health, risk and analytics...advanced analytics will help you assess utilization, total cost of...

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Health, Risk and Analytics

Data-Driven Solutions for a Competitive Advantage

Erin Morrow; Managing Director1-855-858-1946 www.ELMandAssociates.com

http://www.elmandassociates.com/

Strategic Population Health Integration

Empowerment to Contain Costs with Actionable Insights

One of the earliest and most accurate risk adjustment and predictive modelingsolutions, DxCG has emerged as the gold standard, serving as the cornerstone ofmodern value-based healthcare.

>140 models are grouped into 3 primary functional bundles

Budgeting & underwriting Medical Management Performance Assessment

DxCG Intelligence


It’s not enough to produce massive amounts ofdata & reports. It’s to organize that in a waythat allows employers to synthesize andactually develop their strategic plansaccordingly. Employers that gain access tohistorical data can analyze network and otherprovider utilization to identify issuesand patterns that drive cost.

Past – Present - Future


90% of healthcare purchasers believe near-real-time data is imperative to realizing costsavings – it’s not just about the data, butactually having advanced analytics to helpsupport them in their decision-making (“morealgorithmic in nature and actionable for theend user”)1

Past – Present - Future

1National Alliance of Healthcare Purchasers

DxCG Intelligence

This intelligence turns healthcare data into risk scores for individual patients and identifies primary drivers of risk.

Scores correlate with the cost of the individual’s underlying illness burden.

Aggregating scores of individuals with key attributes generates group-level predictive results that can help answer questions fundamental to the ability to manage clinical and financial risks.

Hierarchical Condition Categories (HCC)Recognize that patients have multiple things wrong

Two patients are treated for a cough…Symptom of an

Upper Respiratory Infection

Workup reveals Chronic Obstructive Pulmonary

Disease (COPD)

[far more serious & costly!]

Without the hierarchy, the future costs of people with and without COPD would be mixed together.

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Diabetic Example, too.

Chronic ConditionsControlling Preventable Chronic Conditions Means Controlling Risk and Cost

BMI | 30+

BP | 140/90+

LDL Cholesterol | 160+

Glucose | 126+

Nicotine | Positive

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Review ‘gold standard’ numbers, then Chronic Disease High Risk

Drive Population Health

Understanding the amount of risk a populationbears, the nature of that risk, and the best wayto manage is the first stop on the Population HealthJourney.

The population health management market is in flux,and although some vendors might tell you they have itall, it’s difficult to determine true North. Consideringhow unproven much of the market is – and howunintegrated even a single vendor’s solutions might be– it’s wise to have complete transparency ofsolutions they say they can provide.

Utilizing Advanced Analytics as your GPS

Drive Population Health

assess utilization, total cost of care, and providerperformance in ways other platforms and vendors just can’t.

DATA COLLECTION: holistic, managed, maintained, overcomingdisparity, policy compliance

Avoid inefficiencies and costly mistakes.

Use transparency for control; while securely warehousing datafrom all entities, you ensure stability and consistency in theevent of change-of-the-guard.

Establishing Performance Standards & Pay

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Advanced Analytics will help you assess utilization, total cost of care, and provider performance in ways other platforms and vendors just can’t. It’s not easy to collect all the data required for a holistic healthcare strategy; and then consider that every data source has to be managed and maintained by separate people, departments and/or vendors, according to different rules. Relying on partners and vendors to provide accurate reports in regards to their specific performance and assured savings can be disparate and often costly. Use diabetes management programming as performance standard & pay | change of health plan example

Drive Population Health With a Meaningful, Common-Sense Approach

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CASE MANAGEMENT OPPORTUNITIES | Members who have incurred a high total spend (>$25,000 PMPY) will benefit from Case Management. Utilize the benefits of working with a 3rd party to drill down and assist these members by navigating gaps in care and help their providers coordinate. DISEASE MANAGEMENT OPPORTUNITIES | Members with annual spending less than $25,000 PMPY are considered low cost. Of the low cost members, those with a disease burden greater than 95% of the population are considered high disease burden, and should be addressed through Disease Management monitoring and intervention. WELLNESS MANAGEMENT OPPORTUNITIES | Members with low cost and low disease burden should be primarily addressed through Wellness Programs that reduce the risk factors for developing chronic diseases. Custom plan design with a focus on risk prevention is key for controlling the future of your Health Plan.

Drive Population Health Identification & Stratification

Members non-compliant with quality measures are considered riskier, resulting in:

• Gap Care Index

• Costs, Clinical & Financial prediction models | Care Gaps are linked to provide sophisticated stratification

• Financial & Clinical models are linked to cost-based algorithms to predict financial risk

Drive Population Health Assessing Outcomes DIABETES COHORT

comparing outcomes between Diabetics with

Gaps and one that complied with

guidelines

• PMPM costs are lower for compliance

• Key utilization like hospitalization rates

are lower for managed cohort

Integrating Data In order to access the more complex issues in the healthcare space and how

it relates to human capital, it’s necessary to pull together a robust data setthat represents a holistic picture of an employee

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Note: • Controlling costs in just one area often results in increased costs in other areas, making an integrated approach necessary • For example, more tightly managing workers’ compensation costs can lead to increases in short term disability costs

Breaking Down the Silos Advanced Analytics for Preventative Health & Safety

• From 2000-2009, WC/DB claims for “obese”employees almost tripled (2.4% to 6.6%)1

• Obese employees file twice the numberof claims, incurred 7x higher medicalcosts and incurred 13 more missed daysof work than employees with healthy BMI2

• Obesity-related short-term disabilityincreased 3,330% from 1993-20123

Breaking Down the Silos Advanced Analytics for Preventative Health & Safety

• Obesity-attributable absenteeism estimated to cost $8.65B per year4

• The cost of disability related to lipid abnormality related to cardiovascular conditions are 40% higher than those without5

• Average lost work days of diabetics over those with healthy blood sugar and A1C levels = 10.645

• Average lost work days of those with hypertension over those with healthy BP = 12.135

1National Council on Compensation Insurance2Duke University Medical Center Analysis

3Business Insurance May 2014 – Cigna Analysis4JOEM November 2014 – Yale University Study

5 JOEM July 2015 – University of Arkansas

Worker’s Compensation & the Health Plan Today’s Health Plan Broker – An Invaluable Consultant

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As new Worker’s Compensation Fraud schemes continue to pop up and become more complex, the ability to connect the dots to suspicious claims or patterns of fraudulent activity is critical. Advanced Analytics like DxCG Intelligence finds patterns in complex data sets and navigates the complexities of this dynamic and data-intensive line of business. Your client will be able to: Make more Informed Decisions, Improve Efficiency, Better Manage Expenses, Limit Liability, Curb Losses, Improve Loss Ratios Surges can be the result of many factors, including: Unnecessary treatment, Comorbidities, Use of certain medications, Secondary gain Fraud & more

Worker’s Compensation & the Health Plan Today’s Health Plan Broker – An Invaluable Consultant

With combined ratios still above 100% and

market volatility continuing, employers need to develop new strategies that better

assess and manage risk to maximize profitability.

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With combined ratios still above 100% and market volatility continuing, employers need to develop new strategies that better assess and manage risk to maximize profitability. The ability to contain claim costs is essential. However, scrutinizing your WC system to spot problem areas isn’t straightforward by any means. There is no shortage of data in the WC world; in fact, the amount of data can be overwhelming when you’re trying to analyze it to pinpoint problems or look for trends that could drive your business decisions. AA for WC claims data can help employers identify where claims dollars are going and pinpoint loss ratios across classes of business so they can balance their book. The analytics will show: The average cost per claim by industry, occupation, injury type and body part Total paid amounts attributed to by category Average durations of disability by injury type and body part affected How long injured employees are out of work Although WC/DB is likely not any of your specialty, what kind of value and savings can you bring to your client with a holistic system that can do it all? Solutions such as this are what set traditional health plan brokers apart from healthcare and planning consultants.

Actionable InsightOne Potential Solution

Through a collaborative approach tohealthcare, integrative healthcare solutions(CAM Practitioners) create health daily andprovide superior outcomes compared withusual or conventional care. Patients whowork with CAM practitioners are achievingTriple Aim:• They’re healthier• They have lower health care costs• They report extremely high levels of

patient satisfaction

CAM Examples

Naturopathic Care

Therapeutic Order

Chiropractic Care

Caring for the Whole Person – Integrative Care

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Briefly touch on all 4 with examples

CAM Examples

The majority of CAM users (73%) surveyed reported making behaviorchanges such as eating better and exercising more. The principle reasonspatients reported making such changes included:

• 1) treatment made them feel well enough to make the healthy behavior changes (53%)

• 2) feeling better due to treatment acted as a motivator to change behavior (53%)

• 3) the CAM provider suggested the change (53%)

• 4) treatments themselves helped (48%)

Proof Positive

CAM Overview, Research & Statistics provided by Integrative Healthcare Policy Consortium

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Site other examples

Prevention vs. Reaction

Annual U.S. Healthcare spending is at $2.7T, with up to $250B being spent on fraud, waste and abuse.1

5% of the population drives 30% of next year’s cost.1

45% of those with chronic conditions are not receiving recommended care.1

U.S. healthcare inefficiencies are estimated at $700B.

Reverse Healthcare Trends & Abolish Industry Standards

Prevention vs. Reaction

Productivity losses related to family and personal health problems cost U.S. employers $225.8Beach year, or $1,685 per employee.2

By better integrating big data analytics into healthcare, the industry could reduce healthcare costs of every man, woman and child by $1,000 per year.3

Companies that employ data analytics have created a per employee cost advantage of over $2000; compared to the national average they’re spending $10,258, rather than $12,041.

The 5% anticipated increase is cut by more than half for predictive analytic users.3


1CMS 2008; Overall spending source: CMS 201212Center for Disease Control

3WillisTowersWatson Best Practices in Healthcare 2015

Prevention vs. ReactionDon’t Let Inconsistent Billing Impact Bottom Lines

Last year, inconsistent billing was the leading cause of improper payments.

Duplicate billing accounted for 12% of these improper claim payments.

Unbundling is the most blatant practice in inappropriate billing.

Incorrect Modifiers is another common example.

Clinical Validation sheds light on previously hidden improper billing.

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2: Popular among these claims was the billing of the same venipuncture on the same patient on the same day by both the physician and the lab 3. For instance, our clinical teams identified nearly 32,000 instances of Evaluation and Management services that should have been included in the value of a surgical procedure and were not separately reimbursable. This example saved our clients $1.8 million. 4. Another common error continues to be the use of an incorrect modifier. We frequently see pathologists using modifier 26 in order to bill for the calibration of the machine on each claim for the lab work processed through the machine. Incorrect modifier use errors have surfaced over 117,000 times in 2016, amounting to $1.7 million in excessive payments if allowed to pass through adjudication. 5. DxCG Intelligence typically identifies one to three percent in additional savings on annual claim spend by avoiding potentially erroneous claims when select claims are reviewed by nurses, physicians, and coding specialists. Clinical Validation services can decrease the frequency of false positives, create transparency with and support for providers, and address improper payments that cannot be auto-adjudicated.

Zero In On Unnecessary Healthcare Costs

Examine custom data set for prediction 6-12 months in advance


1CMS 2008; Overall spending source: CMS 201212Center for Disease Control

3WillisTowersWatson Best Practices in Healthcare 2015

Classification of risk score – risk cohort for more efficient care coordination

Examine regional variances

Create more granular medical lists to rein in multiple providers, specialists, medications & pharmacies

Improve chronic care | reduce chronic disease and high risk

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We’ve also seen reduction in unnecessary hospitalization rates of 10% or more. ER utilization immediately comes down and is controlled. Unnecessary admissions, unnecessary testing is also eliminated.

Real World ExamplesReduce Cost with Advanced Analytics

Based on DxCG Intelligence Normative Database Trend

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Empowering Employers Resource

5 StrategiesContain Cost for Your Employer Groups

Pinpoint the Cause of Healthcare Spending

Plan for the Near- and Long-Term Future by Identifying Actionable Pathways

Develop Mutually Beneficial Partnerships with Vendors and Consultants

Make Employees Accountable Stakeholders with Engagement Strategies that Change Risky Behaviors

Detect and Prevent Fraud, Waste, Abuse & Errors

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Refer back to each slide or segment of slides to reiterate. Empowering Employers Resource

6 TipsEnsure Your Quality Offerings Actually Improve Quality

Leadership & Culture

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1: few effective healthcare strategies are successful without strong leadership and cultural alignment. Tee up leadership early in planning, and be prepared to provide coherent and impactful updates using meaningful data points along the way. Your client’s organizational culture is also an essential factor in the success or failure of the program. The best programs make quality improvement a team sport, set a high bar for success, make mistakes and learn from them, and constantly pivot as new information is uncovered.


Risk Management Mentality & Strategy

the systematic process of understanding, evaluating

and addressing today’s healthcare risks to

maximize the chance of objectives being achieved

and ensuring organizations, their

stakeholders and population are sustainable

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2: quality improvement is about understanding your population’s specific needs. Ask yourself, “What am I trying to fix?” “What impact will this have on my population?” “What does success look like for us, and how will we know we’ve achieved it?” Success depends on applying best practices to real-world situations.


Be Proactive

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3: Completing proactive runs early in the measurement year and repeating the runs often to capture all available data sources will help identify opportunities for quality improvement. Use benchmark measures and identify which measures are falling below par and where you may have gaps in your data. By identifying these holes early and correcting them, you can inform your quality management strategy, while also ensuring a smoother measure rate submission. These little successes lead to big sustainability measures. Employers that sustain and grow are ones that hit the ground running in terms of advanced analytics. If your clients are not sustainable, what type of employees do you think you’ll attract? If they’re not sustainable, what do you think will happen to their fixed labor costs if the competition can sustain? This affects salary, bonuses, growth, even jobs.


System Optimization

Every organization is dependent on the efficiency of each of its

individual systems, and their ability to work as a cohesive unit.

Discovering potential weaknesses allows you to strengthen your

organization as a whole, thereby maximizing output, employee satisfaction and bottom lines.

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4: Quality improvement takes a village. From data analysts to front-line providers to your auditor, a team of experts makes data actionable and ensures successful quality reporting and improvement. Defined roles are essential—you don’t want your data analyst giving A1C tests to patients—but the best teams are flexible. Find a communication platform or approach to share best practices, communicate goals, discuss challenges, and develop action plans. This doesn’t have to be sophisticated, but establish it, communicate its existence, and keep it up-to-date. Extend communication to frontline caregivers for insights into what is or is not working. You can use this platform to celebrate your successes, too.


6 Pillars of Prevention

1. Traditional & Integrative/Alternative Medical Theory

2. Physical & Occupational Therapy

3. Fitness4. Nutrition & Supplements5. Stress Management &

Bodywork6. Personal & Strategic

Coaching

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5: If you want to be successful in streamlining quality reporting and reducing gaps in care, you need to evaluate your data throughout the year, necessitating the right tool and knowledge to operate it effectively. A strong analytical platform will enable you to organize data, track progress, as well as identify and report gaps in care to your teams. The right platform can also help connect myriad quality measurements for a holistic quality improvement strategy. Augment your and your client’s team with experts—your auditor, your vendor—that can extract the most value from your data and processes.


Employer & Employee Prosperity

“The role of the CEO is to enable people to excel, help them discover

their own wisdom, engage themselves entirely in their work,

and accept responsibility for making change.”

--Vineet Nayar

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6: There is no substitute for a strong project plan that factors in your seasonal reporting deadlines with ample time for proactive runs and outreach to reduce gaps in care. Create a project plan that is aggressive and detailed, but also flexible, recognizing that new insights gained through your proactive efforts may adjust your focus and member outreach strategy. Each proactive run will help you benchmark your results against established measures, providing critical line of sight into your progress. Share this information with your team, your frontline providers, and your leaders. Over 90% of employees over-estimate their health, thinking they are healthier than they actually are. Employees also underestimate the employer’s share of their benefit plan by more than half. This disconnect equates to failure to see a need for action. Regaining control of unmanageable healthcare costs means helping employees become consumers of their own healthcare, resulting in savings across the board.

Erin Morrow; Managing Director1-855-858-1946 www.ELMandAssociates.com

http://www.elmandassociates.com/

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