Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Healthcare
Michiel Walsteijn, Executive Vice President - International
Enabling Value Based Health Care
April 9, 2015
Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Healthcare
Software Innovator in Healthcare IT
Edifecs is the first Partnership Platform for the healthcare industry
Serving more than 215 Million lives through our 100+ Health Plan customers
Worldwide700+ Employees
LeadersIn Configurable Healthcare Data Interchange & Compliance
70+Provider Customers
MultipleFederal Agencies incl. CMS
8/9National Health Plans
25/37Blue Plans
24/52State Medicaid Programs
Pre-integrated Business Applications, e.g. Value
Based Healthcare
Enterprise Testing & Compliance
Configurable Healthcare Data
InterchangePartnership Platform
1996 2015
Since 1996, Edifecs technology has been helping healthcare insurers, providers, pharmacy benefit management companies, and other healthcare entities address key challenges to scaling partnerships.
Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Healthcare
Some Definitions
Quality (in medicine):
The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge (Institute of Medicine, 1990)
Value:
Outcomes Achieved divided by Resources Expended
Health
Cost
Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Healthcare
Understanding the Shift from
Fee-for-Volume
to
Fee-for-Value
Fee-for-Volume(Old World)
Fee-for-Value(New World)
Providers make money by negotiating higher rates and performing as many services as possible
Providers make money by not only providing services, but other results valued by the industry, such as quality, efficiency, wellness, care coordination, and prevention
Providers see every touch as revenue
Providers see every touch as an expense to be managed
Payers primarily pay providers based on claims
Payers pay providers based on claims plus many other inputs (few of which are automated)
Most providers have little regard for evidence-based medicine.
Providers care a great deal about evidence based medicine
Payers see providers as vendors Payers begin to see providers as partners
Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Healthcare
Value Based ReimbursementA Continuum of Provider Risk
Fee for Service
Fee for Service Plus P4P or
Shared Savings
Episode ofCare / Payment
Bundling
Partial Capitation
Global Capitation
Provider Sophistication
Pro
vid
er
Ris
k
Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Healthcare
Scaling Healthcare Partnerships?
Addressing 3 challenges is emerging as the key to scaling.
Information Exchange and Integration
Process Automation
CommunityCollaboration
Is information flow between partners flow seamlessly ?
Does it comply with industry & partner standards?
Is it timely, trusted and visible ?
Are there any changes to core process or workflow ?
Does the partnership model need new analytics?
Can core systems adapt to support the changes?
Is there a need for shared intelligence between partners?
Do the workflows of the partners need to be linked ?
How can best practices be harvested and propagated
Pathways to Partnerships | Bridging Connections For Valueedifecs confidential
Value Based Care Maturity model
Consume Transactional Data
Value-Based Reimbursement Agreements Align Financial Incentives with Clinical Outcomes
Combine Clinical and Claim Data into Member-centric and Population Views.
Monitor the Population, Create Clinical Intelligence, and Drive Effective Interventions
Share Intelligence and Processes Across Multiple Payers and Providers
Consume & Interpret
Integrate & Share
Intervene: Change Care
Delivery
Expand to Other Partners
Support Payment Reform
Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Healthcare
Value-Based Care Solution
Pathways to Partnerships | Bridging Connections For Valueedifecs confidential
Provider
EMR
Billing
Practice Management
Core Systems
EDI Gateway
Claim adjudication
Membership administration
Other applications
Core Systems
Payer
EDI Gateway
Partnership Enablement
Future
Enterprise Apps
Business Applications for
Providers
Liquid Transaction Data
Liquid Transaction Data
CommunityShared Intelligence and Workflow
Transaction Workflow Transaction Workflow
Edge-based innovation for supporting the industry initiatives. Natural advantage of timeliness and completeness of information. Filter out transactions that add downstream costs.
Edge
Transaction Hub
Admin/ Clinical Transactions
Admin/ Clinical Transactions
Healthcare Information PipeEdgeSmart
Trading(All
Initiatives)
EDI Gateway
Business Applications for
Health Insurers
Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Healthcare
Enabling Value Based Healthcare
Integrated Member Record
Workflow
PrioritizationReportingTrigger Inventions
Set Monitoring/Intervention Rules
Monitor Populations
Health Information Exchange Intervention Platform
AuthorizedCare Team
Clinical Analysts
Population Analysis
Program Targeting
Member Attribution
Savings Modeling
Model Population and Plan Value-Based Agreement
Business/ Executive Manager
Partnership Platform
Population Payment Administrator
Business/ Executive Manager
Payment Calculations
Reporting
Program Automation
Program Optimization
Tasks
Target Populations
Design Contracts
Assemble Integrated Patient Records
Coordinate Care
Measure Outcomes
Pay for ValueTarget Interventions
Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Healthcare
Population Payment
Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Healthcare
Financial Management
Edifecs’ Approach
Easily define, edit and re-use patient and provider sets
Examine costs & stratify risks, drill down by any number of variables
Asses impact of alternative reimbursement models
Perform targeted budget calculations
Leverage pre-defined templates and risk adjustment models
Compare historical and projected budgets
Design dashboards and reports for internal/provider use
Enable reporting transparency to all stakeholders
Automate program savings calculations
Reduce actuarial and regulatory risk
Employ advanced data analyses
Gauge utilization and assess saving opportunities
Provide multi-layer views of program measures
TARGETImprove targeting
DESIGNScale
ADMINISTERMinimize risk, improve experience
OPTIMIZEOptimize
Shared savings and other VBR initiatives
Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Healthcare
Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Healthcare
How are PMPM Costs changing?
What is your budget
to date performanc
e?
What savings
might you anticipate?
How is your attribution changing?
What is your
leakage?
How is your quality
performance so far?
What is your
performance against
KPIs?
What is driving your
costs?
Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Healthcare
Population Health Monitoring
Pathways to Partnerships | Bridging Connections For Valueedifecs confidential
Intervention Gateway
Learning Engine Studio
Observation Agent Learning Engine
Des
ign
-tim
e R
un
tim
e
1
2 3
Enables clinical analysts to define monitoring and intervention rules
Visual toolkit to model and test interventions Collaborate and share concepts and rules across
communities.
Inspect incoming data streams and extract real-time data to trigger interventions
Execute Intervention Rules against streaming data and historical data
Surface the intervention in payer and provider systems
Intervention Rules
List of Data Elements to
Extract
Message Streams Intervention Data Alerts, Inferences
Intervention platform for early detection of changes to risk thresholds, quality thresholds, morbidity patterns, behavioral patterns and protocol compliance
Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Healthcare
Story of George’s Father
January, 1991 – PCP “Need to lose some weight – BMI 38,
waist circumference 41 inches, and you need to stop smoking”
February, 1991 – Routine lab work Triglyceride 160 mg/dL HDL 30 mg/dL Glucose 100 mg/dL Total cholesterol 250 mg/dL
March, 1992 – To ER, “not feel well” “Every is ok except a bit stressed and
blood pressure borderline (145/95)”
November, 1993 Massive heart attack
EHR CCD SNOMED 162864005 LOINC 9844-2 = 41 ICD-9 278.02 ICD-9 305.1
Lab Claims LOINC 2571-8 = 160 LOINC 2085-9 = 30 LOINC 1558-6 = 100 LOINC 2093-3 = 250
ER ADT + EHR CCD ADT-A04 ICD-9 308.9 LOINC 8480-6 = 145 LOINC 8462-4 = 95
Real life Digital life Edifecs logic
Metabolic syndromeFramingham Risk
28%
clipboard
insurance
Physician-supervised weight loss
program
Health and wellness program1
point of intervention
1 Baicker et al. Workplace wellness programs can generate savings. Health Affairs. 2010 Feb 2 HCUP/AHRQ 2009 data. Accessed http://hcup-us.ahrq.gov/reports/factsandfigures/2009/exhibit4_1.jsp 2014 Sep
3 Ford et al. Prevalence and correlates of metabolic syndrome based on a harmonious definition among adults in the US. J Diabetes 2010;2(2):180-93
“Start Statin”
100 Fastest Growing
Companies in WA
Washington’s 100 Best Places to
Work For
Inc. 5000 Fastest- Growing Private
Companies in the US
Deloitte Technology
Fast500 North America
Puget Sound Business Journal
WA Best Workplaces
Seattle Business Magazine’s Tech Impact
Award
Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Healthcare
Appendix
Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Healthcare
1990s All-at-once shift to full provider capitation
1998Physician Profiling (used for public reporting and contract rates)
2000Leading California effort for third party to collect and calculate quality-based payment
2001 Provider owned insurance companies
2003 Bonus payment for submitting quality data
2004 Bonus payment based on quality
2009 Payment based on episode of care
2011 Shared Savings based on total cost of care
2015 New forms of partial capitation
Progression of Payment Reform in US