RowdMap Health Datapalooza Creating a Virtual Cycle: designing networks to mitigate no-value care...

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CREATING A VIRTUOUS CYCLE: DESIGNING NETWORKS TO MITIGATE NO-VALUE CARE FROM FEE FOR SERVICE AND CREATE VALUE-BASED WINS FOR BOTH PAYERS AND PROVIDERS USING CMS BENCHMARK DATA Positive Disruption

Transcript of RowdMap Health Datapalooza Creating a Virtual Cycle: designing networks to mitigate no-value care...

Page 1: RowdMap Health Datapalooza Creating a Virtual Cycle: designing networks to mitigate no-value care from fee for service and create value-based wins for both payers and providers using

CREATINGAVIRTUOUSCYCLE:DESIGNINGNETWORKSTOMITIGATENO-VALUECAREFROMFEEFORSERVICEANDCREATEVALUE-BASEDWINSFORBOTHPAYERSANDPROVIDERSUSINGCMSBENCHMARKDATA

PositiveDisruption

Page 2: RowdMap Health Datapalooza Creating a Virtual Cycle: designing networks to mitigate no-value care from fee for service and create value-based wins for both payers and providers using

OWNINGRISKISTOUGH,BUTIT’SWHERETHEACTION’SAT

Onceuponatimeplans hadlargegroupcommercialpopulationswithyearsofconsistency andproviderssimply deliveredservices forafee.ButgovernmentprogramslikeMedicareAdvantage,Marketplace/ExchangeandMedicaid, havepopulations changingeveryyear,oreveneverymonthandprovidersmanagingapopulation's healthovertime.

Changingpopulations anddynamic paymentmodelsmaymakeittoughtopredictandachievememberoutcomesinafinancially sustainablewaypreciselywhenprovidersaregettinginthegametotakeonrisk.

Public healthdataareproviding solid casestudies ofachievingmemberhealthandhappiness withsustainable financialmodels forallplayersinthisnewgame.

Ifyouaremanagingrisk,considering takingonrisk, orinvestinginorproviding productsorservicestoanyonebearingrisk, campoutinthesesessions tolearnhowtousepublicdataandinternalresourcesto:

§ Effectivelyleverageanalytic approachestomanagerisk

§ Accuratelyassess risksandprojectcosts

§ Effectivelyalignprovidersandincentivizecaredelivery

Page 3: RowdMap Health Datapalooza Creating a Virtual Cycle: designing networks to mitigate no-value care from fee for service and create value-based wins for both payers and providers using

CREATINGAVIRTUOUSCYCLE:DESIGNINGNETWORKSTOMITIGATENO-VALUECAREFROMFEEFORSERVICEANDCREATEVALUE-BASEDWINSFORBOTHPAYERSANDPROVIDERSUSINGCMSBENCHMARKDATA

ValueProposition: DesigningandCuratingaPay-for-ValueReadyNetwork

Moderator:JoshuaRosenthal,Co-FounderandChiefScientificOfficeratRowdMap,Inc.

Panelists:JonathanBlum,ExecutiveVicePresidentatCareFirstBlueCrossBlueShield andFormerPrincipalDeputyAdministratoratCentersforMedicareandMedicaidServices;AliKhan,MedicalOfficeratCareMore,anAnthemCompany;SteveOndra,ChiefMedicalOfficeratHealthCareServiceCorporation(BlueCrossandBlueShieldplansinIllinois,Montana,NewMexico,OklahomaandTexas)andSeniorPolicyAdvisorforHealthAffairsattheDepartmentofVeteransAffairsinWashington,DC

Page 4: RowdMap Health Datapalooza Creating a Virtual Cycle: designing networks to mitigate no-value care from fee for service and create value-based wins for both payers and providers using

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No-ValueCare(30%)

NecessaryUtilization(70%)

CareThatDoesn’tProduceBetterOutcomes$850BillionUnnecessarySpendin2014

(InstituteofMedicine)

No-ValueCare:.30/Each$IsWasted

“It’sgenerallyagreedthatabout30percentofwhatwespendonhealthcareisunnecessary.Ifweeliminatetheunneededcare,therearemorethanenoughresourcesinoursystemtocovereverybody.”

-Dr.ElliottFisher,DartmouthInstitutefor

HealthPolicy

Page 5: RowdMap Health Datapalooza Creating a Virtual Cycle: designing networks to mitigate no-value care from fee for service and create value-based wins for both payers and providers using

No-ValueCare:CMSIsPayingonIt

2016 World Economic ForumAnnual Meeting in Switzerland

Ontracktosunset50%ofFFS

Page 6: RowdMap Health Datapalooza Creating a Virtual Cycle: designing networks to mitigate no-value care from fee for service and create value-based wins for both payers and providers using

No-ValueCare:SuccessDefinedbyIt

“During its first year, the Pioneer ACO program was associated with modest reductions in low-value services, with greater reductions for organizations providing more low-value care. Accountable care organization–like risk contracts may be able to discourage use of low-value services even without specifying services to target.”

Page 7: RowdMap Health Datapalooza Creating a Virtual Cycle: designing networks to mitigate no-value care from fee for service and create value-based wins for both payers and providers using

“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

Page 8: RowdMap Health Datapalooza Creating a Virtual Cycle: designing networks to mitigate no-value care from fee for service and create value-based wins for both payers and providers using

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

No-ValueCare:ConsumersDemandIt

Page 9: RowdMap Health Datapalooza Creating a Virtual Cycle: designing networks to mitigate no-value care from fee for service and create value-based wins for both payers and providers using

No-ValueCare:Doc.s FocusonIt

Over70SpecialtySocieties

Page 10: RowdMap Health Datapalooza Creating a Virtual Cycle: designing networks to mitigate no-value care from fee for service and create value-based wins for both payers and providers using

No-ValueCare:MarketDemandsIt

“TheTaskForcerecommendsthatCMSconsidertheadditionofsuchinformationintobaseline/benchmarkcalculations.”

“Wesuggestthatentitiesstructuringcaremanagementprograms…monitortheextenttowhichtheparticipatingprovidersaredeliveringlow- orno-valuecare.”

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No-ValueCare:DecadesofResearchonIt

Theestimated30%ofmedicalexpensethatgoestono-valuecare.

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

Variation:UnwarrantedorUnexplained?Everyphysicianhasauniquefingerprint

EconomicDrillDown:ExampleUtilizationReviewandActuarialUnitCostAnalysisagainstCareIntensityCurveacrossTotalBasketofCare

Variationacrossgeographiesandwithinpracticesacrossphysicians.“Physician-Level PracticeVariation:WhoYouSeeIsWhatYouGet”BrianPowers,SachinJain,DavidCutler,&ZiadObermeyerHealthAffairs,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.

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No-ValueCare:CMSOpensDataonIt

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

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No-ValueCare:InnovationFoundedonIt

RowdMaphasno-valuecareandpopulationhealthbenchmarks for…

everyphysician

everyhospital

everyzipcode

…intheUnitedStates.

Whatifyouknewwhichproviderswould

driveyoursuccess?

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No-ValueCare:MarketAdoptingIt

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.

Page 15: RowdMap Health Datapalooza Creating a Virtual Cycle: designing networks to mitigate no-value care from fee for service and create value-based wins for both payers and providers using

No-ValueCare:PositiveDisruption:AVirtuousCycle

Told‘ya

MarketIncentive

OpenData

PositiveDisruptioninaComplexSystem

DataLiberators

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VirtuousCyclesThreeExamples

AliKhan,MedicalOfficeratCareMore,anAnthemCompany

SteveOndra,ChiefMedicalOfficeratHealthCareServiceCorporation(BlueCrossandBlueShieldofIllinois,Montana,NewMexico,OklahomaandTexas)andSeniorPolicyAdvisorforHealthAffairsattheDepartmentofVeteransAffairsinWashington,DC

JonathanBlum,ExecutiveVicePresidentatCareFirstBlueCrossBlueShieldandFormerPrincipalDeputyAdministratoratCentersforMedicareandMedicaidServices

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VirtuousCyclesThreeExamples

AliKhan,MedicalOfficeratCareMore,anAnthemCompany

SteveOndra,ChiefMedicalOfficeratHealthCareServiceCorporation(BlueCrossandBlueShieldofIllinois,Montana,NewMexico,OklahomaandTexas)andSeniorPolicyAdvisorforHealthAffairsattheDepartmentofVeteransAffairsinWashington,DC

JonathanBlum,ExecutiveVicePresidentatCareFirstBlueCrossBlueShieldandFormerPrincipalDeputyAdministratoratCentersforMedicareandMedicaidServices

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VirtuousCyclesThreeExamples

AliKhan,MedicalOfficeratCareMore,anAnthemCompany

SteveOndra,ChiefMedicalOfficeratHealthCareServiceCorporation(BlueCrossandBlueShieldofIllinois,Montana,NewMexico,OklahomaandTexas)andSeniorPolicyAdvisorforHealthAffairsattheDepartmentofVeteransAffairsinWashington,DC

JonathanBlum,ExecutiveVicePresidentatCareFirstBlueCrossBlueShieldandFormerPrincipalDeputyAdministratoratCentersforMedicareandMedicaidServices

Page 19: RowdMap Health Datapalooza Creating a Virtual Cycle: designing networks to mitigate no-value care from fee for service and create value-based wins for both payers and providers using

VirtuousCyclesThreeExamples

AliKhan,MedicalOfficeratCareMore,anAnthemCompany

SteveOndra,ChiefMedicalOfficeratHealthCareServiceCorporation(BlueCrossandBlueShieldofIllinois,Montana,NewMexico,OklahomaandTexas)andSeniorPolicyAdvisorforHealthAffairsattheDepartmentofVeteransAffairsinWashington,DC

JonathanBlum,ExecutiveVicePresidentatCareFirstBlueCrossBlueShieldandFormerPrincipalDeputyAdministratoratCentersforMedicareandMedicaidServices


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