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
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
Empowerment to Contain Costs with Actionable Insights
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
Empowerment to Contain Costs with Actionable Insights
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.
Chronic ConditionsControlling Preventable Chronic Conditions Means Controlling Risk and Cost
BMI | 30+
BP | 140/90+
LDL Cholesterol | 160+
Glucose | 126+
Nicotine | Positive
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
Drive Population Health With a Meaningful, Common-Sense Approach
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
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
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.
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
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
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
Reverse Healthcare Trends & Abolish Industry Standards
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.
Zero In On Unnecessary Healthcare Costs
Examine custom data set for prediction 6-12 months in advance
Reverse Healthcare Trends & Abolish Industry Standards
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
Real World ExamplesReduce Cost with Advanced Analytics
Based on DxCG Intelligence Normative Database Trend
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
6 TipsEnsure Your Quality Offerings Actually Improve Quality
Leadership & Culture
6 TipsEnsure Your Quality Offerings Actually Improve Quality
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
6 TipsEnsure Your Quality Offerings Actually Improve Quality
Be Proactive
6 TipsEnsure Your Quality Offerings Actually Improve Quality
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.
6 TipsEnsure Your Quality Offerings Actually Improve Quality
6 Pillars of Prevention
1. Traditional & Integrative/Alternative Medical Theory
2. Physical & Occupational Therapy
3. Fitness4. Nutrition & Supplements5. Stress Management &
Bodywork6. Personal & Strategic
Coaching
6 TipsEnsure Your Quality Offerings Actually Improve Quality
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
Erin Morrow; Managing Director1-855-858-1946 www.ELMandAssociates.com