The 2025 Project - Optum Forum - Health Care Event€¦ · an overall health delivery (physical and...

The 2025 Project: Applying Next-Generation Data and Methods to Market Transformation

Kyle M. Rose VICE PRESIDENT OF ANALYTICS

A NA LY TICS

Kyle Rose serves as vice president of Analytics at

OptumInsights, overseeing product management and

strategy for the Market Performance technology suite.

Previously, Kyle was executive director for Advisory

Board’s market analytics tools. In this capacity, he

founded and oversaw Crimson Market Advantage and

Planning 20/20 (both currently available through Optum

Analytics), which help providers use claims-based

analytics and market data to strengthen referring

relationships and increase market share.

Kyle was also a founding member and general manager

of Advisory Board’s Innovation Center and Technology

Insights research groups.

© 2019 Optum, Inc. All rights reserved. 2

Macro trends

• Payment and regulatory policy driving patients to lower cost settings

• Consumerism and price transparency

• Value-based care is nigh!

“Ambulatory” visibility, VBC among biggest concerns


Urgent needs

• Greater insight into patient journeys, especially in the upstream and downstream ambulatory spaces

• Visibility around patient access and origin

• Quality metrics for all market physicians to ensure appropriate care and control outcomes through care journey

Where Optum Analytics is placing its bets Ensuring your department is mission critical moving forward

Build a high-performing

CIN and Physician Network

Facilitating the bridge

from fee-for-service to

value-based-care with new

functionality for the planner

involvement. Identify

high-value physicians not

just based on volumes, but

care quality as well.

Right-size the

ambulatory footprint

Strategic planning merged

with master and facility

planning to determine what

an overall health delivery

(physical and operational

flow) footprint looks like.

Marrying opportunity

identification with specific

recommendations on the

type, location, size and

capabilities for ambulatory

investments.

Utilize demand

forecasting in a new era

Incorporating new, broad

data sets to bring

unprecedented levels of

accuracy and condition

specificity to demand

projections for custom

market definitions.

Recommend opportunities

for market development

based on a provider’s

maturity in value-based

care transformation.

Leverage the Golden

Consumer Record

Coordination between

planning and marketing

using longitudinal claims

and consumer data with

a strategic objective

around physician and

consumer growth.


Recall the story of Tantalus When will VBC outpace fee-for-service in your market?

2013 2018 2016

0%

10%

20%

30%

40%

50%

KLAS survey on the Pace of Transition from FFS to VBC n=39

<2 years or

already there

3–5 years

6–8 years

9+ years


Everybody’s somewhere … Where are you on a FFS-to-VBC maturity model?

Source: Crossing the Chasm: the Healthcare Chapter, Prashanth Kini.

Fee for service Bundled payments Comprehensive care –

Condition adjusted capitation

Comprehensive care and

bundled payment

Volume Value

Risk


We need to evolve as markets move to VBC How can we be of service during this precarious transition?

Addressing core physician

alignment issues

Aligned, but netw ork not

optimized to deliver on the

value proposition

Coordinating care

management across

the continuum

High-performing care delivery

netw ork built and functional Organizational

maturity:

• Identifying low -cost,

high-quality partners

• Constructing a targeted

clinical netw ork

• Needing to manage

referral leakage

• Moving beyond pilots to

increase number of lives

covered; increasing

geographical reach and

clinical scope

• Positioning to become

the netw ork of choice

• Cross-continuum care

management successes

w ith decreasing

inappropriate utilization

• Shifting referrals to high-

value providers

• Rew arding providers for

improved outcomes

• Partnerships formed across the

continuum: inclusive of

ambulatory, hospital, post-

acute and community providers

• Redesigned an effective

care model

• Obtained performance-

driven contracts

• Achieved “provider of choice”

status w ith the payers

“We invested in new

assets and capabilities,

but I am not sure where to

make future investments.”

“I’ve got physicians

aligned and engaged, but

I am not reaching the ROI

I expected.”

“We invested in new assets

and capabilities, but how

do I leverage them in a

focused, coordinated way?”

“With so many initiatives in play,

how do I strategically manage

the route and pace of migrating

to risk-based contracting?”

You are:

Need to answer:

All FFS All VBC


Using “big data” to help facilitate transition from FFS to VBC

False start #1 — “The 2X2 Matrix” (2012)

Adding a new dimension to

service line planning

Physician

revenue share

REFORM

Dr. A

Dr. B

PROTECT

RECRUIT

Physician quality profile

1. Bubble size represents “Payer Mix” based on % Commercial + Medicare patients.

2. To facilitate apples-to-apples comparisons, physicians A–X are of the same specialty.

AVOID


Physician

revenue share

Physician quality profile

Build a smarter network with blended clinical and claims data

1. Bubble size represents “Payer Mix” based on % Commercial + Medicare patients.

2. To facilitate apples-to-apples comparisons, physicians A–X are of the same specialty.

Low quality, high share

Determine clinical drivers

responsible for low-quality scores and design

performance improvement initiatives to address issues

High quality, high share

Focus on improving

relationship by making physician a “thought

partner” and educating on additional service offerings

High quality, low share

Conduct outreach to

cultivate relationship with physician and drive

increased patient flow to your organization

Low quality, low share

De-prioritize physicians

contributing low total value to the organization

Adding a new dimension to

service line planning

REFORM PROTECT

RECRUIT AVOID


False start #2 — “Project Felix” (2017)

Combining disparate data sources

Public data

CMS Standard Analytic Files,

MD; Hospital Compare

Hospital and physician data

Hospital and practice billing

charge data, clinical data;

admit/discharge/transfer data

Third-party proprietary data

National, all-payer claims data,

clinical society registries, Milliman

population health benchmarks

Qualitative survey data (custom)

Patient and clinician surveys

Other sources

States boards, private payers,

third-party ratings agencies


Drafting off of a decade+ of investments in quality data

360° view into physician performance

Illustrative measures Composite assessment of physicians in the market

Quality Complications, readmissions,

appropriate use

Cost Episode efficiency

Market activity Volumes, intensity mix

Patient access and

experience

Patient satisfaction, time to third

available appointment

MD education/

experience

Board certification, absence of

sanctions, education

Third-party ratings Vitals, castle Connolly, health plan

“preferred” status

Mark

et share

Value


Solving past problems with Optum’s market-leading Symmetry tools

Third time’s a charm!

Expected amounts

• Provider’s observed episodes of care

• Average cost and use from provider peers

Same mix of episodes

(ETGs and Risk Adjustment Unit)

• ETG with severity

• ETG with severity and surgery

• ETG with surgery, if no surgery use severity

Aggregate expected results summarized

• Profile service categories

• Pharmacy benefit Y/N © 2019 Optum, Inc. All rights reserved. 13

Fin

ancia

l valu

e

Clinical value

Goal is to only align with physicians who occupy this market

Symmetry’s benefits

Create a dynamic VBC maturity model powered by data

Quest to quantify a “well-managed market” Know where you stand in the transition from FFS to VBC


Creating a definition of a “well-managed market”

• Identify markets that are

known to have a lot of

risk-bearing contracts and

use them for comparison

• Use populations that are

known to be more highly

coordinated than average

• Ex: Medicare Advantage

or Delivery System

Reform Incentive Payment

(DSRIP)

• Use Symmetry Impact

Intelligence data set,

which includes cost and

care variation information

for all physicians across

all markets

• Objective source of quality

data for physicians

Doppelgänger method Canary in the coal mine method Symmetry method

Forecasting reimagined in the context of VBC

Demand forecasting needs a refresh


• National utilization rates

• Local demographics

• Market-level scenario planning

• Market-level utilization informed by

patient-level behavior

• Local demographics

• Population-level scenario planning

Before // Traditional forecasting After // Market-level forecasting

Pilot work underway with leading health systems

Introducing the forecasting 2.0 project

17

• Market doppelgänger (e.g., Pacific Northwest)

• “Well Managed” market goal-based model

• Apply client’s own ACO data to the rest of the market

Add VBC transition (aging) to current forecasting tool

• New facility

• New doc/practice

• New service

• Impact of share-shifting

Allow for dynamic forecasting

By popular demand: Create an integrated strategic and master planning toolkit

Asset-focused strategic planning Strategic planning merged with master and facility planning

Primary market:

• Hospitals + Health Systems

• HC Services (ED Physicians, Hospice, Dialysis, Specialty Clinics)

• Physician Practices

Demand Capacity Scenario

planning

Actionable

insights

What is the challenge

or opportunity?

What is our current

capacity?

What are the projections

of the proposed options?

What is the best

paths forward?

Secondary market:

• Consultants ( M+A, Strategy, Architects)

• HC Vendors (GE, Stryker, Aramark, Grainger)

• Pharmaceutical

• Payers

• HC Real Estate (REITS, Developers, Lenders)


Let ambulatory data be the impetus to streamline marking and strategic planning

Combining physician and consumer-focused growth into a single ambition

Define, plan and execute the goals

of the health system

Planner’s goal Marketer’s goal

Planning 20/20 helps answer questions like:

• What is my strategy for inpatient/outpatient?

• What assets do I have or need?

• Does this match my consumer needs? Can

I provide the level of service they want?

• What business model does this address?

Improve revenue through targeting consumer

acquisition, engagement and loyalty

Consumer Acquisition Services helps

answer questions like:

• Who are the right consumers to attract

and engage?

• Where can I find them? What gets them

in the door?

• What services match their needs? What

info should I provide? How do I keep

them coming back

Longitudinal data unlocks collaboration between planning and marketing


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The 2025 Project - Optum Forum - Health Care Event€¦ · an overall health delivery (physical and...

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