acsg presentation
DESCRIPTION
The presentation describes an integrated health model for population management through the American Health Data Institute (AHDI) that has been in place for over 10 years with proven results for over 2.5 million members nationwide. The system relies on the use of sophisticated data analytics, identification of the chronically ill and those most likely to incur large claims, establishment of a regimen of care with follow up, Nurse Navigator oversight of care for the chronically ill, active management of large episodic claimants, identification of the chronically ill and triage to the most cost effective and quality medical providers, and active and effective wellness and biometric screening tools.TRANSCRIPT
Creating Value Based Healthcare
Patented Population Management
Presented by:
Jack Hill, Partner
© 2011 Accountable Care Solutions Group, LLC
Your LogoJUNE, 2011
• Key Family of Companies and who we are; Why KBA, AHDI & ACSG?
• Value Based Healthcare for Tomorrow…Turning Data into Intelligence
and the future delivery of integrated healthcare
• ACO Development with Patented Population Management
Contents
1
Key Family of Companies
Key Benefit Administrators - KBA Provides administrative infrastructure for population management
Risk management specialists
Highly integrated administrative infrastructure necessary to support healthcare budget
management
American Health Data Institute - AHDI A data warehouse and targeted utilization management partner that combines all the
necessary elements for controlling healthcare costs from both the demand and supply
side of the healthcare equation
A Premier Partner of TriZetto – The largest claims software vendor in the U.S.
TriZetto represents 353 Payers (62% of all BCBS Organizations), 173 Million Lives
Under Contract (36% of Managed Medicare), and 144 Million Lives in Production
(Processing 38% of Managed Medicaid)
Accountable Care Solutions Group, LLC - ACSG A distribution and consulting firm for managed care strategies and development,
uninsured mitigation programs, and the Patented Population Management processes
applicable to any payer segment2
• Size and Stability – The Key Family was founded in 1979 as a full-service group benefits
administration firm specializing in self-funded medical plans. Since that time, the Key Family has
grown to become one of the country’s largest independently owned third party administrators,
supporting a wide variety of group benefit plans. With its two major locations in Indianapolis,
Indiana, and Fort Mill, South Carolina, the Key Family is a commonly held group of benefits-related
organizations with over 400 employees, over 3,000 corporate customers, and over 500,000
members under management.
• Integrated Systems - All of our systems, nurse coaches, case management and disease
management are all connected. This allows our systems, in combination with AHDI, to deliver
meaningful information so that our clients can make critical decisions relative to their integrated
system or healthcare plan.
• Reporting – AHDI utilizes the payers’ medical and Rx claims data to develop standard reports. In
combination with these statistics, an expansive industry data set, and sophisticated analytical tools,
AHDI performs multiple analysis necessary to evaluate costs, quality and efficiency. Ordinary
claims data is transformed into powerful, actionable intelligence.
• Resources - As part of our package, you will have access to a Medical Director and ERISA
Attorney to assist you with plan design, HIPAA compliance, COBRA issues and Healthcare Reform.
• Planning - It is not just about what happens during an “ACO readiness assessment” or the
inaugural launch of an integrated healthcare solution; it’s truly about supporting the demands of
your local payer community and ensuring that value is delivered.
Key Family of Companies
3
AHDI: Calculation of Value Based Healthcare
• Effectively control healthcare costs while improving health quality, the
following data must be analyzed:
– Population health statistics
– Provider data: quality, cost and compliance
• To ensure standardization, implement the application of the same
statistical measures across all payers
• The American Health Data Institute (AHDI) has been measuring
population health and provider data in order to provide actionable
intelligence to payers
• AHDI has been the central technology engine among a variety of payers
in any given geography
4
• Provider practice and cost deviations– Practice patterns which result in low total costs for the types of illnesses comparable to other
physicians of the same specialty (cost efficiency index)
– Delivery of high levels of post-primary preventive care services for chronically ill patients
– Patterns of clinical and billing practices that avoid service up-coding, services that are not
appropriate for the diagnosis, invalid diagnostic coding and services performed more frequently
than typically appropriate.
• It has been statistically validated that Endorsed Providers are on average 40% less expensive than providers who do not pass the three, clinically based tests
• There are on average 15% Non-Endorsed Providers in areas where there are enough episodes to statistically measure
• It has been actuarially validated that Non-Endorsed Providers on average will add 10% excess cost to an employers health plan costs
AHDI: Provider Practice & Cost Deviation
6 5
• AHDI’s Chronic Disease Management Program has documented the
following results:
– Multiple payers in two different large geographic areas of the country saved
between 6.4% and 7.3% of medical claims cost each year by using the AHDI
model for managing chronic conditions
– After 5 years these multiple payers
saved between 11-17% of medical
claims cost by using the AHDI model
for managing chronic conditions
AHDI: Results
7 6
AHDI: ResultsSelf Funded Employer Groups – Case Studies for 200-1,000 Employee Lives
8
$-
$1,000,000
$2,000,000
$3,000,000
$4,000,000
$5,000,000
$6,000,000
2005 2006 2007 2008 2009 2010
Tota
l Me
dic
al C
ost
s
Company 2 Trend
$-
$1,000,000
$2,000,000
$3,000,000
$4,000,000
$5,000,000
$6,000,000
2005 2006 2007 2008 2009 2010
Tota
l Me
dic
al C
ost
s
Company 1 Trend
32%
Savings17%
Savings
Company 1 Textile Manufacturer - Healthcare Index 1.22 Company 2 Trucking Company - Healthcare Index 1.21
$1,600,000
$2,600,000
$3,600,000
$4,600,000
$5,600,000
$6,600,000
$7,600,000
2008 2009 2009
Tota
l Me
dic
al C
ost
s
Company 3 Trend
12%
Savings
Company 3 City Government - Healthcare Index 1.25
7
The Role of ACSG within an Integrated
Healthcare Management System
Structural
Organization
Phys
Hosp/etc
Data
Warehousing
Medical
Referral
Control
Employer
Stop Loss
Data Drill
Down
Capabilities
Gain
Sharing
Formulas
Small
Employer
Financial
Targets
Recognition
of High Cost
Patients
Geographic
Benchmarks
Gain Sharing
Distribution
Methodologies
Episodic
AnalysisPredictive
Modeling
Clinically
Integrated NetworkDelivery of Quality Healthcare
Controlled Healthcare Costs
Healthier Members
=
Step Down
UM
Management
Ongoing
Educational
Resources
Employee
Healthcare
Indexing
Employer
Benefit
Consulting
Hospital/
Physician
Discounts
Physician
Profiling
Employer
Healthcare
Indexing
ACO
Medical
Director
Chronic
Disease
Management
Treatment
Criteria
Compliance
Member
Incentive
Program
Personal
Health
Records
Wellness
Programs
On-site
Testing
Professional
Telephonic
Nurse Coaching
Health
Risk
Assessments
* *
*
* * *
* *
* *
*
*
The services work together to provide an end result where the whole is greater
than the sum of its parts.
*Items incorporated in United States Patent #7,711,577
8
What Could ACSG Bring to Your Community?
Clinically Integrated Network
CMS Employer 1
TPA 2
Employer 2
Blue Cross & Blue Shield Plan
Gain Sharing
Employer DistributionACO Distribution – Hospitals &
Physicians
Data Extract to AHDIIndividual & Aggregate Employer
Reporting PackageACO Reporting
9
The Role of Your ACO with our Patented
Integrated Healthcare Management System
A proven system of
population management that
can assist medical providers
in their management of new
payment reforms under
Medicare, Medicaid,
commercial health plan risk
contracts, and proprietary
employer health plan
management.
10
Population Management Patent – So What?
• Patent awarded in 2010.
• Identifies patients from a covered population likely to
generate expensive healthcare, determines whether
they have received healthcare services, sets up a
regimen of care, identifies qualified providers with best
practices, and prompts patients to obtain needed care.
• Broadly defined definitions on processes that
encompass most managed care delivery systems (e.g.,
PHOs, HMOs, IPAs, etc.), including ACOs.
• Health Economic Zones can be states, zip codes,
counties, cities, etc.
• US Patent Office did not uncover any “Prior Art”
concerning processes being used by any other
organization.
• Patented processes have been utilized with
quantifiable results.
11
What is ACSG’s Value? So What?
Support of ACO Infrastructure
• ACSG through ADHI can support all key elements, such as data warehouse and data
sources, the use of disease registries to provide physicians and their care teams with
meaningful information inclusive of reports for tracking financial and clinical performance.
• Through nurse navigator coaching and beneficiary compliance with minimum levels of
care;
– Interventions can quickly generate savings and ROI
– Support of long-term interventions aimed at better managing chronic disease
• Can support One-sided & Two-sided Models through financial reporting and management.
– Can measure all the claims-based clinical quality measures under CMS/ACO regulations
– Risk Management model with access to “integrated” reinsurance for Two-sided models.
• Can support bundled payments, partial and full capitation models.
• Can support eligibility management for various attribution and commercial membership
models.
• Can assist in establishing three-year cost and utilization reporting in addition to trend
analysis.
– Cost and utilization trend reports, mix of services analysis, provider reimbursement analysis,
utilization management analysis, and disease management and other medical intervention analysis
12
What is ACSG’s Value? So What?
Support of ACO Infrastructure
• Operational services:
– Access to data to identify and attribute beneficiaries;
– Use of our contract rates with ACO participating provider;
– Use of our contract rates with providers “outside” the ACO;
– Claims adjudication;
– Data analysis services performed by our actuarial and analytical staff;
– Use of our utilization management services such as nurse navigators, nurse help-line and contracts
with PBMs; and
– Calculation of bonus amounts according to agreed-upon formulas.
• Can supply ACO with deployment of a proprietary employer based program(s) for
population management:
– Utilizing our proven results;
– Utilizing our patented processes;
– Utilizing our gain sharing methodologies;
– For small and large employers; and
– Establishing ACO’s benchmarks for future CMS Medicare launch.
13