawed
benchmark
Population Health Proficiency as
Profit Driver
Profit through pop health management and low value care reduction
Short Term:Capture Savings from Program Design Flaws
Success driven by market drivers & network performance
Long Term:Success from Efficient Networks
Value driven by overall population health outcomes and system efficiency
Make the leap
Are You Risk-Ready?Making the Leap
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Any use, reproduction or distribution of this information, in whole or in part, or the disclosure of any of its contents without the prior written consent of the Company, is prohibited.
We’ve Been Asking the Wrong Questions
How can we capture value by keeping a population healthy?
The best clinical performers may be generating the most no-value
care because of FFS incentives
Are You Risk-Ready?Ask the Right Questions
6
Are You Risk-Ready?The High Stakes of Low-Value Care
The economic driver for pay for value programs is the ability of a government program or marketplace arrangement to not only achieve Triple Aim goals but to also mitigate Low-Value services, which account for thirty cent of every dollar spent on the delivery of care.
Over $9B in Orange County, CA
$850 Billion Unnecessary Spend in 2014(Institute of Medicine)
Institute of Medicine (IOM) report, “Best Care at Lower Cost,” (Sept. 2012) estimates that the United States lost $750 billion in 2012. (Adjusted in 2013 at $800BB, 2014 at $850BB.)
This is about 3% of GDP or roughly the DOD budget for the Iraq War over an 8 year span.
No-Value Care (30%)
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
“Bigger than higher prices, administrative expenses, and
fraud, however, was the amount spent on unnecessary health-care
services.” In just a single year, up to 42% of patients receive
“No Value” Care.
- Dr. Atul Gawande, Department of Health Policy and
Management at the Harvard School of Public Health &
Department of Surgery at Harvard Medical School
All contents are proprietary to RowdMap, Inc. and are being provided on a confidential basis.Any use, reproduction or distribution of this information, in whole or in part, or the disclosure of any of its contents
without the prior written consent of the Company, is prohibited.
CMS is Paying On It
2016 World Economic ForumAnnual Meeting in Switzerland
On track to sunset 50% of FFS
They Mean Business!
All contents are proprietary to RowdMap, Inc. and are being provided on a confidential basis.Any use, reproduction or distribution of this information, in whole or in part, or the disclosure of any of its contents
without the prior written consent of the Company, is prohibited.
Media Is Reporting on It
“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.
As value-based payments increase, physicians will finally be rewarded for quality, rather than quantity of care.
With financial incentives, doctors who practice efficient medicine will get even better, while doctors who have made a living on fee-for-service will have to change their practice patterns, or be left behind.
Our Risk-Readiness® metrics will make your material unique in educating the general public on the changes that are coming to their health care.
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CMS is committed to value-based care.Physicians and Payers know it. Now let’s tell consumers.
Population Health in a Value Based World The High Stakes of Low-Value Care
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without the prior written consent of the Company, is prohibited.
Patients Demand It
"It's no secret that patients often undergo unnecessary procedures that can be dangerous and costly." Through our collaboration with RowdMap, we are providing patients with meaningful information about these no- or low-value treatments, allowing them to make better, more informed decisions about their doctors, hospitals and medical care.”
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No Value Care Meets No IT NeededNo Value Care
The economic driver behind both the policy push and market drive towards value based programs, as well as the criteria for success in value based programs is the ability of a government program to reduce Low-Value Services.
Research Evaluating CMS & Private Plan Programs: “Do they reduce Low Value care?”
CMS Critique of Fee for Service: “FFS has too much Low Value care.”
Popular Press Reporting and Provider Rankings:“Consumers are/should avoid Low value care.”
“…care management programs should incorporate a system for evaluating low- or no-value care (i.e., higher intensity treatments that do not yield better outcomes).”
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Leading the way…
US CTO on RowdMap: “Visionary
Genius”
ABOUT ROWDMAPCMS Knows We Help You
…in the shift from fee-for service to pay-for-value.
CMS: 50% of FFS will be gone by 2018 Current payment models aren’t changing
provider behavior. Providers need help.
Effects of Health Care Payment Models on Physician Practice in the United States, May 2015.
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Any use, reproduction or distribution of this information, in whole or in part, or the disclosure of any of its contents without the prior written consent of the Company, is prohibited.
RowdMap is a Risk Management Tool to match and support the evolution of the payment
system towards paying for long-term value (better health outcomes for fewer $ over time)
RowdMap identifies the fundamental building blocks that enable the consistent delivery of high value care
ABOUT ROWDMAPWhat We Do
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ABOUT ROWDMAPWhat We Do
RowdMap’s Risk-Readiness® benchmarks help health plans, physician groups, and hospital systems identify, quantify, and reduce delivery of
no-value care—a central tenet of successful pay-for-value programs.
RowdMap has no-value care and population health benchmarks for…
every physician
every hospital
every zip code
…in the United States.
“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
No-Value Care (30%)
Necessary Utilization(70%)
Did you know that more than $850 billion in no-value care is delivered annually in the U.S?
15All contents are proprietary to RowdMap, Inc. and are being provided on a confidential basis.
Any use, reproduction or distribution of this information, in whole or in part, or the disclosure of any of its contents without the prior written consent of the Company, is prohibited.
Health plans and providers in 46 states and the District of Columbia use RowdMap’s benchmarks to reduce the delivery of no-value care.
RowdMap’s benchmarks help manage the $850 billion the nation spends on care that leads to no better outcomes.
The clients RowdMap serves collectively cover the lives of more than 91 million Americans.
RowdMap was founded in 2011 and has grown to more than 30 employees with offices in Louisville, KY and Portland, ME.
ABOUT ROWDMAPRowdMap by the Numbers
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No Value Care Meets No IT NeededUnexplained Variation
Often Low-Value Care is the result of perverse incentives from Fee for Service payment models but identifiable as unexplained variation within practice patterns.
The estimated 30% of medical expense that goes to no-value care.
Unnecessary spending drives billing in a fee-for-serve economic model, but success in pay-for-value comes from managing and mitigating these pockets of variation.
Variation: Unwarranted or Unexplained?Every physician has a unique fingerprint
Economic Drill Down: Example Utilization Review and Actuarial Unit Cost Analysis against Care Intensity Curve across Total Basket of Care
Variation across geographies and within practices across physicians.“Physician-Level Practice Variation: Who You See Is What You Get”
Brian Powers, Sachin Jain, David Cutler, and Ziad ObermeyerHealth Affairs, September 23, 2015
Definitions, research and geocoding by Hospital Referral Regional available via the Dartmouth Atlas for Unwarranted Variation:www.dartmouthatlas.org
NB: Unwarranted variation refers to practice patterns, which hold up across populations but pricing variation may also be unwarranted and marked fluctuates across insurance product and lines and geography. “The Price Ain’t Right.” Cooper, Craig, Gaynor and Van Reenen, 2015.
17All contents are proprietary to RowdMap, Inc. and are being provided on a confidential basis.
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Providers in a MarketGroups
Individual Physicians
What is driving a provider’s Risk-Readiness®? Is it procedures, prescriptions, referrals or visits?
How big is a provider’s panel?
How ready is a provider to succeed in risk
compared to peers? By specialty?
Within a region?
Finger print with practice patterns that mitigate no-value care = Green Dot
Finger print with practice patterns that create no-value care = Red Dot
Benchmarks for Risk-Readiness®
No Value Care Meets No IT NeededIdentifying Success in Pay for Value
18All contents are proprietary to RowdMap, Inc. and are being provided on a confidential basis.
Any use, reproduction or distribution of this information, in whole or in part, or the disclosure of any of its contents without the prior written consent of the Company, is prohibited.
No Value Care Meets No IT NeededNew Government Data
Referral Files(Patient flows between PCPS, specialists, hospitals and post acute centers)
Dartmouth Atlas of Health Care & Choosing Wisely(Decades of research and data on unwarranted variation by condition and geography to keep things apples-to-apples for comparisons)
CMS FFS Data Sets, CDC Data Sets (MEDPAR, Part B, Part D, BRFSS)(Individual providers, groups, hospitals and post acute centers)
Provider Pattern Intensity Profiles and Risk Readiness® for every provider, hospital, post acute center in the US. All preloaded with no IT.
Affordable Care Act data to determine Risk-Readiness® of Providers / Networks
Trick Is Tying It together
19All contents are proprietary to RowdMap, Inc. and are being provided on a confidential basis.
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No Value Care Meets No IT NeededBackend Technology
Your long term approach to Population Health
must emphasize high value networks
above all else.
20
You can’t reach true population health by chasing inconsistent and imperfect experimental programs
Pop Health is only profitable when you are able to identify, quantify and eliminate low value services.
A network built on efficient providers is the key to success in moving towards true population health.
Are you Ready for Risk?Share benchmarks with physiciansIncorporate benchmarks into compensation/gain shareInclude Efficiency criteria in hiring or network inclusion decisions
Are Your Partners Risk Ready?Make a short list of key partnersManage referrals into these key partnersInclude key partners in additional gain share opportunities
What are my best Opportunities for Risk?Assess your Network’s ability to succeed in arrangements/programsStrategically plan for an efficient network and take on more riskLearn to negotiate with payers from a position of strength
Risk-ReadinessⓇ benchmarks answer three questions:
No Value Care Meets No IT NeededEfficiency Networks Drive Value
21All contents are proprietary to RowdMap, Inc. and are being provided on a confidential basis.
Any use, reproduction or distribution of this information, in whole or in part, or the disclosure of any of its contents without the prior written consent of the Company, is prohibited.
Are you Ready for Risk?Manage Internal Variation Provider Contracting Strategy Provider Compensation Strategy Process Variation & Improvement Service Line Benchmarking Provider Reporting Provider Recruitment & CIN Build Value Chain & Leakage Reporting Medical Economics Reporting
Are Your Partners Risk Ready?Pick the Best Partners for Risk Arrangements Primary Care Referral Source Analysis Acute Care Partner Reporting Post Acute Partner Reporting Consulting/Specialty Partner Analysis Competing Groups/Orgs Analysis
What are my best Opportunities for Risk?Match Providers to Risk• Risk-Matching to Payers: Government & Private Payers • Payer Negotiation Reporting • Medical Economics Modeling
No Value Care Meets No IT NeededIdentifying Success in Pay for Value
22All contents are proprietary to RowdMap, Inc. and are being provided on a confidential basis.
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How do groups and individual providers within the groups compare to their peers and competition?
Share information about a provider’s risk-readiness against peers and competition to compare how well they are able to succeed in value base
and risk arrangements.
Provider ReportingPhiladelphia, PA
No Value Care Meets No IT NeededIdentifying Success in Pay for Value
23All contents are proprietary to RowdMap, Inc. and are being provided on a confidential basis.
Any use, reproduction or distribution of this information, in whole or in part, or the disclosure of any of its contents without the prior written consent of the Company, is prohibited.
No Value Care Meets No IT NeededIdentifying Success in Pay for Value
PCPs
Regional Benchmarks
Pima Co, AZ
Am I incentivizing providers in a way that will be successful in risk arrangements?
Incentivize individual physicians based on their overall risk-readiness benchmark and their individual drivers (procedures, prescriptions and
referrals) to succeed in value based and risk arrangements.
Provider Compensation Strategy
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No Value Care Meets No IT NeededIdentifying Success in Pay for Value
Provider Recruitment & CIN Build
How do you design and implement CIN that succeed in value based arrangements?
Select providers that are risk-ready and complement each other’s practice patterns to create a CIN that succeeds in value based and risk
arrangements.
Saint Louis, MO
25All contents are proprietary to RowdMap, Inc. and are being provided on a confidential basis.
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No Value Care Meets No IT NeededIdentifying Success in Pay for Value
Value Chain & Leakage Reporting
Primary Care Docs
Specialist Post Acute Facility
Thickness of lines indicates the number of referrals. Note: Some markets are
oversupplied. This market is controlled by one provider.
Less efficient
More efficient
How does your population flow through the care continuum and when and where do they fall out?
Identify natural patient flows and determine if your network is breaking them or reinforcing high value pathways then incentivize
providers to optimize referrals.
Target this PCP / DX Radiologist to refer more patients to the higher
performing specialist
26All contents are proprietary to RowdMap, Inc. and are being provided on a confidential basis.
Any use, reproduction or distribution of this information, in whole or in part, or the disclosure of any of its contents without the prior written consent of the Company, is prohibited.
No Value Care Meets No IT NeededIdentifying Success in Pay for Value
Value Chain & Leakage Reporting
How does your population flow through the care continuum and when and where do they fall out?
Identify natural patient flows and determine if your network is breaking them and causing leakage address through
contracting, education and incentives.
University of Miami is underperforming and referrals are internal.
This is a concentrated, low value pathway.
Holy Cross has high performing specialists, but its PCPs are referring to a variety of specialists.
This is a fragmented, but high value pathway.
Group Receiving Referrals
GroupSending Referrals
27All contents are proprietary to RowdMap, Inc. and are being provided on a confidential basis.
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No Value Care Meets No IT NeededIdentifying Success in Pay for Value
Medical Economics Reporting
How much no value care are you paying for and how much you can save by line of business and down to individual providers?
Determine the specific economic impact that you create for whoever owns the risk you manage.
Decreased Cost
Average
Increased Cost
Less
Effi
cien
t
1
2
3
4
5
Mor
e Effi
cien
t
$ PMPY per Specialty & Efficiency Score
CARDIAC SURGERY
GASTROENTEROLOGY
ORTHOPEDIC SURGERY
DIAGNOSTIC RADIOLOGY PATHOLOGY
$609 $228 $334 $65 $79
$770 $253 $365 $71 $88
$973 $271 $419 $72 $91
$1,191 $303 $467 $121 $106
$1,299 $387 $624 $245 $212
Cardiac Surgery
Gastroenterology
OrthoSurgeon
Diagnostic Radiology Pathology
Impact on Spend
Risk-Readiness®Benchmark
Florida
28All contents are proprietary to RowdMap, Inc. and are being provided on a confidential basis.
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No Value Care Meets No IT NeededIdentifying Success in Pay for Value
Medical Economics Reporting
How much no value care are you paying for and how much you can save by line of business and down to individual providers?
Identify how much no-value care you are mitigating and the specific cost savings it generates for whoever owns the risk.
$ PMPY per Specialty by County In & Out
Network
In Network
Out of Network
Scenario: Removing the lowest performing physicians
Drill down into Pima County (Phoenix) The highest $PMPY in
Phoenix is with in network GI docs at $643
In this scenario, they would have the greatest drop
in $PMPY at $119. ($634 - $119 = $524)
Arizona
$ PMPY per Specialty & Efficiency Score
29All contents are proprietary to RowdMap, Inc. and are being provided on a confidential basis.
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No Value Care Meets No IT NeededIdentifying Success in Pay for Value
Primary Care Referral Source Analysis
Referrals to Orthopedists
GroupSending Referrals
Group Receiving Referrals
Group Receiving Referrals
Group Receiving Referrals
Group Receiving ReferralsGroup Receiving Referrals
Individual Physicians
Receiving Referrals
Number of Referrals Performance of Physicians Receiving
Referrals
Which PCPs are sending patients to a given specialist and how well do those PCPs perform?
Make sure your PCPs are sending to high performing specialists who are Risk-Ready to succeed in value based and risk arrangements.
30All contents are proprietary to RowdMap, Inc. and are being provided on a confidential basis.
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No Value Care Meets No IT NeededIdentifying Success in Pay for Value
Acute Care Partner Reporting
Which Hospitals are Risk Ready and what are the drivers of success?
Identify the hospitals that are risk-ready and the drivers behind their practice patterns to succeed in pay for value and risk arrangements.
California
31All contents are proprietary to RowdMap, Inc. and are being provided on a confidential basis.
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No Value Care Meets No IT NeededIdentifying Success in Pay for Value
Acute Care Partner ReportingCost by DRG
Norton
Medical SurgicalMedical
Surgical
Baptist
Which Hospitals are Risk Ready and what are the drivers of success?
Determine which hospitals are the most efficient and have incentive to work with your specialty in value based arrangements.
32All contents are proprietary to RowdMap, Inc. and are being provided on a confidential basis.
Any use, reproduction or distribution of this information, in whole or in part, or the disclosure of any of its contents without the prior written consent of the Company, is prohibited.
No Value Care Meets No IT NeededIdentifying Success in Pay for Value
Post Acute Care Partner ReportingWestchester County, NY
Which Post Acute Facilities are Risk Ready and what are the drivers of success?
Identify the post acute centers that are risk-ready and the drivers behind their practice patterns to succeed in pay for value and risk
arrangements
Home Health Top ProvidersOrange = Preferred
33All contents are proprietary to RowdMap, Inc. and are being provided on a confidential basis.
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Regional Benchmarks
Consulting/Specialty Partner Analysis
Which Partners are Risk Ready and what are the drivers of success?
Identify the consulting and specialty partners that are risk-ready and the drivers behind their practice patterns to succeed in pay for value
and risk arrangements
Harris County, TX
No Value Care Meets No IT NeededIdentifying Success in Pay for Value
34All contents are proprietary to RowdMap, Inc. and are being provided on a confidential basis.
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Risk-Matching to Payers: Government & Private Payers Largest Counties in TX
Regional Benchmarks
Risk Scores Health Rank
Network Opportunity
Profit Opportunity
MA
Profit Opportunity
Exchange
MedicareEligibles /
MA Enrolled
ExchangeSubsidy Eligibles /Exchange Enrolled
MedicaidBeneficiary Eligibles /
Beneficiaries
Which value based programs or risk arrangements will be successful in my population?
Identify my population’s socio-demographics, health behaviors and prevalence that lead to success in specific value based programs and
private payer risk arrangements
No Value Care Meets No IT NeededIdentifying Success in Pay for Value
35All contents are proprietary to RowdMap, Inc. and are being provided on a confidential basis.
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Payer Negotiation Reporting
How do I use government benchmark data to negotiate to my strengths and a payer’s weaknesses?
Identify performance against national and regional benchmarks. Highlight where you perform well, addresses and have an explanation
and/or plan for areas that need work.
No Value Care Meets No IT NeededIdentifying Success in Pay for Value
36All contents are proprietary to RowdMap, Inc. and are being provided on a confidential basis.
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Population Health & Supply Impact on Risk-Readiness®
Risk-Matching to Payers: Government & Private Payers
Which value based programs or risk arrangements will be successful in my population?
You practice in geographies with specific population health profiles and a specific supply of care, so these are the pressures you will face
No Value Care Meets No IT NeededIdentifying Success in Pay for Value
37All contents are proprietary to RowdMap, Inc. and are being provided on a confidential basis.
Any use, reproduction or distribution of this information, in whole or in part, or the disclosure of any of its contents without the prior written consent of the Company, is prohibited.
RowdMap provides data and analysis on Population Health factors that drive success in value-based programs:
Behaviors – Broader Definitions of Health with Behaviors
Utilization – Utilization and Costs of Procedures and Drugs
Prevalence – Major Diseases and Conditions
Supply – Number of Primary Care Physicians and Specialists
Socio-demographics – Income, Environment, etc.
Match your strategies to
your population to succeed in value-based
programs
No Value Care Meets No IT NeededIdentifying Success in Pay for Value
38All contents are proprietary to RowdMap, Inc. and are being provided on a confidential basis.
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What is the financial impact of no value care that you create for payers that you are not getting credit for?
Identify performance against national and regional benchmarks. Highlight where you perform well, addresses and have an explanation
and/or plan for areas that need work.
Each dot is a physician.
Groups are created from specialty, network status,
Efficiency score, and geography
Dr. SpockNPI: 15000000123
$PMPY: $874
Savings for removing 5’s
form in Network
Medical Economics Modeling
No Value Care Meets No IT NeededIdentifying Success in Pay for Value
39All contents are proprietary to RowdMap, Inc. and are being provided on a confidential basis.
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Find the right value based program based on your provider patterns around no-value care.
Identify the most efficient providers; this may not show up in utilization
review or unit cost analysis. Then negotiate like a pro.
Now, take on risk to capture the value you create through pop health
No Value Care Meets No IT NeededCapture the Value You Create
40All contents are proprietary to RowdMap, Inc. and are being provided on a confidential basis.
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No Value Care Meets No IT NeededCapture the Value You Create
CMS: 50% of FFS will be gone by 2018
What if you knew which providers would
drive your success?
What if you knew which providers would sink you? WHAT WOULD YOU DO IF YOU KNEW
who will win and who will lose in value based arrangements