moving to value based care – leveraging advanced analytics to measure physician performance
TRANSCRIPT
Moving to Value Based Care – Leveraging advanced analytics to measure physician performanceWebinarFebruary 25, 2016
This presentation cannot be duplicated or reproduced in part or in whole without written consent from LexisNexis. Copyright © 2016 LexisNexis. All rights reserved.
Today’s Speakers
Lizzy FelicianoSr. Director, Marketing
Kathy MosbaughVP, Clinical Solutions
Gordon GiffenDirector Product Development
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Agenda
• Market drivers and recent trends
• Implications of value based care for network design
• Leveraging analytics to meet new market demands
• Q&A
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Polling Question: What type of organization do you represent?
• Health Plan
• Hospital System/Integrated Delivery Network
• Physician or Physician Practice
• Pharmaceutical Manufacturer
• Life Sciences Company (i.e.. Durable medical equipment, etc.)
• Pharmacy Benefit Manager
• Other
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Performance Use Cases
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Planning
Forecasting
Targeting
Identify Eligible Participants
Improve Compliance Reporting
Optimize Provider Networks
Treatment Patterns
Pay for Performance
Care Management
Care Coordination
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“Instead of payment that asks, How much did you do?, the Affordable Care Act clearly moves us toward payment that asks, How well did you do?, and more importantly, How well did the patient do?”
Dr. Donald Berwick, April 2011
“...it is the glory of science to become ever more and more precise in its measurements, and it is the agony of the scientist to discover that when his measurements are really precise, what he has measured is just to one side of what he is after.”
F. Fremont-Smith, 1956
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Payment Reform is driving the creation of
physician networks that provide
HIGH-QUALITY care for a fair
price.
Payment Model is moving from
“volume” of care to “value” of care.
Physicians expect fair measurement of quality against their peers and
payers expect to pay physicians a
fair price.
Effective monitoring of physician
efficiency and quality to identify
drivers for behavior change.
Market Drivers are Increasing the Demand for Measuring Physician Cost AND Quality Performance
Balancing Costs with Increased Access, New and Unknown Health Risks, Provider Network Adequacy, and Quality Performance
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The Aging of America
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According to the Centers for Disease Control and Prevention (CDC): 1
• Chronic illness affects one of every two adults in the U.S.
• They are responsible for 75 percent of health-care costs
• In 2008, those costs were 16.8 percent of GDP
• By 2022 they are projected to be just shy of 20 percent
Source:1 Milken Institute2 U.S. Department of Housing and Urban Development
Needless to say, the demand for health care services will be
increasing significantly.
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Worsening Physician Shortage
Ever Increasing Risk Adjustment
PROGRAM POPULATION STATES METHODOLOGY
Part C-Medicare Advantage ALL CMS- HCC's (Hierarchical Condition Categories)
Part D- Perscription Drug Plans ALL CMS-RxHCC's
17 CDPS (Chronic Disease Management System)
4 ACG's (Adjusted Clinical Groups)
3 Other (i.e. CRG's-Clinical Risk Groups
ACA
Non-grandfathered Individual
and Small Group market
on and off exchange
ALL CMS-Modified HCC's
Medicaid Managed CareMedicaid
Medicare
• The trend is all in the direction of MORE risk adjustment• Different processes and methodologies by program• Significant administrative burden
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Align quality measures among all payers Identify more actionable, meaningful
measures Achieve greater consistency and rigor with
consumer information Leverage new technology and big data to
identify and assess quality metrics Make sure measures reflect actual clinical
quality, not factors like socioeconomic status that are out of health systems' control
Attribute results to specific providers Improve consumer engagement
Risk Adjustment for Socioeconomic Status or Other Sociodemographic Indicators
TECHNICAL REPORT
National Quality Forum is Discussing Risk Adjustment for Socioeconomic Indicators
Revenue Enhancement
Focus on risk adjustment that is used to determine payment
Cost & Quality Improvement
Focus on the right members and the right providers for outreach and impact
Revenue vs. Cost Strategies – Lots of Confusion
RISK: Missed revenue opportunity, Increases in premiums
RISK: Poor Health Outcomes and Missed Cost Savings
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Narrow Networks Create Both Advantages and Challenges
According to the Robert Wood Johnson study, "insurers generally did not report any efforts to design a network built on providers' performance, quality metrics or patient outcomes." Instead, the primary reason for
including or excluding a provider was largely based on price.
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Advantages• Contains costs for plan• Affords lower premiums• Maintains benefits and
lower out of pocket costs for members
Challenges• Restricts consumer choice • Reduces network adequacy • Increases provider
administrative burden
Polling Question: Where are analytics used most often within your organization?
• Revenue Enhancement
• Cost Containment
• Quality Improvement
• Marketing
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Risk Stratification & Care Coordination
Opportunity Identification
Risk, Financial, & Trend Analysis
Provider Performance
Measurement
Information Sharing & Physician
Engagement
Analysis around Evidence-based
Medicine Compliance
EMR DATAMEDICAL & PHARMACY
CLAIMS
PATIENT HRAs
Multiple Sources and Uses of Data for Cost and Quality Improvement
LAB DATA
Patient Centric Analytics
SOCIOECONOMIC DATA16
Polling Question: What data sources do you access and apply effectively today?
• Claims Data (medical and/or pharmacy)
• Clinical/EHR Data
• Socioeconomic Data
• Health Risk Assessment Data
• Lab Data
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Use analytics as a differentiated advantage for delivering better care
Create High-Value Networks Leveraging Analytics
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Narrow Networks
Optimized Networks
Utilize the most efficient physicians to manage health outcomes
Build a relationship of trust with physicians
Concurrently manage provider and patient quality compliance
Value-Based Care
Fee for Service
Broad Networks
Polling Question: When will you concurrently measure provider efficiency and quality to design optimized networks?
• Doing so today
• Within 6 months
• Within 1 year
• Within 2 years
• No plans. Not a priority.
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Are You Building a Relationship of Trust with Physicians?
• Ensure severity adjustment
• Evaluate case complexity
• Measure illness burden
Fair Measurement
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Are You Building a Relationship of Trust with Physicians?
• External Industry benchmarks
• Internal Client specific benchmarks
• Peer Groups By Specialty, Disease Condition, and/or Geographic Location
Fair Comparison
• Ensure severity adjustment
• Evaluate case complexity
• Measure illness burden
Fair Measurement
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Are You Building a Relationship of Trust with Physicians?
• External Industry benchmarks
• Internal Client specific benchmarks
• Peer Groups By Specialty, Disease Condition, and/or Geographic Location
Fair Comparison
• Ensure severity adjustment
• Evaluate case complexity
• Measure illness burden
Fair Measurement
• Closer alignment to optimal performance
• Evaluate and monitor cost drivers and practice patterns
• Avoid immediate excess resource consumption and future healthcare costs
Effective Monitoring
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Are you Concurrently Managing Provider and Patient Quality Compliance?
• Optimal compliance versus outliers
• Patient gaps in careIdentify Drivers
• Coaching and mentoring providers
• Spreading best practices
• Provider incentive and disincentives
Implement Improvement Strategies
• By Measure Category and Measure
• Compliance rates by provider
• Compliance rates by patient
Understand Compliance
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Are You Utilizing the Most Efficient Provider to Manage Patient Health Risk?
Referring provider is:
•Motivated to reduce costs and improve efficiency
•Willing to refer to efficient specialists in network
•Willing to match right specialist to the right patient
Influence Toward Best Practices
• Identify providers who are not following best practices
• Identify providers to mentor or manage out of networks
Implement Improvement Strategies
• Providers and specialists most aligned to benchmarks
• Referrals to providers within the same network
•Out of network referrals by exception only
Follow Best Practices
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Summary: To remain competitive, at-risk organizations must leverage advanced analytics. Both fair measurement and flexible comparisons are necessary to design optimized networks both for efficiency and quality.
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Optimize provider networks to deliver high quality care for
a fair price
Compare provider performance
against customized peer groups and
benchmarks
Fairly measure PCP and Specialty
performance using severity
adjusted scores
LexisNexis® Clinical Analytics Suite
A portfolio of risk stratification tools, predictive analytics, unique severity-
adjustment methodology, member engagement resources and clinical expertise.
Provider Performance
MonitorFacilitate transition to value-based care with
robust physician performance analysis.
Population Health Monitor
Improve care management efforts, risk stratification
initiatives and the health of member populations.
SocioeconomicHealth Score
Improve health risk predictions for new enrollees
and augment existing analytics with a unique score based on socioeconomic data derived from public records.
Socioeconomic Health Attributes
Improve accuracy of predictive models and analytics with tested
socioeconomic attributes.
MemberPoint™
Improve member engagement by populating member profiles
with the most current and comprehensive contact and
demographic data.
Public record identity data-based products
Socioeconomic data-based products
Claims-based products
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LexisNexis® Health Care
Summary:Advanced analytics using medical claims and pharmacy/PBM data can standardize how maturing organizations can measure and monitor provider performance –both for efficiency and quality.
Future Topics:• Member engagement
strategies• Provider Network Adequacy
Q&A
Linkedin.com/company/lexisnexis-risk-solutions
Youtube.com/user/lexisnexisnetwork
Twitter.com/lexisnexisrisk
Facebook.com/lexisnexisrisk
27This presentation cannot be duplicated or reproduced in part or in whole without written consent
from LexisNexis. Copyright © 2016 LexisNexis. All rights reserved.
Contact information: Kim [email protected]