unexpected transparency: underserved populations, unwarranted variation and unnecessary spend

Applications of Transparency:

From Visibility to ActionAs transparency in health care has emerged as a crucial enabler towards achieving the Triple Aim, myriad sources and types of information have become available in the last few years. Join this session to learn new ways of understanding the behaviors of patients and providers, and novel approaches to payment and delivery already underway.

Moderator: Ben Harder, U.S. News & World Report

Panelists: Elizabeth Mitchell, NRHI;

Jeanne Pinder, ClearHealthCosts;

Josh Rosenthal, PhD, RowdMap, Inc.

Unexpected Transparency:

Underserved Populations,

Unwarranted Variation and

Unnecessary Spend

How valuable is a doctor to a population?

Which doctors start with higher intensity options? Which will succeed in Pay for Value?

Which doctors create the most no-value care and unnecessary spend?

This is different than ranking docs by cost of drugs or treatment, or the basics of care and operations.

Another way to think about it

What do my rankings measure?

How much an antibiotic costs?

How nice the doctor’s office is while waiting for the antibiotic?

Or…

Whether the doctor should have started with the antibiotic out of the gate in the first place?

David Wennberg,RowdMap Advisory Board

Open Data Is Powerful, DisruptiveOutperforms claims-based models for risk adjustment

New Government Released Referral Data(Patient flows between PCPS, specialists, hospitals and post acute centers)

Dartmouth Atlas for Unwarranted Variation(Decades of research and data on unwarranted variation by condition and geography to keep things apples-to-apples for comparisons, hence “Unwarranted” in the name)

New Government Released Performance Data (Individual providers, groups, hospitals and post acute centers including the new part B&D)

Provider Pattern Intensity Profiles and Risk Readiness for every provider, hospital, post acute center in the US. All preloaded with no IT.

Incredibly Meaningful RankingsParticularly powerful when pulled together

Affordable Care Act data to determine Risk-Readiness of Providers / Networks

The business context has changed- health plans, government payers, providers, and hospital systems need

to develop Risk-Readiness SM strategies to excel as they transition 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.

Featured NationallyUS CTO on RowdMap: “Visionary

Genius”

Chronic prevalence & physician supplyPopulation Health ReportPopulation Report Card

Match practice patterns to the right risk arrangements – Pay for Value ReadinessGroup Risk-Readiness SM ReportPhysician Risk-Readiness SM ReportHospital Risk-Readiness SM ReportPost Acute Center Risk-Readiness SM ReportRisk-Readiness SM Arrangement Match-Maker

Manage clinical care and costs – Remove No Value CareGroup Unnecessary Cost ReportPhysician Unnecessary Cost ReportHospital Unnecessary Cost ReportPost Acute Center Unnecessary Cost ReportUnnecessary Cost Referral and Value Chain Report

Unexpected Transparency:Underserved Populations, Unwarranted Variation and Unnecessary Spend

Chronic Prevalence &Physician Supply

Match Practice Patterns to the right Risk Arrangements – Pay for Value Readiness

Manage Clinical Care and Costs – Remove No Value Care


Diabetes Prevalence - Westchester

Use this data to allocate providers and care management resources around condition-specific population needs by zip.

Locate clinics, health fairs, etc. based on chronic needs.

Income

Obesity

Depression

Health Opportunity IndexLots of diabetics

but few PCPs

Lots of diabetics and lots of PCPs

What type of populations?

Medicare FFS Geo. Variation: http://go.cms.gov/1D8j7LE CDC Behavioral Risk Factor Surveillance: http://1.usa.gov/1PzcisT Medicare FFS Part B: http://go.cms.gov/OCmyoy Medicare FFS Part D: http://bit.ly/1mGyBxk

PCP Density –Westchester

Demand and Supply

http://go.cms.gov/1D8j7LE

http://1.usa.gov/1PzcisT

http://go.cms.gov/OCmyoy

http://bit.ly/1mGyBxk

12

County ProfilesLargest Counties In Ohio

People use this data to calibrate expectations for profitability by incorporating population health and provider performance into

product strategy. Use excess to subsidize operations in counties with fewer high-performing resources

Risk Scores Total CostPMPM

Reimbursement Overall Star Chronic Star Health Rank

MA Profit Opportunity -

MA

Profit Opportunity -

Exchange

MA Eligibles

MA Enrolled

Exchange Subsidized

ExchangeEnrolled

Compare to National and Regional Benchmarks

Medicare FFS Geo. Variation: http://go.cms.gov/1D8j7LE CDC Behavioral Risk Factor Surveillance: http://1.usa.gov/1PzcisT Medicare FFS Part B: http://go.cms.gov/OCmyoy Medicare FFS Part D: http://bit.ly/1mGyBxk

Demand and Supply

http://go.cms.gov/1D8j7LE

http://1.usa.gov/1PzcisT



At the core of Risk-Readiness SM is

Unwarranted Variation:

RowdMap applies the Dartmouth Atlas for Unwarranted Variation methodologies to data on Medicare Parts B & D. This research has been repeatedly validated over the last 30 years and we now have a national data set to apply the methodologies at a large scale.

The estimated 30% of medical expense that goes to unnecessary care. This unnecessary spend drives billing in a fee-for-serve economic model, but success in pay-for-value comes from managing and mitigating these pockets of variation.

Every provider has a unique practice pattern that informs Risk-Readiness SM

Pay for Value Readiness

Los Angeles, CA

Compare to National or Regional Benchmarks

Pay for Value ReadinessProvider Profiles

Identify highly efficient, Risk-Ready practices and physicians to profitably grow into. Improve profitability of lower performing practices with large panel sizes through modified arrangements

or performance improvement plans.

Medicare FFS Part B: http://go.cms.gov/OCmyoy Medicare FFS Part D: http://bit.ly/1mGyBxkReferrals: http://1.usa.gov/1FzoEOV



http://1.usa.gov/1FzoEOV

Identify high and low performing hospitals and post-acute facilities— are there post acute facilities that hospitals with poor chronic

readmits are routing members to?


EOL Hosp Days: Which hospitals fewer end-of-life days than their peers?

Chronic Admits: Which hospitals see their most chronic population repeatedly/ with the most frequency?

Cardiac Imaging: Which hospitals are more likely to over-utilize cardiac imaging compared to their peers?

Dartmouth Atlas: http://bit.ly/1GXvlJpCMS Hospital Compare: https://goo.gl/p8MtoICMS Hospital Readmissions: http://goo.gl/02KnQdCMS Nursing Home Compare: https://goo.gl/3DpT8m

http://bit.ly/1GXvlJp

https://goo.gl/p8MtoI


Great profile for aggressive risk

Tread carefully for some risk

Match appropriate risk arrangements based on provider practice patterns and Population characteristics within a geography.

Remove no-value CareManage Unnecessary Spend

Risk-Readiness℠ looks at a different category of spending

Shift focus from clinical edits, audits, and recovery efforts to identifying care that is clinically appropriate, but unnecessary. Historical efforts have shown returns, but they only look at a fraction of total spending. Unnecessary care can account for up to 30% of total spending and provides significantly larger opportunities for cost containment and quality improvement.

Clinically Appropriate, but Unnecessary Care

(30% of spend)

Claims Spend for a Health Plan

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


RowdMap tackles the 30% of the U.S. health care spend that goes to clinically appropriate, but unnecessary care

Over $9B in Orange County, CA

How much unnecessary spend is in your market?

Over $66B in Florida

$850 Billion Unnecessary Spend* in 2014

Least Unnecessary Spend

Most Unnecessary Spend

RowdMap tackles the 30% of U.S. health care spend that goes to clinically appropriate, but unnecessary care. RowdMap’s models identify the cost-savings opportunities in a geography based on the collective intensity of care delivered by doctors in that area.

* Unnecessary Spend = (Dartmouth Avg cost) * (Population) * (RowdMap Network Opportunity Index)


Unnecessary Spend in Florida

In Broward Co. alone, there is over $7.6B in unnecessary spend.

Let’s look at which hospitals, groups and physicians account for this and for what conditions

Physician Marketshare by Major Clinical Categories


Match appropriate risk arrangements based on provider practice patterns and Population characteristics within a geography.

Hospital Marketshare by Major Clinical Categories

Provider Group Marketshare by Major Clinical Categories

Unnecessary Spend in BrowardBy condition across hospitals, groups and physicians

This Physician.Let’s start hereThis GroupThis Hospital

Circulatory

Muscular-skeletal

Respiratory


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.

Physicians Driving Unnecessary Care in Broward

Musculoskeletal care is major contributor to unnecessary spend in Broward. Let’s take a physician who is not an outlier but in the middle of the pack such as Dr. Spend*. Let’s walk through what his clinically acceptable, but medically unnecessary, practice pattern creates

in unnecessary spend.


Least Unnecessary Spend Most

Unnecessary Spend

Option 2: Reinforce highest-performing referral

and care pathways. Increase the number of patient interactions

with green dot doctors.

Option 1: Change provider behavior. Requires lots of provider education. Requires

payer to make up a significant portion of a provider’s revenue. Increase the number of

green dot doctors.

Zoom to zip


Referral Patterns and Physician Value Chains

Identify high performing providers and downstream referral patterns. Encourage referrals to

high-performing specialists.


If had same ratio as :• His decompression rate would drop from

6.01 to 0.436 per patient.• Which translates to 2,608 fewer

decompressions per year.• At an average cost of $332 per

decompression, this represents potential savings of over $850K

If decompression to fusion rate were average for orthopedic surgeons:

• He would have 1629 fewer decompressions for a potential savings of $540K.

*Actual physician names have been changed.

For every 10 back fusions, does 103 decompressions

For every 10 back fusions, does 2 decompressions.

Dr. Save*

Dr. Spend’s

Dr. Spend*

Dr. Save*

That’s one physician, with one procedure, in one clinical condition. This savings would not be picked up in unit cost or utilization analysis,

but cumulatively dwarfs fraud, waste and abuse outliers. Intense practice patterns like this power FFS arrangements

but success in Pay for Value comes from identifying Risk-Ready providers.

Dr. Spend*

Benchmark cost structures, benefit designs, value of providers and networks, even over/under coding and which types of risk arrangements will succeed

+ + =

Profit Opportunity Network Opportunity Price Sensitivity

Surprise:Report Cards for Health Plans

Start with Data for Business Context then add Tech.

The ACA at your finger tipsFor Payers & Providers

unexpected transparency: underserved populations, unwarranted variation and unnecessary spend

Health & Medicine

risk readiness

riskreadiness sm strategies

risk adjustment

right risk arrangements

health care

clinical care

basics of care

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