CREATING A VIRTUOUS CYCLE - ehcca.com · FOR BOTH PAYERS AND PROVIDERS USING CMS BENCHMARK DATA...
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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 CREATING A VIRTUOUS CYCLE - ehcca.com · FOR BOTH PAYERS AND PROVIDERS USING CMS BENCHMARK DATA...
CREATINGAVIRTUOUSCYCLE:DESIGNINGNETWORKSTOMITIGATENO-VALUECAREFROMFEEFORSERVICEANDCREATEVALUE-BASEDWINSFORBOTHPAYERSANDPROVIDERSUSINGCMSBENCHMARKDATA
PositiveDisruption
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
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
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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
No-ValueCare:CMSIsPayingonIt
2016 World Economic ForumAnnual Meeting in Switzerland
Ontracktosunset50%ofFFS
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.”
“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
No-ValueCare:Doc.s FocusonIt
Over70SpecialtySocieties
No-ValueCare:MarketDemandsIt
“TheTaskForcerecommendsthatCMSconsidertheadditionofsuchinformationintobaseline/benchmarkcalculations.”
“Wesuggestthatentitiesstructuringcaremanagementprograms…monitortheextenttowhichtheparticipatingprovidersaredeliveringlow- orno-valuecare.”
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.
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
No-ValueCare:InnovationFoundedonIt
RowdMaphasno-valuecareandpopulationhealthbenchmarks for…
everyphysician
everyhospital
everyzipcode
…intheUnitedStates.
Whatifyouknewwhichproviderswould
driveyoursuccess?
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.
No-ValueCare:PositiveDisruption:AVirtuousCycle
Told‘ya
MarketIncentive
OpenData
PositiveDisruptioninaComplexSystem
DataLiberators
VirtuousCyclesThreeExamples
AliKhan,MedicalOfficeratCareMore,anAnthemCompany
SteveOndra,ChiefMedicalOfficeratHealthCareServiceCorporation(BlueCrossandBlueShieldofIllinois,Montana,NewMexico,OklahomaandTexas)andSeniorPolicyAdvisorforHealthAffairsattheDepartmentofVeteransAffairsinWashington,DC
JonathanBlum,ExecutiveVicePresidentatCareFirstBlueCrossBlueShieldandFormerPrincipalDeputyAdministratoratCentersforMedicareandMedicaidServices
VirtuousCyclesThreeExamples
AliKhan,MedicalOfficeratCareMore,anAnthemCompany
SteveOndra,ChiefMedicalOfficeratHealthCareServiceCorporation(BlueCrossandBlueShieldofIllinois,Montana,NewMexico,OklahomaandTexas)andSeniorPolicyAdvisorforHealthAffairsattheDepartmentofVeteransAffairsinWashington,DC
JonathanBlum,ExecutiveVicePresidentatCareFirstBlueCrossBlueShieldandFormerPrincipalDeputyAdministratoratCentersforMedicareandMedicaidServices
VirtuousCyclesThreeExamples
AliKhan,MedicalOfficeratCareMore,anAnthemCompany
SteveOndra,ChiefMedicalOfficeratHealthCareServiceCorporation(BlueCrossandBlueShieldofIllinois,Montana,NewMexico,OklahomaandTexas)andSeniorPolicyAdvisorforHealthAffairsattheDepartmentofVeteransAffairsinWashington,DC
JonathanBlum,ExecutiveVicePresidentatCareFirstBlueCrossBlueShieldandFormerPrincipalDeputyAdministratoratCentersforMedicareandMedicaidServices
VirtuousCyclesThreeExamples
AliKhan,MedicalOfficeratCareMore,anAnthemCompany
SteveOndra,ChiefMedicalOfficeratHealthCareServiceCorporation(BlueCrossandBlueShieldofIllinois,Montana,NewMexico,OklahomaandTexas)andSeniorPolicyAdvisorforHealthAffairsattheDepartmentofVeteransAffairsinWashington,DC
JonathanBlum,ExecutiveVicePresidentatCareFirstBlueCrossBlueShieldandFormerPrincipalDeputyAdministratoratCentersforMedicareandMedicaidServices
