network as strategic advantage: curating a risk-ready network to succeed in a value-based market
TRANSCRIPT
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.
2All 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.
What RowdMap Does
Risk-Readiness SM and You
BCBS as Best Practice
3All 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.
What RowdMap Does
Risk-Readiness SM and You
BCBS as Best Practice
4All 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.
WHAT WE DOIt’s Time for Risk
CMS: 50% of FFS will be gone by 2018
CMS Means Business!
These are just the first pieces to move and transforming
payment across the system!
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.
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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.
Featured Nationally US CTO on RowdMap: “Visionary
Genius”
WHO WE AREFounders & Team
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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.
Melanie Rosenthal – Chief Executive OfficerCo-Founder & CEO @ Sprigley [acquired by Eliza Corporation, 2008]; VP of Product Ops @ Eliza [Majority Equity Investment Parthenon Capital, 2011]; Health Dialog, Yale, Human Genome Project, Tufte, Solstice Capital
Burak Sezen – Chief Information OfficerCo-Founder & CTO @ Sprigley [acquired by Eliza Corporation, 2008]; Platform Architect @ Eliza [Majority EquityInvestment Parthenon Capital, 2011], Health Dialog, Pricewaterhouse Coopers; Ernst & Young; Standards Committees
Joshua Rosenthal, PhD – Chief Scientific OfficerCo-Founder & CSO @ Sprigley [acquired by Eliza Corporation, 2008]; VP of Product Ops @ Eliza [Majority Equity Investment Parthenon Capital, 2011], Fulbright, Sorbonne (Applied Institute for Advanced Studies),HHS/CMS/ONC/NCHVS Public Adviser (Technology & Innovation, Market & Policy, Data Access) and HCTTFSpeaker/Guest Lecturer/Guest @ Harvard, Johns Hopkins, MIT , SXSW, HDI, RWJ, AF4Q, NPR (with US CTO and HHS CTO)
Henriette Coetzer, MD – Chief Clinical Risk OfficerClinical Transformation, NHS (National Health Service, United Kingdom); Global Medical Director, Towers Watson; Senior MedicalDirector and Clinical Analytics, BUPA and Health Dialog; Product Development, Healthways; Practicing Physician; Patent Holder
Kimberly Spalding, CPA – Chief Financial OfficerCo-Founder Tech Republic [acquired by CNET, 2001]; Co-founder & CFO Narrowcast [acquired by QuinStreet, 2011]; Ernst &Young’s Entrepreneurial Services
Bryant Hutson & Ashley Distler – Senior Client StrategistsCornell, Xavier; Cincinnati Children’s Hospital, Optimity Advisors, Presence Health; Skydiver, Travel Connoisseur
WHO WE AREFounders & Team
Industry Leading Advisory Board
WHO WE AREWhere It’s Worked
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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.
RowdMap Success Stories• Increased a plan’s membership through smart growth by 40,000
in 12 months; and another plan’s by 40% in the same time
• Reduced membership attrition for a SNP plan in a competitive metro by 20%
• Launched high-end concierge plan that broke member price sensitivity and generated significant profit, doubling original membership goal
• Launched a purpose-built plan for a curated provider network
• Increased a plan’s Star scores by a full point through provider-centric growth
• Designed product strategy and corresponding benefits for a major metro areathat lead to plan’s first profitable product portfolio in three years
• Aligned a plan’s sales and network team strategy around providers
• Tripled a plan’s original goal of contracting with targeted providers (and in some cases, out of exclusivity arrangements)
• Shifted a plan’s majority of membership from PPO to HMO, doubling original goal
• Moved a plan’s membership in target providers from 2% to 30% in target providers in 12 months
• Articulated clear data-driven MA strategy for board-level presentations that resulted in additional investments
• Developed comprehensive strategy for government affairs that created an advantageous environment for plan and members
Where we’ve done it…
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What You Get with RowdMapTechnology and Professional Service
EnterprisePlatformLicenseLicense covers entire enterprise across all functional units and all (reasonable) users and usage
RowdMap UOnline Learning CenterOne of a kind web-based resource with tips, tricks, tutorials and functionally-oriented resources to help users understand, and interpret the information
BenchmarksDrill Downs and ProfilesPayer Profiles, Provider Profiles, Market and Geographic Profiles Including Social Determinants and Health Behaviors
On-site Analytic WorkshopsRowdMap prepares an analysis across functional areas and presents data, interpretation and recommendations
Auto-Generated ReportingSelf-serve dashboards and reporting with tagging and sharing that export as PDF or PPT
EnrichmentClient DataRowdMap accepts and integrates your data and incorporates it within the RowdMap platform
Risk Readiness Your Provider Profiles,Available Risk Arrangements,Risk Arrangement Matching,Payer/Provider Risk Profiles
Year in the Life Custom Analyses & SupportProvider Performance Profiles and Risk-Readiness AnalysisNew Payment Model Opportunity AnalysisReimbursement Opportunity and Payer Profile AnalysisPolicy and Regulatory Analysis
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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.
What RowdMap Does
Risk-Readiness SM and You
BCBS as Best Practice
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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.
Risk-Readiness℠ looks at a different category of spending
30 Cents of Every Dollar You SpendGoes to No-Value Care
Clinically Appropriate, but Unnecessary Care
(30% of spend)
Claims Spend for a Health Plan / Government Program
Necessary Utilization(70%)
“Bigger than higher prices, administrative expenses, and fraud, however, was the amount spent on unnecessary health-care services. Now a far more detailed study confirmed that such waste was pervasive.”
In just a single year, up to 42% of patients receive “No Value” Care.
Dr. Atul Gawande, Professor, Department of Health Policy and Management at the Harvard School of Public Health & the Department of Surgery at Harvard Medical School.
“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
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At the core of Risk-Readiness SM is
Unwarranted Variation: Every provider has a unique practice pattern that informs Risk-Readiness SM
Low and Now Value Care Defined by Decades of Publicly Available Research
Apply the Dartmouth Atlas for Unwarranted Variation methodologies to the newly released CMS data. 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.
Grey area outside of obvious fraud but based on choice of two options for care that yield same outcomes, but one at marked
higher costs. Definitions across PCP care, specialties.
Provider with High Intensity Practice Pattern
Maximizing Fee for Service
Provider with Low IntensityPractice Pattern Maximizing Pay for Value
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Medicare DocGraph Referral file (Patient flows between PCPS, specialists, hospitals and post acute centers)
Dartmouth Atlas of Health Care & Choosing Wisely(Decades of research and data on unwarranted variation by condition and geography to keep things apples-to-apples for comparisons)
CMS FFS Data Sets, CDC Data Sets (MEDPAR, Part B, Part D, BRFSS)(Individual providers, groups, hospitals and post acute centers)
Provider Pattern Intensity Profiles and Risk Readiness for every provider, hospital, post acute center in the US. All preloaded with no IT.
New Government Benchmark DataParticularly powerful when pulled together
Affordable Care Act data to determine Risk-Readiness SM of Providers / Networks
CMS Historic Releases of Largest Provider Data;Virtually Every Provider, Group, Hospital, Etc.
Here’s why these benchmarks are so powerful
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Government benchmark data serves as the common languagenecessary to build relationships with providers to improve the member experience and profitability
The benchmarks are available today with no IT involvement
The data already have a level of analysis on top, so you can see if a provider is over/under benchmarks
It’s from CMS; it’s a standard; it’s already used to day to drive reimbursement
CMS Benchmarks Work across all Geographies, Populations, P&Ls (Care, Caid, Commercial, etc.)
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Where are populations, and how healthy are they? Who are Risk-Ready SM providers?
How do we match the right providers to the right risk arrangements and manage variation to contain costs?
How do we design products, clinical programs, and networks around risk?
WHAT WE DORisk-Readiness SM in Four Questions
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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.
UNDERSTAND POPULATIONSWhat type of populations?
Diabetes Prevalence PCP Density
Income
Obesity
Depression
Demand vs. Supply
Sick and underserved
Westchester, NY
Allocate providers and care management resources around condition-specific population needs by zip. Focus contracting on PCPs
and/or locate retail clinics, RVs and health fairs based on chronic needs.
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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.
UNDERSTAND GEOGRAPHY What’s Going on in Your Market?
Largest Counties in CA
Regional Benchmarks
Risk Scores
Total Cost
PMPM
Reimbursement
Overall Star
Chronic Star
Health Rank
Network Opportunity
Profit Opportunity
MA
Profit Opportunity
Exchange
MedicareEligibles /
MA Enrolled
ExchangeSubsidy Eligibles /Exchange Enrolled
MedicaidBeneficiary Eligibles /
Beneficiaries
What drives profitability in your geography? Consider:
CMS reimbursement and risk models, population cost share thresholds, clinical performance outcomes, population health behaviors,
network performance, product eligibles & penetration.
17All 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.
Risk-Readiness SM Practice Profiles
Orange County, CA
Regional Benchmarks
Identify highly efficient, Risk-Ready practices to profitably grow into. Improve profitability of lower performing practices with
large panel sizes through modified arrangements or performance improvement plans.
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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.
Risk-Readiness SM Physician Profiles
PCPs
Identify low cost, highly efficient physicians and make them your stars. Grow into them. Make them the featured doctor in
marketing collateral.
Regional Benchmarks
Louisville, KY
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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.
Risk-Readiness SM Hospital Profiles
California
Regional Benchmarks
Use benefit designs and network designs to send members to the highest performing hospitals within your geography.
EOL Hosp Days: Which hospitals have 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?
20All 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.
Decreased Cost
Average
Increased Cost
Less
Eff
icie
nt
1
2
3
4
5
Mo
re E
ffic
ien
t
Miami Dade, Florida
Risk-Readiness SM
Benchmark
Impact on Spend
MANAGE VARIATIONQuantify No Value Spending by Provider
$ PMPY per Specialty & Efficiency Score
Networks can be optimized by excluding specific doctors or shifting members/patients within a network.
Tactic 1: 'Manage' the red dot doctors
Tactic 2: Create curated networks with varsity providers.
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MANAGE VARIATIONProvider Value Chains
Primary Care Docs
SpecialistPost Acute
Facility
Thickness of lines indicates the number of referrals. Note: Some markets are
oversupplied. This market is controlled by one provider.
Less efficient
More efficient
Identify PCPs that refer to higher intensity specialists. Consider new contracting arrangements and provider education to
improve overall care efficiency.
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MANAGE ACROSS FUNCTIONSProduct, Growth & Clinical
After developing an overall Risk-Readiness SM Strategy, plans use RowdMap to…
Manage product portfolios and design benefits
Identify areas for growth and expansion
Design and manage clinical programs
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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.
CMS: 50% of FFS will be gone by 2018
What if you knew which providers would
drive your success?
What if you knew which providers would sink you? WHAT WOULD YOU DO IF YOU KNEW
who will win and who will lose in value based arrangements
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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.
What RowdMap Does
Risk-Readiness SM and You
BCBS as Best Practice
David GoodsonVice President, Enterprise Medicareat Blue Cross and Blue Shield of Illinois, Montana, New Mexico, Oklahoma & Texas
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Blue Cross and Blue Shield of Illinois, Montana, New Mexico, Oklahoma & TexasBest Practice at Risk-Readiness SM
Blue Cross and Blue Shield of Illinois, Montana, New Mexico, Oklahoma & Texas
Using data to answer all four major questions including:
1 - Where are the populations and how healthy are they?
2 - Who are Risk-Ready Providers?
3 - How do we match the right providers to the right arrangements and manage variation to contain costs?
4 - How do we design products, clinical programs and growth strategies around risk?
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Blue Cross and Blue Shield of Illinois, Montana, New Mexico, Oklahoma & TexasBest Practice at Risk-Readiness SM
Questions for David Goodson, Vice President Enterprise Medicare,
at Blue Cross and Blue Shield of Illinois, Montana, New Mexico, Oklahoma & Texas
1 – What have you done to achieve this Risk-Readiness SM ?
2 – What does this data allow you to do and what are your plans?