Page 1
Session 73 Employer to Provider Direct Contracting - Whats The
Big Deal
SOA Antitrust Disclaimer SOA Presentation Disclaimer
2019 Health Meeting
KEVIN DOTSON FSA MAAA [LEE HEALTH]
JAY HAZELRIGS ASA MAAA [OPTUM]
ROB NATION ASA MAAA [OPTUM]
Employer to Provider Direct Contracting - Whats The Big Deal June 25 2019
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The United States antitrust laws aim to protect consumers by preserving the free economy and prohibiting anti-competitive business practices they promote competition There are both state and federal antitrust laws although state antitrust laws closely follow federal law The Sherman Act is the primary US antitrust law pertaining to association activities The Sherman Act prohibits every contract combination or conspiracy that places an unreasonable restraint on trade There are however some activities that are illegal under all circumstances such as price fixing market allocation and collusive bidding
There is no safe harbor under the antitrust law for professional association activities Therefore association meeting participants should refrain from discussing any activity that could potentially be construed as having an anti-competitive effect Discussions relating to product or service pricing market allocations membership restrictions product standardization or other conditions on trade could arguably be perceived as a restraint on trade and may expose the SOA and its members to antitrust enforcement procedures
While participating in all SOA in person meetings webinars teleconferences or side discussions you should avoid discussing competitively sensitive information with competitors and follow these guidelines
bull Do not discuss prices for services or products or anything else that might affect prices
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bull Do leave a meeting where any anticompetitive pricing or market allocation discussion occurs
bull Do alert SOA staff andor legal counsel to any concerning discussions bull Do consult with legal counsel before raising any matter or making a statement that may involve competitively sensitive information
Adherence to these guidelines involves not only avoidance of antitrust violations but avoidance of behavior which might be so construed These guidelines only provide an overview of prohibited activities SOA legal counsel reviews meeting agenda and materials as deemed appropriate and any discussion that departs from the formal agenda should be scrutinized carefully Antitrust compliance is everyonersquos responsibility however please seek legal counsel if you have any questions or concerns
2
Presentation Disclaimer
Presentations are intended for educational purposes only and do not replace independent professional judgment Statements of fact and opinions expressed are those of the participants individually and unless expressly stated to the contrary are not the opinion or position of the Society of Actuaries its cosponsors or its committees The Society of Actuaries does not endorse or approve and assumes no responsibility for the content accuracy or completeness of the information presented Attendees should note that the sessions are audio-recorded and may be published in various media including print audio and video formats without further notice
3
Employer to Provider Direct Contracting
Background discussion Jay Hazelrigs
Case Study 1 ndash Pop Health Approach Rob Nation
Case Study 2 ndash Larger Employer Rob Nation
Pitfalls and challenges from a health system perspective Kevin Dotson
Q amp A
4
Background Discussion
6
Stakeholder Landscape
Source Re-Igniting the Growth Engine Part 2 Winning Increased Share of Lucrative Patient Volumes Advisory Board
68 68 55 55
42 49
40 44 40 47 50
80 80 80
68 60 60 50
60 50
53 55
0
5
10
Health care trend after plan changes (total plan costs)
Health care trend before plan changes
Consumer Price Index for all urban consumers (CPI-U)Source Willis Towers Watson 23rd Annual Best Practices in Health Care Employer Survey
Hos
pita
ls Are experiencing a compression of margins due to lower revenue and higher expense trends
Seek improvement in market share and improved margins Em
ploy
ers Face unstainable year over year healthcare costs To
mitigate costs they are forced to implement annual benefit plan changes
Seek lower more predictable medical expenses and healthy productive employees
Direct Contacting Arrangement Types
7
Bundled Payments prospective payment which covers patientrsquos care from start to finish
Reference Based Pricing (RBP) plan pays up to fixed amount for procedure any excess is billed to member
bull PCP-centric bull Level of provider risk can vary from partial to full bull May be offered with other options or full replacement if adequate network
bull Promotes shopping for services via price transparency bull Most common for elective procedures ndash joint surgeries spine gastric bypass
bull Appropriate for high volume procedures bull Medical expense more predictable for these services may not be fixed price bull May result in lower provider revenue than FFS providers seek steerage volume
Center of Excellence (COE) designated provider identified for specific procedures that may require travel
bull Appropriate for high volume procedures bull Specialization amp operational efficiencies reduce utilization variations improves patient
experience amp improves outcomes (eg lower LOS return to work time) bull Members out-of-pocket often low to $0 including travelhotel not always lowest ldquopricerdquo
Accountable Care Organization (ACO) provider reimbursements are directly tied to quality and financial outcomes
Mos
t Com
mon
Ar
rang
emen
ts
On-site health education seminars
Wellness services
On-site clinic
Bundled payments
Employer liaison coordinator
On-site coaching Andor counseling
Care pathways
Direct contracting narrow networks
Source Re-Igniting the Growth Engine Part 2 Winning Increased Share of Lucrative Patient Volumes Advisory Board
Boeing 1UW Med 2Memorial Care 3Mercy MO 4Roper St Francis 5ProvSwedish
DART amp Baylor Scott and White Health
Intel amp 1 Presbyterian ACO 2 Arizona Care Network
Quallcom amp Scripps Health
Stanford Healthcare Alliance
General Motors amp Henry Ford Health
Disney amp 1Orlando Health 2Florida Hospital
Walmart amp 1 Banner 2 Emory 3 Memorial Hermann 4 Mercy AK 5Mercy OK 6 Mercy MO 7Oschner Health 8 Presbyterian 9 St Lukersquos 10 Unity Point 11 Cleveland Clinic 12 Geisinger Health 13Johns Hopkins 14Mayo Clinic AZ 15Mayo Clinic FL 16Mayo MN 17Mercy MO
1 2
3
4 5
6
8
7
9
10
1
3
4 2
1
2
1
Whole Foods amp Adventis Health
11 12 13
14
15
16
17
Emergence of Direct Contracting
8
DC with providers to secure improved pricing
COE through a carve-out provider
COE within the health plans
Source Willis Towers Watson 23rd Annual Best Practices in Health Care Employer Survey Full report and high-performance insights httpswwwwillistowerswatsoncom-mediaWTWPDFInsights201812willis-towers-watson-23rd-annual-best-practices-in-health-care-employer-survey-full-reportpdf 2018
Trends in Direct Contracting amp COE
According to Willis Towers Watsonrsquos survey employers are using COEs mostly through their health plans however direct contracting considerations are expected to grow considerably
6
7
48
2
2
7
14
13
20
0 20 40 60 80
Action taken or tactic used in 2018
Planning for 2019
Considering for 2020
bull Almost 50 use COEs in 18rsquo expected to rise to 2 out of 3 by 2020
bull Employers engaging employees in multiple ways to use COE bull Ongoing communications bull Reducing member cost share
to use bull Increasing member cost
share when not using bull Mandatory use
9
16
12
18
9
3
6
2
50
39
19
22
26
11
10
15
19
31
30
31
22
11
Transplants
Bariatric Surgery
Knees hips or spine
Cardiovascularcardiac
Cancer
Fertility
Other Procedures
Yes with incentives Yes but no incentives No but considering
10
A 2015 survey by the National Business Group on Health shows the status of large employersrsquo contracts with COEs (note reflects all COEs not specifically direct contracts)
Source Large Employersrsquo 2016 Health Plan Design Survey copy 2015 National Business Group on Health
Other centers of excellence programs include maternity NICU sleep apnea pancreas cornea and kidney
National Business Group on Healthrsquos Large Employers 2019 Health Care Strategy and Plan Design Survey showed DC arrangements between employers and bull Health systemsproviders will
increase from 3 in 2018 to 11 in 20191
bull COEs will increase from 12 in 2018 to 18 in 20191
bull Cancer cardiovascular and fertility COEs are experiencing the greatest growth
Source National Business Group on Health ldquoLarge US Employers Eye Changes to Health Care Delivery System as Cost to Provide Health Benefits Nears $15000 per Employeerdquo August 2018
10
Trends in Direct Contracting amp COE
Outcomes amp Benefits bull Employers with COE arrangements are seeing reduction in procedures
bull Walmart (15rsquo-18rsquo) 50+ of spine surgeries amp 20 of kneehip procedures recommended by local providers were determined lsquonot necessaryrsquo by COE (see table)
bull Employers like Walmart amp Boeing continue to sign new providers which suggest (employersrsquo) continued interest in pursuing DC arrangements2 However Boeing and Providence Swedish did end relationship due to inability to capture enoughright data to estimate cost of care3
bull John Hopkinsrsquo Bayview campus COE emerging metrics4
bull 121 referrals in the first three months
bull 352 referrals and 183 surgeries over 18 months
bull 23 of all joint replacement volumes at facility now attributed to travel program
bull 96 of patients said they would recommend this program to family friends coworkers
bull Bingham Memorial in Idaho direct contracting emerging metrics4
bull 17 companies participating covering over 5000 lives
bull +3000 new patients as of October 2018
bull +$3M Revenue from new patients
11
1 How Employers Are Fixing Health Care Harvard Business Review March 2019 2 httpswwwhealthleadersmediacomstrategywalmart-escalates-strategy-solve-employee-healthcare Health Leaders Media Nov 18rsquo 3 Do Providers Have the Data chops to Success with Direct Contract Modern Healthcare August 2018 4 Re-Igniting the Growth Engine Part 2 Winning Increased Share of Lucrative Patient Volumes Advisory Board 5 httpswwwautonewscomarticle20180806OEM180809831gm-signs-major-health-care-services-deal-for-salaried-employees
Walmart COE Programs1
Program Key Benefits
Spin
e Su
rger
y 2300 EEs 50 COE approved of those applied
bull 95 lower readmission bull 14 less time in hospital bull 1 COE vs 5 non-COE patients discharged to SNF bull Returned to work sooner reducing 20 of OOO
time bull More-effective less dangerous amp less expensive bull The COE surgery ldquopricerdquo is 8 higher but value in
earlier discharge lower readmission rates far less utilization of SNF faster return to work
Join
t
1836 EEs 18 COE approved of those applied
bull 32 less time in hospital bull 70 less likely to be readmitted than non-COE
patients bull Fewer postsurgical complications bull 0 COE vs 5 non-COE patients discharged to SNF bull COE patients returned to work a 15 weeks sooner bull Cost of surgery is 15 less at COE hospitals
Baria
tric
300+ EEs
bull Preliminary data suggests the weight loss from surgery reduces absenteeism or presentism (working while sick)
bull Dramatically cuts pharmacy amp medical costs Complications of obesity drop sharply as does the need for medication
bull GMrsquos direct contract benefit plans with Henry Ford allows it to offer similarly designed plans to that of Blue Cross with savings in monthly EE contributions ranging from $300-$19805
Walmartrsquos Travel (Surgery) Program
Mem
ber F
eedb
ack
12
Looking beyond traditional cost management techniques Walmart designed a program to address wild variations in cost and become directly in improving quality of care for its employees FIRST SELECTING PROVIDERS 1 Identify providers with high volume and high quality 2 Target regions in country to support Walmartrsquos employees 3Focus on Integrated Health Systems Hospitals within these systems were best aligned to Walmarts mission could take on risks associated with bundling 4 Eliminate systems unwilling to do bundled payments model were
PROVIDERS VALUE IN PARICIPATING
Build Bundles bull Define bundles and negotiate price (typically 10-15 below FFS ) bull Definitions of service limit disputes of what is covered vs not (covers
entryexit of facility SNF not part of bundle) bull Contract flexibility covers unforeseen testcosts and reinforces
Walmarthealth system partnership bull Warrantees if further treatment - can return in 30 days no
additional cost to Walmart bull Strict criteria and providers with track record of clinically sound
decisions are included to mitigate any incentivizing of volume Business bull 100 travelaccom brings
new volume of patients from outside of market
bull More stable payments for services (vs Medicare or commercial FFS)
bull Increased visibility and attract new business
Clinical bull lsquoHalorsquo effect ndash Building a highly
efficient multidiscipline program brings improvements throughout health system
bull Onsite collaboration among health systems allows sharing of outcomesbest practices
Source How Employers Are Fixing Health Care Harvard Business Review March 2019
5000 participants in the program
95 satisfiedvery satisfied
Denied by care because not deemed necessary by COE Treatment denied due to lifestyle weightsmoking
The Member Experience
13
Engagement begins when employee on clear
path to surgery
Patient contacts with COE TPA
TPA team triages and ensures basic criteria
met
Employee put in touch with nurse team
Car pick-up Flight Hotel all arranged by
TPA
Navigators and nurse coordinators help
throughout the stay
Patient visits to hospital to understand
exceptions of procedure and meet treatment
team
Surgery occurs typically next day
Stay length according to procedure typically a
few days
Discharged from facility Travel home COE team updates local
PCP and discuss follow up care
COE provider checks in with local physician
frequently Revert back to standard coverage
Source How Employers Are Fixing Health Care Harvard Business Review March 2019
Case Study 1
Case study 1 ndash Pop Health Approach bull ProblemCircumstance Large multi-employer group needs to
evaluate benefit design disease prevalence health spend and utilization to manage their population
bull ConsiderationsValue Prop Unique industry and geography drive chronic conditions and utilization patterns
bull Solution Provide opportunity assessment comparing this population to other benchmarks to understand where to target intervention and management as well as assess efforts already taken
15
Market Comparison Preference Sensitive Procedures
16
Legend vs
Mt States vs
National gt120 gt110
110-120 105-110 lt80 lt90
Source Multi-payer commercial benchmark Results are weighted by AgeGender Broader market area includes multi-payer data from the mountain regions
Preference Sensitive Procedures Benchmark Comparison
Dartmouth Atlas Preference Sensitive Procedures
IP allowed dollars ALOS Employer vs
Mt States Employer
vs National FY 2017 FY 2018 FY 2017 FY 2018
Hysterectomy for Uterine Fibroids Rate $569354 $436932 45 54 124 140 CABG Rate $1800260 $2400608 53 60 218 130 Cholycystectomy Rate $832675 $755565 68 39 92 120 C-Section Rate 116 110 HighTech Radiology Rate 103 101 PCIPTCA Rate $934486 $1133708 37 55 82 80 Back Surgery Rate $3237613 $4003212 39 57 52 70 Knee Replacement Rate $3086693 $2177334 41 48 50 64 Total Hip Replacement Rate $1023675 $747491 45 64 37 34
Strengths (+)
Employer compares favorably for orthopedic procedures (back hip knee)
Opportunity (-)
Employer has higher than expected rates for CABG and hysterectomy (Note Low PTCA rate combined with high CABG rate may suggest provider practice patterns favoring CABG)
0 50 100 150 200 250
Total Hip Replacement
Knee Replacement
Back Surgery
PCIPTCA
Cholycystectomy
HighTech Radiology
C-Section
CABG
Culinary VsNational
Culinary Vs MtStates
Employer vs Mt States
Employer vs National
Market Comparison Condition Prevalence
17 Source Multi-payer commercial benchmark Results are weighted by AgeGender Broader market area includes multi-payer data from the mountain regions
Condition Prevalence Benchmark Comparison
Condition Employer vs
Mt States Employer vs
National Prevalence Diabetes Rate 229 219 Prevalence Hyperlipidemia Rate 259 207 Prevalence Kidney Disease Rate 143 174 Prevalence Migraine Rate 166 164 Prevalence Low Back Pain Rate 136 139 Prevalence Hypertension Rate 156 134 Prevalence Asthma Rate 146 128 Prevalence CAD Rate 175 115 Prevalence Pregnancy Rate 110 109 Prevalence Adult Preventive Screening Rate 114 91 Prevalence Depression Rate 63 60
Strengths (+)
Rate of depression is low (Note May be due to incomplete behavioral health claims)
Opportunity (-)
Employer has a higher prevalence of most chronic conditions including asthma CAD diabetes hypertension hyperlipidemia Kidney Disease LBP and migraines
0
100
200
300Hyperlipidemia
Diabetes
CAD
Migraine
Hypertension
AsthmaKidney Disease
Low Back Pain
Pregnancy
Depression
Employer vsMt States
Employer vsNational Legend
vs Mt States
vs National
gt120 gt110 110-120 105-110
lt80 lt90
Market Comparison Utilization Rates
18
A higher preventive office visit rate is better Source Multi-payer commercial benchmark Results are weighted by AgeGender Broader market area includes multi-payer data from the mountain regions
Strengths (+)
Lower than average utilization of ED and high dollar patient rate
Opportunity (-)
Higher LOS lengthy admits avoidable admits and readmissions which all drive significantly more spend
Utilization Benchmark Comparison
Condition Employer vs
Mt States Employer vs
National Avoidable Admit Rate 142 144 Lengthy Admit Rate 175 136 Outpatient Problem Focused Office Rate 146 131 Readmission Rate (readmitadmit) 135 126 Average LOS 125 116 One Day Admit Rate 76 103 Office Visit Rate 106 96 Acute Admit Rate 80 95 Avoidable ED Rate 68 86 ED Rate 54 69 Preventive Office Rate 95 68 High Dollar Patient Rate 49 51 Frequent ED User (gt3 times) Rate 24 36
Legend vs
Mt States vs
National gt120 gt110
110-120 105-110 lt80 lt90
0 50 100 150 200
Frequent ED User (gt3 times)
High Dollar Patient
Preventive Office
ED
Avoidable ED
Acute Admit
Office Visit
One Day Admit
Average LOS
Readmissionhellip
Outpt Problem Focusedhellip
Lengthy Admit
Avoidable Admit
Employer vsNational
Employer vsMt States
ED and Avoidable ED
19
Potentially Avoidable ED - Trend View Overall ED
Period Change FY 2017 FY 2018 Count Rate
Measure Mbrs Rate Mbrs Rate Overall ED 16394 12626 13820 10745 -16 -15 FREQUENT ED UTILIZER (mbr1k) 1581 1218 1468 1141 -7 -6 AVOIDABLE ED 6371 4907 5288 4111 -17 -16 Potentially Avoidable ED
Period Change FY 2017 FY 2018 Count Rate
Avoid ED Condition Mbrs Rate Mbrs Rate ABDOMINAL_PAIN 1092 841 895 696 -18 -17 ENT_INFECTION 854 658 742 577 -13 -12 FEVER 715 551 700 544 -2 -1 URINARY 650 501 468 364 -28 -27 HEADACHE 558 430 434 337 -22 -21 BACK_PAIN 414 319 423 329 2 3 NAUSEA 394 303 271 211 -31 -31 ASTHMA 294 226 209 162 -29 -28 CELLULITIS 210 162 198 154 -6 -5 GASTROENTERITIS 254 196 171 133 -33 -32 OTITIS_MEDIA 201 155 160 124 -20 -20 COPD 132 102 108 084 -18 -17 DIABETES 123 095 91 071 -26 -25 BACT_PNEUMONIA 111 085 86 067 -23 -22 DENTAL 93 072 83 065 -11 -10 DEHYDRATION 98 075 81 063 -17 -17 HYPERTENSION 16 012 24 019 50 51 CHF 4 003 3 002 -25 -24 ANGINA 8 006 3 002 -63 -62 IMMUNIZATION_RELATED 2 002 0 000 -100 -100 Grand Total 6371 4907 5288 4111 -17 -16
AHRQ avoidable ED visits are based on the logic for ambulatory care sensitive ED visits from AHRQ and diagnosis code driven
696
577
544 364
337
329
211 162
154 133 ABDOMINAL_PAIN
ENT_INFECTION
FEVER
URINARY
HEADACHE
BACK_PAIN
NAUSEA
- 200 400 600 800
1000 1200
2017 Members 2018 Members
Top Ten 2018 Conditions by Rate
Top Ten Conditions by Member Count
ED Avoidable ED and the impact of new on-site clinic
20
0
1000
2000
3000
4000
5000
6000
0200400600800
10001200140016001800
Clinic Visits ED Visits
Avoidable ED VisitsED Visits (non-avoidable)Clinic EampM Visits
0
500000
1000000
1500000
2000000
2500000
3000000
3500000
$s
Clinic EampM Profess DollarsAvoidable ED Dollars
bull Clinic visits have a clear impact on ED and avoidable ED use and spend
bull Combined ED visits are down on average 157 in FY 18 from FY 17
bull Combined ED spend is down 128 in FY 18 from FY 17
Clinic Live 62017
Pitfalls and Challenges bull Face many of the challenges similar to startup health
plan bull Critical to determine how you will deliver value and
communicate the value to potential customers and brokersconsultants
bull Care management bull Network
21
Considerations in Offering Development bull Care Management Model
bull Traditional care model bull Case management bull Utilization management bull Disease management
bull Longitudinal care model with value based care philosophy bull Primary care driven bull Local care management
bull Predictive analytics and risk stratification model bull Claims history and ongoing data bull EMR data
22
Case Study 2
Case study 2 ndash Large Employer bull Business Problem Large employer wants to contract
directly with 2 major hospital systems developing professional fee schedules
bull ConsiderationsValue Prop Fee schedule should be competitive but also nuanced to minimize gap relative to current reimbursement at physician level
bull Solution Data-driven approach using current market-wide reimbursement distinguished by service level
24
Evaluate Provider Spend Top 25 Service Lines by Allowable Spend
Evaluate Provider Spend Top 20 Professional CPTs by Total Spend
Understand relative market pricing position
27
21
-1
-28
14 10
28
-22
-11 -13
24
3
20 21
8
-20
13
3 9
-39
56
-26
4
-42
60
MRI Colonoscopy Cardiac Cath Lab - OrganPanel
Memorial Hospital Beta Hospital Delta Hospital Charlie Hospital Echo Hospital Alpha Medical Center
ndash25 5 -15 10 0 39
State Charges as a Percent of Peer Average Weighted Averages for MRI Colonoscopy Cardiology and Lab
Total Percent Above Below Market Average2
Memorial Hospital Beta Hospital Delta Hospital Charlie Hospital Echo Hospital Alpha Medical Center
Develop fee schedule relative to market
28
Service Line Procedure CPT CodeDRG
Memorial Hospital
Beta Hosptial
Charlie Hospital
Delta Hospital
Echo Hospital
Alpha Medical Center
Arthroscopy Ligament Repair 29888 $ 5062 $ 9557 $ 5983 $ 10096 $ 7519 $ 2502 Knee Arthroscopy 29881 $ 5069 $ 4185 $ 3837 $ 3022 $ 3729 $ 2266 Upper GI Endoscopy 43239 $ 3075 $ 2539 $ 2012 $ 1132 $ 1565 $ 2240 Lap Sleeve Gastrectomy DRG 621 $ 20421 $ 20815 $ 12105 $ 13230 $ 14600 $ 17800 Colonoscopy and biopsy 45380 $ 3075 $ 3071 $ 2013 $ 1244 $ 1972 $ 859 Diagnostic Colonoscopy 45378 $ 3075 $ 2805 $ 2013 $ 1244 $ 1972 $ 859 MRI Brain w amp wo dye 70553 $ 1238 $ 1468 $ 1117 $ 967 $ 2805 $ 1052 MRI Joint of Lower Extremity wo dye 73721 $ 1238 $ 1398 $ 1042 $ 967 $ 925 $ 557 MRI Abdomen w amp wo dye 74183 $ 1238 $ 1468 $ 1106 $ 967 $ 2805 $ 836 X-ray Chest 71020 $ 115 $ 266 $ 305 $ 279 $ 375 $ 72 CT Thorax wo dye 71250 $ 882 $ 810 $ 505 $ 491 $ 579 $ 319 Ultrasound Abdomen Complete 76700 $ 397 $ 538 $ 545 $ 195 $ 190 $ 168 Mammogram Screening G0202 $ 141 $ 328 $ 431 $ 294 $ 425 $ 168 Computer Detection Add-on 77052 $ 112 $ 99 $ 41 $ 15 $ 45 $ 23 Comp Metabolic Panel 80053 $ 56 $ 15 $ 24 $ 56 $ 51 $ 25 Tissue Exam by Pathologist 88305 $ 236 $ 307 $ 80 $ 152 $ 78 $ 232 Cardiovascular Stress Test 93017 $ 383 $ 432 $ 1299 $ 907 $ 717 $ 797 TTE w Doppler 93306 $ 960 $ 1566 $ 1388 $ 1173 $ 1125 $ 1157
Obstetrics Vaginal Delivery DRG 755 7290$ 5730$ 4654$ 4607$ 5855$ 4688$
GI
Lab
Radiology
Medical Cardiology
Orthopedics
KEY OBSERVA TIONS bull Potential exposure on GI bull Opportunity to align price and acuity in MRI bull Opportunity to raise rates on chest x-ray and mammogram
Percentile Bands Emory Allowables Heatmap TEC ASC Heatmap Allowable Comp Analysis Portal Pricing Sheet1 image1png A few words on Bundled Payments bull Bundled payments are growing as a type of direct contracting bull In some cases third parties match-make between employers
and providers bull Contracts may vary in definitions prepost admission
coverage duration readmission cause (ie all-cause vs medically related) outlier provisions LOS caps andor per diems
bull Providers need to be strategic in pricing to enable profitable growth of market share
29
Considerations in Offering Development bull Network Development
bull Build off existing structure eg health system employee plan network bull How does this fit into your broader value based care strategy bull Employed and independent physicians bull How do you want to approach the buildout of high performance
network bull Quality focus bull Cost efficiency
bull Integrated behavioral health bull Wrap network for other markets
30
Considerations in Offering Development bull Target Market
bull Consideration of employer profile in market bull Fully-insured vs ASO bull Total cost of care vs bundled services
bull Distribution bull Direct marketing bull Brokerconsultant community
bull Plan designs bull Standard designs vs flexible ndash Dependent on target market
bull Claims administration bull Data sharing amp analytics
31
Considerations in Offering Development bull Other components of comprehensive offering
bull Pharmacy bull Preventive health bull Onsite clinics bull Wellness programs bull Technology platform
32
Sample Bundle Analysis
33
Cover page Dotson Hazelrigs Nation Mainly of charge of fixed Cardiovascular stress test TTE wDoppler complete Colonoscopy and biopsy (Combined) Diagnostic colonoscopy (Combined) Upper gi endoscopy biopsy (Combined) Knee Arthroscopy (Combined) Arthroscopy Ligament Repair Comp Metabolic Panel Surgical Path Tissue Exam MRI Abdomen MRI Brain MRI Joint Lower Extremity CT Thorax wo contrast X-ray Chest Screening mammography Mammo Computer Aided US Abdomen Complete Officeoutpatient visit new pt 30 min Vaginal delivery Lap Sleeve Gastrectomy
Piedmont Piedmont Piedmont Piedmont Northside Northside Northside Northside Gwinnett Gwinnett Gwinnett Gwinnett WellStar WellStar WellStar WellStar AMC - Tenet AMC - Tenet AMC - Tenet AMC - Tenet CPT Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing 29881 $11312 $10872 NA NA $7476 $9338 NA $23655 $11856 $3668 NA $17871 $12253 NA NA $15645 $5490 NA NA $23039 29888 NA NA NA NA NA NA NA $23784 NA $8261 NA $18000 NA NA NA $15774 NA NA NA $23168 43239 NA $4408 NA NA NA NA $5997 $8852 NA $3304 NA $7424 $1267 NA NA $9230 NA $2458 NA $8274 43644 $26468 NA NA NA $3382 $12050 NA $1861 NA NA NA $1316 $7841 NA NA $3444 $18892 $27950 NA $979 43775 NA NA NA NA NA NA NA $352 NA NA NA $302 NA NA NA $413 NA NA NA $83 45378 $2705 $2530 NA NA $4381 $3676 $4496 $1022 $2938 $2138 NA $695 $5504 NA NA $2036 NA NA NA $372 45380 $3075 $2600 NA NA $4723 $3527 $3012 $1757 $4215 $2285 NA NA $5298 NA NA $3268 NA NA NA $627 59400 $6160 NA NA NA NA $5100 NA $1851 NA NA NA $1304 $9035 NA NA $3427 $9116 $5150 NA $966 70553 $2985 NA $1153 NA $2182 NA $1192 $492 NA NA $803 $489 $1512 NA $985 $1187 NA NA NA $197 71020 $61 $69 $43 NA $113 $319 $307 NA $183 $59 $32 NA $213 $66 $40 NA $83 $53 NA NA 71250 $1837 $621 $989 NA $1490 $931 $755 NA NA $745 $401 NA $1067 $982 $616 NA NA $304 NA NA 73721 NA $1098 $1153 NA $2042 $1065 $1192 NA NA $998 $803 NA NA $1275 $985 NA NA $644 NA $178 74183 $2971 $1144 NA NA NA $1092 $1192 $6884 NA $1098 $803 NA $2960 $1197 $985 $5454 NA NA NA $7607 76700 $364 $247 $207 NA $427 $708 $614 $13267 $428 $214 $152 NA $747 $263 $189 $9139 NA $235 NA NA 77052 NA NA NA NA NA NA NA $4744 NA NA NA NA NA NA NA $3070 NA NA NA $5611 93306 $1220 $1117 NA NA $1877 $1657 $2100 $4605 $1433 $413 $945 NA $1336 $1434 $1951 $2931 NA $2399 NA $5472 G0202 $262 $187 NA NA $431 NA NA $4605 $292 NA NA NA $530 $281 NA $2931 $327 NA NA $5472
Provider Group 29881_6 29888_6 43239_6 43644_1 43775_1 45378_6 45380_6 59400_1 70553_2 71020_2 71250_2 73721_2 74183_2 76700_2 77052_2 77052_5 80053_8 88305_8 93306_2 99203_4 G0202_2 G0202_5 93017_2 Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Atlanta Gastroenterology Associates $2399 $536 348 $1628 $536 204 $2400 $536 348 Atlanta Medical Center $24889 $2266 999 $25897 $2502 935 $11449 $2240 411 $81927 $15300 435 $75815 $17800 326 $7317 $859 752 $7317 $859 752 $12821 $4688 173 $6581 $1052 526 $645 $72 796 $3265 $319 925 $3450 $557 519 $7398 $836 785 $1576 $133 1084 $73 $23 217 $635 $25 2440 $891 $232 285 $2967 $1157 156 $344 $168 105 $1265 $797 59 Atlanta Womens Health Physicians Group $29 $14 107 $40 $13 208 $396 $188 111 $278 $118 135 $450 $231 95 Gwinnett Hospital $11941 $3022 295 $21654 $10096 114 $3551 $1132 214 $34384 $10800 218 $56472 $13230 327 $3003 $1244 141 $3533 $1244 184 $8984 $4607 95 $3901 $967 303 $417 $279 49 $2247 $491 358 $4000 $967 314 $3755 $967 288 $1593 $195 717 $50 $15 233 $186 $56 233 $505 $152 233 $1750 $1173 49 $418 $294 42 $1396 $907 54 Northside Hospital $15482 $4185 270 $21651 $9557 127 $4885 $2539 92 $35176 $17000 107 $35233 $20815 69 $3883 $2805 38 $5256 $3071 71 $10911 $5730 90 $4856 $1468 231 $443 $266 67 $2379 $810 194 $3776 $1398 170 $5105 $1468 248 $942 $538 75 $167 $99 69 $379 $15 2427 $433 $307 41 $2252 $1566 44 $459 $328 40 $576 $432 33 Piedmont Hospital $14772 $3837 285 $35493 $5983 493 $5069 $2012 152 $38320 $17750 116 $37125 $12105 207 $3485 $2013 73 $4993 $2013 148 $10143 $4654 118 $5939 $1117 432 $542 $305 78 $2983 $505 491 $3410 $1042 227 $6067 $1106 449 $1364 $545 150 $75 $41 85 $231 $24 863 $657 $80 721 $2041 $1388 47 $490 $431 14 $1780 $1299 37 Piedmont Physicians Group $42 $22 87 $318 $179 78 $239 $159 50 Resurgens $8558 $2036 320 $9293 $2258 312 $4638 $2067 124 $4039 $2164 87 $4392 $2164 103 $2252 $1371 64 $459 $330 39 Wellstar Hospital $9330 $3729 150 $17479 $7519 132 $5261 $1565 236 $35794 $18200 97 $46780 $14600 220 $3707 $1972 88 $4928 $1972 150 $13549 $5855 131 $5054 $2805 80 $528 $375 41 $3222 $579 457 $3694 $925 299 $5495 $2805 96 $1355 $190 615 $66 $45 46 $73 $51 43 $133 $78 71 $1785 $1125 59 $599 $425 41 $1010 $717 41 Avg Mark UpProcedure Atlanta Medical Center 634 Gwinnett Hospital 223 Northside Hospital 233 Piedmont Hospital 259 Wellstar Hospital 155 Emory 105
Atlanta Gastroenterology Associates Atlanta Medical Center Atlanta Womens Health Gwinnett Hospital Northside Hospital Piedmont Hospital Piedmont Physicians Group Resurgens Wellstar Hospital CPT Code CPT Proc Cat Comp Avg Allow Allow Allow Allow Allow Allow Allow Allow Allow 29881 KNEE ARTHROSCOPYSURGERY 6 $3179 $2266 $3022 $4185 $3837 $2036 $3729 29888 KNEE ARTHROSCOPYSURGERY 6 $6319 $2502 $10096 $9557 $5983 $2258 $7519 43239 UPPER GI ENDOSCOPY BIOPSY 6 $1727 $536 $2240 $1132 $2539 $2012 $2067 $1565 43644 LAP GASTRIC BYPASSROUX-EN-Y 1 $15810 $15300 $10800 $17000 $17750 $18200 43775 LAP SLEEVE GASTRECTOMY 1 $17800 $13230 $20815 $12105 $14600 45378 DIAGNOSTIC COLONOSCOPY 6 $1656 $536 $859 $1244 $2805 $2013 $2164 $1972 45380 COLONOSCOPY AND BIOPSY 6 $1694 $536 $859 $1244 $3071 $2013 $2164 $1972 59400 OBSTETRICAL CARE 1 $5107 $4688 $4607 $5730 $4654 $5855 70553 MRI BRAIN WO amp WDYE 2 $1482 $1052 $967 $1468 $1117 $2805 71020 CHEST X-RAY 2 $259 $72 $279 $266 $305 $375 71250 CT THORAX WO DYE 2 $541 $319 $491 $810 $505 $579 73721 MRI JNT OF LWR EXTRE WO DYE 2 $978 $557 $967 $1398 $1042 $925 74183 MRI ABDOMEN WO amp WDYE 2 $1436 $836 $967 $1468 $1106 $2805 76700 US EXAM ABDOM COMPLETE 2 $320 $133 $195 $538 $545 $190 77052 COMP SCREEN MAMMOGRAM ADD-ON 2 $45 $23 $15 $99 $41 $45 77052 COMP SCREEN MAMMOGRAM ADD-ON 5 $14 $14 80053 COMPREHEN METABOLIC PANEL 8 $29 $25 $13 $56 $15 $24 $22 $51 88305 TISSUE EXAM BY PATHOLOGIST 8 $174 $232 $188 $152 $307 $80 $179 $78 93306 TTE WDOPPLER COMPLETE 2 $1297 $1157 $1173 $1566 $1388 $1371 $1125 93017 STRESS TEST 5 $830 $797 $907 $432 $1299 $717 99203 OFFICEOUTPATIENT VISIT NEW 4 $139 $118 $159 G0202 Screeningmammographydigital 2 $329 $168 $294 $328 $431 $330 $425 G0202 Screeningmammographydigital 5 $231 $231
Service Line Procedure CPT Code Emory Atlanta Gastroenterology Associates Resurgens Atlanta Womens Health Piedmont Physicians Group Orthopedics (ASC) Knee Arthroscopy 29881 $3467 $2036 Arthroscopy Ligament Repair 29888 $3386 $2258 GI (ASC) Upper GI Endoscopy 43239 $2758 $536 Diagnostic Colonoscopy 45378 $2348 $536 Colonoscopy and biopsy 45380 $2181 $536 Radiology Mammogram Screening G0202 $164 $231 Computer Detection Add-on 77052 $93 $14 Lab Comp Metabolic Panel 80053 $53 $13 $22 Tissue Exam by Pathologist 88305 $277 $188 $179 EampM (TEC) Office Visit new pt 99203 $269 $118 $159
Service Line Procedure CPT CodeDRG Memorial Hospital Beta Hosptial Charlie Hospital Delta Hospital Echo Hospital Alpha Medical Center Atlanta Gastroenterology Associates Resurgens Atlanta Womens Health Piedmont Physicians Group Market Avg Emory abovebelow Orthopedics Arthroscopy Ligament Repair 29888 $ 5062 $ 9557 $ 5983 $ 10096 $ 7519 $ 2502 $ 2258 $ 6319 -20 Knee Arthroscopy 29881 6 $ 5069 $ 4185 $ 3837 $ 3022 $ 3729 $ 2266 $ 2036 $ 3179 59 GI Upper GI Endoscopy 43239 6 $ 3075 $ 2539 $ 2012 $ 1132 $ 1565 $ 2240 $ 536 $ 1671 84 Lap Sleeve Gastrectomy DRG 621 $ 20421 $ 20815 $ 12105 $ 13230 $ 14600 $ 17800 $ 15710 30 Colonoscopy and biopsy 45380 $ 3075 $ 3071 $ 2013 $ 1244 $ 1972 $ 859 $ 536 $ 1616 90 Diagnostic Colonoscopy 45378 6 $ 3075 $ 2805 $ 2013 $ 1244 $ 1972 $ 859 $ 536 $ 1572 96 Radiology MRI Brain w amp wo dye 70553 2 $ 1238 $ 1468 $ 1117 $ 967 $ 2805 $ 1052 $ 1482 -16 MRI Joint of Lower Extremity wo dye 73721 2 $ 1238 $ 1398 $ 1042 $ 967 $ 925 $ 557 $ 978 27 MRI Abdomen w amp wo dye 74183 2 $ 1238 $ 1468 $ 1106 $ 967 $ 2805 $ 836 $ 1436 -14 X-ray Chest 71020 $ 115 $ 266 $ 305 $ 279 $ 375 $ 72 $ 259 -56 CT Thorax wo dye 71250 $ 882 $ 810 $ 505 $ 491 $ 579 $ 319 $ 541 63 Ultrasound Abdomen Complete 76700 $ 397 $ 538 $ 545 $ 195 $ 190 $ 168 $ 327 21 Mammogram Screening G0202 2 $ 141 $ 328 $ 431 $ 294 $ 425 $ 168 $ 231 $ 313 -55 Computer Detection Add-on 77052 2 $ 112 $ 99 $ 41 $ 15 $ 45 $ 23 $ 14 $ 39 183 Lab Comp Metabolic Panel 80053 8 $ 56 $ 15 $ 24 $ 56 $ 51 $ 25 $ 13 $ 22 $ 29 88 Tissue Exam by Pathologist 88305 8 $ 236 $ 307 $ 80 $ 152 $ 78 $ 232 $ 188 $ 179 $ 174 36 Medical Cardiology Cardiovascular Stress Test 93017 $ 383 $ 432 $ 1299 $ 907 $ 717 $ 797 $ 830 -54 TTE w Doppler 93306 2 $ 960 $ 1566 $ 1388 $ 1173 $ 1125 $ 1157 $ 1282 -25 Obstetrics Vaginal Delivery DRG 755 $ 7290 $ 5730 $ 4654 $ 4607 $ 5855 $ 4688 $ 5107 43 EampM Office Visit new pt 99203 4 $ 248 $ 118 $ 159 $ 139 78 Colonoscopy and biopsy (HOSPITAL ONLY) 45380 Surg 2530 $ 307591 Diagnostic colonoscopy (HOSPITAL ONLY) 45378 Surg 2255 $ 307591 Upper gi endoscopy biopsy (HOSPITAL ONLY) 43239 Surg 1787 $ 307591 Knee Arthroscopy (HOSPITAL ONLY) 29881 Surg 10900 $ 506893 Arthroscopy Ligament Repair (HOSPITAL ONLY) 29888 Surg 10900 $ 506200 Key 1 Facility - Inpatient 2 Facility - Imaging 3 Physician - Imaging 4 Physician 5 Global - Imaging 6 Facility - Outpatient 8 Lab 41 Physician - Primary Care 42 Physician - Specialist
Blue Cross United - EJCH EUH EUHM WW United - SJH Non Options United - SJH Options Aetna - ASC TEC (HMO) Cigna - ASC TEC (HMO) Aetna - EJCH ESJH ECHM WW Cigna - EJCH (HMO) Cigna - ESJH EUHM (HMO) List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract Description CPT Code Charge Average Final Price (all plans) Emory Mark Up Reimbursement Method ( of charge or fixed) - 1713 Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Cardiovascular stress test 93017 Cardio $543 $ 425 28 of Charge 70 $ 380 of Charge 65 $ 353 of Charge 60 $ 326 of Charge 70 $ 380 of Charge 70 $ 380 of charge 100 $ 543 of Charge 70 $ 380 of charge 100 $ 543 of charge 100 $ 543 TTE wDoppler complete 93306 Cardio $1226 $ 960 28 of Charge 70 $ 858 of Charge 65 $ 797 of Charge 60 $ 736 of Charge 70 $ 858 of Charge 70 $ 858 of charge 100 $ 1226 of Charge 70 $ 858 of charge 100 $ 1226 of charge 100 $ 1226 Colonoscopy and biopsy (HOSPITAL ONLY) 45380 Surg $2530 $ 3076 -18 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 of Charge 70 $ 1771 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Diagnostic colonoscopy (HOSPITAL ONLY) 45378 Surg $2255 $ 3076 -27 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 of Charge 70 $ 1579 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Upper gi endoscopy biopsy (HOSPITAL ONLY) 43239 Surg $1787 $ 3076 -42 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Knee Arthroscopy (HOSPITAL ONLY) 29881 Surg $10900 $ 5069 115 Fixed Rate SC 4 $ 3865 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 449300 $ 4493 Fixed Rate $ 654700 $ 6547 of Charge 70 $ 7630 Fixed Rate $ 401000 $ 4010 of Charge 70 $ 7630 Fixed Rate $ 398300 $ 3983 Fixed Rate $ 398100 $ 3981 Arthroscopy Ligament Repair (HOSPITAL ONLY) 29888 Surg $10900 $ 5062 115 Fixed Rate SC 3 $ 3121 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 556900 $ 5569 Fixed Rate $ 770100 $ 7701 of Charge 70 $ 7630 Fixed Rate $ 323900 $ 3239 of Charge 70 $ 7630 Fixed Rate $ 321700 $ 3217 Fixed Rate $ 321400 $ 3214 Comp Metabolic Panel 80053 Lab $132 $ 56 138 RBRVS Fee (100) $ 1437 of Charge 65 $ 86 of Charge 65 $ 86 of Charge 65 $ 86 of Charge 70 $ 92 RBRVS Fee (100) $ 1437 $ 14 of Charge 70 $ 92 RBRVS Fee (100) $ 1437 $ 14 RBRVS Fee (100) $ 1437 $ 14 Surgical Path Tissue Exam 88305 Lab $326 $ 236 38 of Charge 150 $ 51 of Charge 65 $ 212 of Charge 65 $ 212 of Charge 65 $ 212 of Charge 70 $ 228 of charge 100 $ 326 of Charge 70 $ 228 of charge 100 $ 326 of charge 100 $ 326 MRI Abdomen 74183 Radiology $6960 $ 1238 462 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 MRI Brain 70553 Radiology $6804 $ 1238 450 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 MRI Joint Lower Extremity 73721 Radiology $3067 $ 1238 148 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 CT Thorax wo contrast 71250 Radiology $2199 $ 882 149 Fixed Rate $ 771 Fixed Rate $ 47100 $ 471 Fixed Rate $ 81700 $ 817 Fixed Rate $ 116000 $ 1160 of Charge 70 $ 1539 Fixed Rate $ 80100 $ 801 Fixed Rate $ 79200 $ 792 Fixed Rate $ 79300 $ 793 Fixed Rate $ 79500 $ 795 X-ray Chest 71020 Radiology $280 $ 115 142 of Charge 150 $ 25 of Charge 65 $ 182 of Charge 60 $ 168 of Charge 70 $ 196 of Charge 70 $ 196 RBRVS Fee (150) $ 2534 $ 25 of Charge 70 $ 196 RBRVS Fee (150) $ 2534 $ 25 RBRVS Fee (150) $ 2534 $ 25 Screening mammography G0202 Radiology $279 $ 141 98 Fixed Rate $ 128 Fixed Rate $ 13100 $ 131 Fixed Rate $ 14300 $ 143 Fixed Rate $ 16100 $ 161 of Charge 70 $ 195 Fixed Rate $ 13300 $ 133 Fixed Rate $ 13500 $ 135 Fixed Rate $ 13000 $ 130 Fixed Rate $ 11200 $ 112 Mammo Computer Aided 77052 Radiology $75 $ 112 -33 Fixed Rate $ 9 Fixed Rate $ 13100 $ 131 Fixed Rate $ 14300 $ 143 Fixed Rate $ 16100 $ 161 of Charge 70 $ 53 Fixed Rate $ 13300 $ 133 Fixed Rate $ 13500 $ 135 Fixed Rate $ 13000 $ 130 Fixed Rate $ 11200 $ 112 US Abdomen Complete 76700 Radiology $917 $ 397 131 of Charge 150 $ 125 of Charge 65 $ 596 of Charge 60 $ 550 of Charge 70 $ 642 of Charge 70 $ 642 RBRVS Fee (150) $ 12519 $ 125 of Charge 70 $ 642 RBRVS Fee (150) $ 12519 $ 125 RBRVS Fee (150) $ 12519 $ 125 Officeoutpatient visit new pt 30 min (TEC) 99203 EampM $316 $ 248 28 of Charge 70 $ 221 of Charge 65 $ 205 of Charge 60 $ 190 of Charge 70 $ 221 of Charge 70 $ 221 of charge 100 $ 316 of Charge 70 $ 221 of charge 100 $ 316 of charge 100 $ 316 Vaginal delivery 59409 Surg $14484 $ 7290 99 Fixed Rate DRG - 775 $ 5437 2 Day Case Rate + LOC 561700 $ 5617 BaseCMS Weight 584741 $ 5847 BaseCMS Weight 726146 $ 7261 No IP Terms $ - 0 No IP BaseCMS Weight 659343 $ 6593 BaseContract Weight 479451 100 $ 14484 BaseCMS Weight 579110 $ 5791 Lap Sleeve Gastrectomy 43775 Surg $29961 $ 20421 47 Fixed Rate DRG - 621 $ 14872 BaseCMS Weight 1810697 $ 18107 BaseCMS Weight 1835178 $ 18352 BaseCMS Weight 2278911 $ 22789 No IP Terms $ - 0 No IP BaseCMS Weight 2069315 $ 20693 BaseCMS Weight 1730442 100 $ 29961 BaseCMS Weight 1817507 $ 18175 105 Colonoscopy and biopsy (ASC ONLY) Surg $ 219200 $ 2181 Diagnostic colonoscopy (ASC ONLY) Surg $ 267100 $ 2348 Upper gi endoscopy biopsy (ASC ONLY) Surg $ 207500 $ 2758 Knee Arthroscopy (ASC ONLY) Surg $ 417900 $ 3467 Arthroscopy Ligament Repair (ASC ONLY) Surg $ 504800 $ 3386
Cpt Code CPT Description Procedure Category Claims Min 25thNtile 50thNtile Emorys Rates 75thNtile 90thNtile Max 20 Below 50th Ntile 20 Above 50th Ntile 93017 CARDIOVASCULAR STRESS TEST 5 82 $80 $125 $321 $382 $568 $791 $930 $257 $386 71020 CHEST X-RAY 2 2638 $11 $45 $152 $115 $289 $373 $585 $122 $182 71020 CHEST X-RAY 5 8106 $25 $34 $38 $54 $57 $69 $30 $46 45380 COLONOSCOPY AND BIOPSY 6 1256 $541 $560 $572 $2877 $1000 $2024 $3289 $458 $686 77052 COMP SCREEN MAMMOGRAM ADD-ON 2 194 $13 $15 $25 $38 $47 $134 $20 $30 77052 COMP SCREEN MAMMOGRAM ADD-ON 5 2411 $13 $16 $20 $23 $26 $28 $16 $24 80053 COMPREHEN METABOLIC PANEL 8 13019 $9 $19 $23 $55 $24 $25 $69 $19 $28 71250 CT THORAX WO DYE 2 302 $165 $372 $545 $878 $1658 $2067 $436 $654 71250 CT THORAX WO DYE 5 209 $53 $127 $203 $289 $419 $534 $162 $244 45378 DIAGNOSTIC COLONOSCOPY 6 1479 $484 $515 $536 $2914 $831 $1971 $2828 $428 $643 29881 KNEE ARTHROSCOPYSURGERY 6 152 $1650 $1826 $2036 $5235 $3054 $4216 $6461 $1629 $2443 29888 KNEE ARTHROSCOPYSURGERY 6 82 $1682 $3615 $5081 $5145 $7553 $12924 $18532 $4065 $6097 43644 LAP GASTRIC BYPASSROUX-EN-Y 1 21 $11821 $13873 $17050 $18391 $25029 $31079 $13640 $20460 43775 LAP SLEEVE GASTRECTOMY 1 38 $4215 $8250 $13253 $20421 $19197 $21509 $24260 $10602 $15903 74183 MRI ABDOMEN WO amp WDYE 2 120 $919 $987 $1015 $1237 $1252 $2534 $3177 $812 $1218 74183 MRI ABDOMEN WO amp WDYE 5 112 $475 $490 $521 $1154 $1337 $1696 $417 $625 70553 MRI BRAIN WO amp WDYE 2 324 $633 $987 $1142 $1237 $1706 $2805 $3331 $914 $1370 70553 MRI BRAIN WO amp WDYE 5 467 $280 $539 $1023 $1277 $1363 $1726 $818 $1228 73721 MRI JNT OF LWR EXTRE WO DYE 2 304 $804 $859 $967 $1237 $1063 $1598 $2485 $774 $1160 73721 MRI JNT OF LWR EXTRE WO DYE 5 1130 $500 $520 $530 $628 $679 $859 $424 $636 59400 OBSTETRICAL CARE 1 494 $3699 $4402 $4969 $6655 $7307 $8613 $3975 $5963 99203 OFFICEOUTPATIENT VISIT NEW 4 6776 $88 $101 $112 $138 $155 $169 $90 $134 G0202 Screeningmammographydigital 2 7444 $123 $206 $285 $380 $425 $479 $228 $342 G0202 Screeningmammographydigital 5 2754 $117 $165 $195 $230 $247 $252 $156 $234 88305 TISSUE EXAM BY PATHOLOGIST 8 20834 $51 $74 $112 $235 $168 $261 $478 $90 $134 93306 TTE WDOPPLER COMPLETE 2 931 $194 $377 $739 $960 $1267 $1480 $1849 $591 $887 93306 TTE WDOPPLER COMPLETE 5 2299 $151 $296 $373 $538 $573 $834 $298 $448 43239 UPPER GI ENDOSCOPY BIOPSY 6 1264 $424 $514 $550 $800 $1838 $2833 $440 $660 76700 US EXAM ABDOM COMPLETE 2 321 $96 $165 $271 $509 $584 $857 $217 $325 76700 US EXAM ABDOM COMPLETE 5 444 $111 $129 $147 $156 $220 $279 $118 $176 Key 1 Facility - Inpatient 2 Facility - Imaging 3 Physician - Imaging 4 Physician 5 Global - Imaging 6 Facility - Outpatient 8 Lab 41 Physician - Primary Care 42 Physician - Specialist Cardiovascular stress test $ 38279 TTE wDoppler complete $ 96037 Colonoscopy and biopsy $ 287709 Diagnostic colonoscopy $ 291434 Upper gi endoscopy biopsy $ 300526 Knee Arthroscopy $ 523584 Arthroscopy Ligament Repair $ 514501 Comp Metabolic Panel $ 5552 Surgical Path Tissue Exam $ 23570 MRI Abdomen $ 123786 MRI Brain $ 123786 MRI Joint Lower Extremity $ 123786 CT Thorax wo contrast $ 88213 X-ray Chest $ 11548 Screening mammography $ 14098 Mammo Computer Aided $ 11179 US Abdomen Complete $ 39695 Officeoutpatient visit new pt 30 min $ 24753 Vaginal delivery $ 729025 Lap Sleeve Gastrectomy $ 2042124
Page 2
2019 Health Meeting
KEVIN DOTSON FSA MAAA [LEE HEALTH]
JAY HAZELRIGS ASA MAAA [OPTUM]
ROB NATION ASA MAAA [OPTUM]
Employer to Provider Direct Contracting - Whats The Big Deal June 25 2019
SOCIETY OF ACTUARIES Antitrust Compliance Guidelines
Active participation in the Society of Actuaries is an important aspect of membership While the positive contributions of professional societies and associations are well-recognized and encouraged association activities are vulnerable to close antitrust scrutiny By their very nature associations bring together industry competitors and other market participants
The United States antitrust laws aim to protect consumers by preserving the free economy and prohibiting anti-competitive business practices they promote competition There are both state and federal antitrust laws although state antitrust laws closely follow federal law The Sherman Act is the primary US antitrust law pertaining to association activities The Sherman Act prohibits every contract combination or conspiracy that places an unreasonable restraint on trade There are however some activities that are illegal under all circumstances such as price fixing market allocation and collusive bidding
There is no safe harbor under the antitrust law for professional association activities Therefore association meeting participants should refrain from discussing any activity that could potentially be construed as having an anti-competitive effect Discussions relating to product or service pricing market allocations membership restrictions product standardization or other conditions on trade could arguably be perceived as a restraint on trade and may expose the SOA and its members to antitrust enforcement procedures
While participating in all SOA in person meetings webinars teleconferences or side discussions you should avoid discussing competitively sensitive information with competitors and follow these guidelines
bull Do not discuss prices for services or products or anything else that might affect prices
bull Do not discuss what you or other entities plan to do in a particular geographic or product markets or with particular customers bull Do not speak on behalf of the SOA or any of its committees unless specifically authorized to do so
bull Do leave a meeting where any anticompetitive pricing or market allocation discussion occurs
bull Do alert SOA staff andor legal counsel to any concerning discussions bull Do consult with legal counsel before raising any matter or making a statement that may involve competitively sensitive information
Adherence to these guidelines involves not only avoidance of antitrust violations but avoidance of behavior which might be so construed These guidelines only provide an overview of prohibited activities SOA legal counsel reviews meeting agenda and materials as deemed appropriate and any discussion that departs from the formal agenda should be scrutinized carefully Antitrust compliance is everyonersquos responsibility however please seek legal counsel if you have any questions or concerns
2
Presentation Disclaimer
Presentations are intended for educational purposes only and do not replace independent professional judgment Statements of fact and opinions expressed are those of the participants individually and unless expressly stated to the contrary are not the opinion or position of the Society of Actuaries its cosponsors or its committees The Society of Actuaries does not endorse or approve and assumes no responsibility for the content accuracy or completeness of the information presented Attendees should note that the sessions are audio-recorded and may be published in various media including print audio and video formats without further notice
3
Employer to Provider Direct Contracting
Background discussion Jay Hazelrigs
Case Study 1 ndash Pop Health Approach Rob Nation
Case Study 2 ndash Larger Employer Rob Nation
Pitfalls and challenges from a health system perspective Kevin Dotson
Q amp A
4
Background Discussion
6
Stakeholder Landscape
Source Re-Igniting the Growth Engine Part 2 Winning Increased Share of Lucrative Patient Volumes Advisory Board
68 68 55 55
42 49
40 44 40 47 50
80 80 80
68 60 60 50
60 50
53 55
0
5
10
Health care trend after plan changes (total plan costs)
Health care trend before plan changes
Consumer Price Index for all urban consumers (CPI-U)Source Willis Towers Watson 23rd Annual Best Practices in Health Care Employer Survey
Hos
pita
ls Are experiencing a compression of margins due to lower revenue and higher expense trends
Seek improvement in market share and improved margins Em
ploy
ers Face unstainable year over year healthcare costs To
mitigate costs they are forced to implement annual benefit plan changes
Seek lower more predictable medical expenses and healthy productive employees
Direct Contacting Arrangement Types
7
Bundled Payments prospective payment which covers patientrsquos care from start to finish
Reference Based Pricing (RBP) plan pays up to fixed amount for procedure any excess is billed to member
bull PCP-centric bull Level of provider risk can vary from partial to full bull May be offered with other options or full replacement if adequate network
bull Promotes shopping for services via price transparency bull Most common for elective procedures ndash joint surgeries spine gastric bypass
bull Appropriate for high volume procedures bull Medical expense more predictable for these services may not be fixed price bull May result in lower provider revenue than FFS providers seek steerage volume
Center of Excellence (COE) designated provider identified for specific procedures that may require travel
bull Appropriate for high volume procedures bull Specialization amp operational efficiencies reduce utilization variations improves patient
experience amp improves outcomes (eg lower LOS return to work time) bull Members out-of-pocket often low to $0 including travelhotel not always lowest ldquopricerdquo
Accountable Care Organization (ACO) provider reimbursements are directly tied to quality and financial outcomes
Mos
t Com
mon
Ar
rang
emen
ts
On-site health education seminars
Wellness services
On-site clinic
Bundled payments
Employer liaison coordinator
On-site coaching Andor counseling
Care pathways
Direct contracting narrow networks
Source Re-Igniting the Growth Engine Part 2 Winning Increased Share of Lucrative Patient Volumes Advisory Board
Boeing 1UW Med 2Memorial Care 3Mercy MO 4Roper St Francis 5ProvSwedish
DART amp Baylor Scott and White Health
Intel amp 1 Presbyterian ACO 2 Arizona Care Network
Quallcom amp Scripps Health
Stanford Healthcare Alliance
General Motors amp Henry Ford Health
Disney amp 1Orlando Health 2Florida Hospital
Walmart amp 1 Banner 2 Emory 3 Memorial Hermann 4 Mercy AK 5Mercy OK 6 Mercy MO 7Oschner Health 8 Presbyterian 9 St Lukersquos 10 Unity Point 11 Cleveland Clinic 12 Geisinger Health 13Johns Hopkins 14Mayo Clinic AZ 15Mayo Clinic FL 16Mayo MN 17Mercy MO
1 2
3
4 5
6
8
7
9
10
1
3
4 2
1
2
1
Whole Foods amp Adventis Health
11 12 13
14
15
16
17
Emergence of Direct Contracting
8
DC with providers to secure improved pricing
COE through a carve-out provider
COE within the health plans
Source Willis Towers Watson 23rd Annual Best Practices in Health Care Employer Survey Full report and high-performance insights httpswwwwillistowerswatsoncom-mediaWTWPDFInsights201812willis-towers-watson-23rd-annual-best-practices-in-health-care-employer-survey-full-reportpdf 2018
Trends in Direct Contracting amp COE
According to Willis Towers Watsonrsquos survey employers are using COEs mostly through their health plans however direct contracting considerations are expected to grow considerably
6
7
48
2
2
7
14
13
20
0 20 40 60 80
Action taken or tactic used in 2018
Planning for 2019
Considering for 2020
bull Almost 50 use COEs in 18rsquo expected to rise to 2 out of 3 by 2020
bull Employers engaging employees in multiple ways to use COE bull Ongoing communications bull Reducing member cost share
to use bull Increasing member cost
share when not using bull Mandatory use
9
16
12
18
9
3
6
2
50
39
19
22
26
11
10
15
19
31
30
31
22
11
Transplants
Bariatric Surgery
Knees hips or spine
Cardiovascularcardiac
Cancer
Fertility
Other Procedures
Yes with incentives Yes but no incentives No but considering
10
A 2015 survey by the National Business Group on Health shows the status of large employersrsquo contracts with COEs (note reflects all COEs not specifically direct contracts)
Source Large Employersrsquo 2016 Health Plan Design Survey copy 2015 National Business Group on Health
Other centers of excellence programs include maternity NICU sleep apnea pancreas cornea and kidney
National Business Group on Healthrsquos Large Employers 2019 Health Care Strategy and Plan Design Survey showed DC arrangements between employers and bull Health systemsproviders will
increase from 3 in 2018 to 11 in 20191
bull COEs will increase from 12 in 2018 to 18 in 20191
bull Cancer cardiovascular and fertility COEs are experiencing the greatest growth
Source National Business Group on Health ldquoLarge US Employers Eye Changes to Health Care Delivery System as Cost to Provide Health Benefits Nears $15000 per Employeerdquo August 2018
10
Trends in Direct Contracting amp COE
Outcomes amp Benefits bull Employers with COE arrangements are seeing reduction in procedures
bull Walmart (15rsquo-18rsquo) 50+ of spine surgeries amp 20 of kneehip procedures recommended by local providers were determined lsquonot necessaryrsquo by COE (see table)
bull Employers like Walmart amp Boeing continue to sign new providers which suggest (employersrsquo) continued interest in pursuing DC arrangements2 However Boeing and Providence Swedish did end relationship due to inability to capture enoughright data to estimate cost of care3
bull John Hopkinsrsquo Bayview campus COE emerging metrics4
bull 121 referrals in the first three months
bull 352 referrals and 183 surgeries over 18 months
bull 23 of all joint replacement volumes at facility now attributed to travel program
bull 96 of patients said they would recommend this program to family friends coworkers
bull Bingham Memorial in Idaho direct contracting emerging metrics4
bull 17 companies participating covering over 5000 lives
bull +3000 new patients as of October 2018
bull +$3M Revenue from new patients
11
1 How Employers Are Fixing Health Care Harvard Business Review March 2019 2 httpswwwhealthleadersmediacomstrategywalmart-escalates-strategy-solve-employee-healthcare Health Leaders Media Nov 18rsquo 3 Do Providers Have the Data chops to Success with Direct Contract Modern Healthcare August 2018 4 Re-Igniting the Growth Engine Part 2 Winning Increased Share of Lucrative Patient Volumes Advisory Board 5 httpswwwautonewscomarticle20180806OEM180809831gm-signs-major-health-care-services-deal-for-salaried-employees
Walmart COE Programs1
Program Key Benefits
Spin
e Su
rger
y 2300 EEs 50 COE approved of those applied
bull 95 lower readmission bull 14 less time in hospital bull 1 COE vs 5 non-COE patients discharged to SNF bull Returned to work sooner reducing 20 of OOO
time bull More-effective less dangerous amp less expensive bull The COE surgery ldquopricerdquo is 8 higher but value in
earlier discharge lower readmission rates far less utilization of SNF faster return to work
Join
t
1836 EEs 18 COE approved of those applied
bull 32 less time in hospital bull 70 less likely to be readmitted than non-COE
patients bull Fewer postsurgical complications bull 0 COE vs 5 non-COE patients discharged to SNF bull COE patients returned to work a 15 weeks sooner bull Cost of surgery is 15 less at COE hospitals
Baria
tric
300+ EEs
bull Preliminary data suggests the weight loss from surgery reduces absenteeism or presentism (working while sick)
bull Dramatically cuts pharmacy amp medical costs Complications of obesity drop sharply as does the need for medication
bull GMrsquos direct contract benefit plans with Henry Ford allows it to offer similarly designed plans to that of Blue Cross with savings in monthly EE contributions ranging from $300-$19805
Walmartrsquos Travel (Surgery) Program
Mem
ber F
eedb
ack
12
Looking beyond traditional cost management techniques Walmart designed a program to address wild variations in cost and become directly in improving quality of care for its employees FIRST SELECTING PROVIDERS 1 Identify providers with high volume and high quality 2 Target regions in country to support Walmartrsquos employees 3Focus on Integrated Health Systems Hospitals within these systems were best aligned to Walmarts mission could take on risks associated with bundling 4 Eliminate systems unwilling to do bundled payments model were
PROVIDERS VALUE IN PARICIPATING
Build Bundles bull Define bundles and negotiate price (typically 10-15 below FFS ) bull Definitions of service limit disputes of what is covered vs not (covers
entryexit of facility SNF not part of bundle) bull Contract flexibility covers unforeseen testcosts and reinforces
Walmarthealth system partnership bull Warrantees if further treatment - can return in 30 days no
additional cost to Walmart bull Strict criteria and providers with track record of clinically sound
decisions are included to mitigate any incentivizing of volume Business bull 100 travelaccom brings
new volume of patients from outside of market
bull More stable payments for services (vs Medicare or commercial FFS)
bull Increased visibility and attract new business
Clinical bull lsquoHalorsquo effect ndash Building a highly
efficient multidiscipline program brings improvements throughout health system
bull Onsite collaboration among health systems allows sharing of outcomesbest practices
Source How Employers Are Fixing Health Care Harvard Business Review March 2019
5000 participants in the program
95 satisfiedvery satisfied
Denied by care because not deemed necessary by COE Treatment denied due to lifestyle weightsmoking
The Member Experience
13
Engagement begins when employee on clear
path to surgery
Patient contacts with COE TPA
TPA team triages and ensures basic criteria
met
Employee put in touch with nurse team
Car pick-up Flight Hotel all arranged by
TPA
Navigators and nurse coordinators help
throughout the stay
Patient visits to hospital to understand
exceptions of procedure and meet treatment
team
Surgery occurs typically next day
Stay length according to procedure typically a
few days
Discharged from facility Travel home COE team updates local
PCP and discuss follow up care
COE provider checks in with local physician
frequently Revert back to standard coverage
Source How Employers Are Fixing Health Care Harvard Business Review March 2019
Case Study 1
Case study 1 ndash Pop Health Approach bull ProblemCircumstance Large multi-employer group needs to
evaluate benefit design disease prevalence health spend and utilization to manage their population
bull ConsiderationsValue Prop Unique industry and geography drive chronic conditions and utilization patterns
bull Solution Provide opportunity assessment comparing this population to other benchmarks to understand where to target intervention and management as well as assess efforts already taken
15
Market Comparison Preference Sensitive Procedures
16
Legend vs
Mt States vs
National gt120 gt110
110-120 105-110 lt80 lt90
Source Multi-payer commercial benchmark Results are weighted by AgeGender Broader market area includes multi-payer data from the mountain regions
Preference Sensitive Procedures Benchmark Comparison
Dartmouth Atlas Preference Sensitive Procedures
IP allowed dollars ALOS Employer vs
Mt States Employer
vs National FY 2017 FY 2018 FY 2017 FY 2018
Hysterectomy for Uterine Fibroids Rate $569354 $436932 45 54 124 140 CABG Rate $1800260 $2400608 53 60 218 130 Cholycystectomy Rate $832675 $755565 68 39 92 120 C-Section Rate 116 110 HighTech Radiology Rate 103 101 PCIPTCA Rate $934486 $1133708 37 55 82 80 Back Surgery Rate $3237613 $4003212 39 57 52 70 Knee Replacement Rate $3086693 $2177334 41 48 50 64 Total Hip Replacement Rate $1023675 $747491 45 64 37 34
Strengths (+)
Employer compares favorably for orthopedic procedures (back hip knee)
Opportunity (-)
Employer has higher than expected rates for CABG and hysterectomy (Note Low PTCA rate combined with high CABG rate may suggest provider practice patterns favoring CABG)
0 50 100 150 200 250
Total Hip Replacement
Knee Replacement
Back Surgery
PCIPTCA
Cholycystectomy
HighTech Radiology
C-Section
CABG
Culinary VsNational
Culinary Vs MtStates
Employer vs Mt States
Employer vs National
Market Comparison Condition Prevalence
17 Source Multi-payer commercial benchmark Results are weighted by AgeGender Broader market area includes multi-payer data from the mountain regions
Condition Prevalence Benchmark Comparison
Condition Employer vs
Mt States Employer vs
National Prevalence Diabetes Rate 229 219 Prevalence Hyperlipidemia Rate 259 207 Prevalence Kidney Disease Rate 143 174 Prevalence Migraine Rate 166 164 Prevalence Low Back Pain Rate 136 139 Prevalence Hypertension Rate 156 134 Prevalence Asthma Rate 146 128 Prevalence CAD Rate 175 115 Prevalence Pregnancy Rate 110 109 Prevalence Adult Preventive Screening Rate 114 91 Prevalence Depression Rate 63 60
Strengths (+)
Rate of depression is low (Note May be due to incomplete behavioral health claims)
Opportunity (-)
Employer has a higher prevalence of most chronic conditions including asthma CAD diabetes hypertension hyperlipidemia Kidney Disease LBP and migraines
0
100
200
300Hyperlipidemia
Diabetes
CAD
Migraine
Hypertension
AsthmaKidney Disease
Low Back Pain
Pregnancy
Depression
Employer vsMt States
Employer vsNational Legend
vs Mt States
vs National
gt120 gt110 110-120 105-110
lt80 lt90
Market Comparison Utilization Rates
18
A higher preventive office visit rate is better Source Multi-payer commercial benchmark Results are weighted by AgeGender Broader market area includes multi-payer data from the mountain regions
Strengths (+)
Lower than average utilization of ED and high dollar patient rate
Opportunity (-)
Higher LOS lengthy admits avoidable admits and readmissions which all drive significantly more spend
Utilization Benchmark Comparison
Condition Employer vs
Mt States Employer vs
National Avoidable Admit Rate 142 144 Lengthy Admit Rate 175 136 Outpatient Problem Focused Office Rate 146 131 Readmission Rate (readmitadmit) 135 126 Average LOS 125 116 One Day Admit Rate 76 103 Office Visit Rate 106 96 Acute Admit Rate 80 95 Avoidable ED Rate 68 86 ED Rate 54 69 Preventive Office Rate 95 68 High Dollar Patient Rate 49 51 Frequent ED User (gt3 times) Rate 24 36
Legend vs
Mt States vs
National gt120 gt110
110-120 105-110 lt80 lt90
0 50 100 150 200
Frequent ED User (gt3 times)
High Dollar Patient
Preventive Office
ED
Avoidable ED
Acute Admit
Office Visit
One Day Admit
Average LOS
Readmissionhellip
Outpt Problem Focusedhellip
Lengthy Admit
Avoidable Admit
Employer vsNational
Employer vsMt States
ED and Avoidable ED
19
Potentially Avoidable ED - Trend View Overall ED
Period Change FY 2017 FY 2018 Count Rate
Measure Mbrs Rate Mbrs Rate Overall ED 16394 12626 13820 10745 -16 -15 FREQUENT ED UTILIZER (mbr1k) 1581 1218 1468 1141 -7 -6 AVOIDABLE ED 6371 4907 5288 4111 -17 -16 Potentially Avoidable ED
Period Change FY 2017 FY 2018 Count Rate
Avoid ED Condition Mbrs Rate Mbrs Rate ABDOMINAL_PAIN 1092 841 895 696 -18 -17 ENT_INFECTION 854 658 742 577 -13 -12 FEVER 715 551 700 544 -2 -1 URINARY 650 501 468 364 -28 -27 HEADACHE 558 430 434 337 -22 -21 BACK_PAIN 414 319 423 329 2 3 NAUSEA 394 303 271 211 -31 -31 ASTHMA 294 226 209 162 -29 -28 CELLULITIS 210 162 198 154 -6 -5 GASTROENTERITIS 254 196 171 133 -33 -32 OTITIS_MEDIA 201 155 160 124 -20 -20 COPD 132 102 108 084 -18 -17 DIABETES 123 095 91 071 -26 -25 BACT_PNEUMONIA 111 085 86 067 -23 -22 DENTAL 93 072 83 065 -11 -10 DEHYDRATION 98 075 81 063 -17 -17 HYPERTENSION 16 012 24 019 50 51 CHF 4 003 3 002 -25 -24 ANGINA 8 006 3 002 -63 -62 IMMUNIZATION_RELATED 2 002 0 000 -100 -100 Grand Total 6371 4907 5288 4111 -17 -16
AHRQ avoidable ED visits are based on the logic for ambulatory care sensitive ED visits from AHRQ and diagnosis code driven
696
577
544 364
337
329
211 162
154 133 ABDOMINAL_PAIN
ENT_INFECTION
FEVER
URINARY
HEADACHE
BACK_PAIN
NAUSEA
- 200 400 600 800
1000 1200
2017 Members 2018 Members
Top Ten 2018 Conditions by Rate
Top Ten Conditions by Member Count
ED Avoidable ED and the impact of new on-site clinic
20
0
1000
2000
3000
4000
5000
6000
0200400600800
10001200140016001800
Clinic Visits ED Visits
Avoidable ED VisitsED Visits (non-avoidable)Clinic EampM Visits
0
500000
1000000
1500000
2000000
2500000
3000000
3500000
$s
Clinic EampM Profess DollarsAvoidable ED Dollars
bull Clinic visits have a clear impact on ED and avoidable ED use and spend
bull Combined ED visits are down on average 157 in FY 18 from FY 17
bull Combined ED spend is down 128 in FY 18 from FY 17
Clinic Live 62017
Pitfalls and Challenges bull Face many of the challenges similar to startup health
plan bull Critical to determine how you will deliver value and
communicate the value to potential customers and brokersconsultants
bull Care management bull Network
21
Considerations in Offering Development bull Care Management Model
bull Traditional care model bull Case management bull Utilization management bull Disease management
bull Longitudinal care model with value based care philosophy bull Primary care driven bull Local care management
bull Predictive analytics and risk stratification model bull Claims history and ongoing data bull EMR data
22
Case Study 2
Case study 2 ndash Large Employer bull Business Problem Large employer wants to contract
directly with 2 major hospital systems developing professional fee schedules
bull ConsiderationsValue Prop Fee schedule should be competitive but also nuanced to minimize gap relative to current reimbursement at physician level
bull Solution Data-driven approach using current market-wide reimbursement distinguished by service level
24
Evaluate Provider Spend Top 25 Service Lines by Allowable Spend
Evaluate Provider Spend Top 20 Professional CPTs by Total Spend
Understand relative market pricing position
27
21
-1
-28
14 10
28
-22
-11 -13
24
3
20 21
8
-20
13
3 9
-39
56
-26
4
-42
60
MRI Colonoscopy Cardiac Cath Lab - OrganPanel
Memorial Hospital Beta Hospital Delta Hospital Charlie Hospital Echo Hospital Alpha Medical Center
ndash25 5 -15 10 0 39
State Charges as a Percent of Peer Average Weighted Averages for MRI Colonoscopy Cardiology and Lab
Total Percent Above Below Market Average2
Memorial Hospital Beta Hospital Delta Hospital Charlie Hospital Echo Hospital Alpha Medical Center
Develop fee schedule relative to market
28
Service Line Procedure CPT CodeDRG
Memorial Hospital
Beta Hosptial
Charlie Hospital
Delta Hospital
Echo Hospital
Alpha Medical Center
Arthroscopy Ligament Repair 29888 $ 5062 $ 9557 $ 5983 $ 10096 $ 7519 $ 2502 Knee Arthroscopy 29881 $ 5069 $ 4185 $ 3837 $ 3022 $ 3729 $ 2266 Upper GI Endoscopy 43239 $ 3075 $ 2539 $ 2012 $ 1132 $ 1565 $ 2240 Lap Sleeve Gastrectomy DRG 621 $ 20421 $ 20815 $ 12105 $ 13230 $ 14600 $ 17800 Colonoscopy and biopsy 45380 $ 3075 $ 3071 $ 2013 $ 1244 $ 1972 $ 859 Diagnostic Colonoscopy 45378 $ 3075 $ 2805 $ 2013 $ 1244 $ 1972 $ 859 MRI Brain w amp wo dye 70553 $ 1238 $ 1468 $ 1117 $ 967 $ 2805 $ 1052 MRI Joint of Lower Extremity wo dye 73721 $ 1238 $ 1398 $ 1042 $ 967 $ 925 $ 557 MRI Abdomen w amp wo dye 74183 $ 1238 $ 1468 $ 1106 $ 967 $ 2805 $ 836 X-ray Chest 71020 $ 115 $ 266 $ 305 $ 279 $ 375 $ 72 CT Thorax wo dye 71250 $ 882 $ 810 $ 505 $ 491 $ 579 $ 319 Ultrasound Abdomen Complete 76700 $ 397 $ 538 $ 545 $ 195 $ 190 $ 168 Mammogram Screening G0202 $ 141 $ 328 $ 431 $ 294 $ 425 $ 168 Computer Detection Add-on 77052 $ 112 $ 99 $ 41 $ 15 $ 45 $ 23 Comp Metabolic Panel 80053 $ 56 $ 15 $ 24 $ 56 $ 51 $ 25 Tissue Exam by Pathologist 88305 $ 236 $ 307 $ 80 $ 152 $ 78 $ 232 Cardiovascular Stress Test 93017 $ 383 $ 432 $ 1299 $ 907 $ 717 $ 797 TTE w Doppler 93306 $ 960 $ 1566 $ 1388 $ 1173 $ 1125 $ 1157
Obstetrics Vaginal Delivery DRG 755 7290$ 5730$ 4654$ 4607$ 5855$ 4688$
GI
Lab
Radiology
Medical Cardiology
Orthopedics
KEY OBSERVA TIONS bull Potential exposure on GI bull Opportunity to align price and acuity in MRI bull Opportunity to raise rates on chest x-ray and mammogram
Percentile Bands Emory Allowables Heatmap TEC ASC Heatmap Allowable Comp Analysis Portal Pricing Sheet1 image1png A few words on Bundled Payments bull Bundled payments are growing as a type of direct contracting bull In some cases third parties match-make between employers
and providers bull Contracts may vary in definitions prepost admission
coverage duration readmission cause (ie all-cause vs medically related) outlier provisions LOS caps andor per diems
bull Providers need to be strategic in pricing to enable profitable growth of market share
29
Considerations in Offering Development bull Network Development
bull Build off existing structure eg health system employee plan network bull How does this fit into your broader value based care strategy bull Employed and independent physicians bull How do you want to approach the buildout of high performance
network bull Quality focus bull Cost efficiency
bull Integrated behavioral health bull Wrap network for other markets
30
Considerations in Offering Development bull Target Market
bull Consideration of employer profile in market bull Fully-insured vs ASO bull Total cost of care vs bundled services
bull Distribution bull Direct marketing bull Brokerconsultant community
bull Plan designs bull Standard designs vs flexible ndash Dependent on target market
bull Claims administration bull Data sharing amp analytics
31
Considerations in Offering Development bull Other components of comprehensive offering
bull Pharmacy bull Preventive health bull Onsite clinics bull Wellness programs bull Technology platform
32
Sample Bundle Analysis
33
Cover page Dotson Hazelrigs Nation Mainly of charge of fixed Cardiovascular stress test TTE wDoppler complete Colonoscopy and biopsy (Combined) Diagnostic colonoscopy (Combined) Upper gi endoscopy biopsy (Combined) Knee Arthroscopy (Combined) Arthroscopy Ligament Repair Comp Metabolic Panel Surgical Path Tissue Exam MRI Abdomen MRI Brain MRI Joint Lower Extremity CT Thorax wo contrast X-ray Chest Screening mammography Mammo Computer Aided US Abdomen Complete Officeoutpatient visit new pt 30 min Vaginal delivery Lap Sleeve Gastrectomy
Piedmont Piedmont Piedmont Piedmont Northside Northside Northside Northside Gwinnett Gwinnett Gwinnett Gwinnett WellStar WellStar WellStar WellStar AMC - Tenet AMC - Tenet AMC - Tenet AMC - Tenet CPT Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing 29881 $11312 $10872 NA NA $7476 $9338 NA $23655 $11856 $3668 NA $17871 $12253 NA NA $15645 $5490 NA NA $23039 29888 NA NA NA NA NA NA NA $23784 NA $8261 NA $18000 NA NA NA $15774 NA NA NA $23168 43239 NA $4408 NA NA NA NA $5997 $8852 NA $3304 NA $7424 $1267 NA NA $9230 NA $2458 NA $8274 43644 $26468 NA NA NA $3382 $12050 NA $1861 NA NA NA $1316 $7841 NA NA $3444 $18892 $27950 NA $979 43775 NA NA NA NA NA NA NA $352 NA NA NA $302 NA NA NA $413 NA NA NA $83 45378 $2705 $2530 NA NA $4381 $3676 $4496 $1022 $2938 $2138 NA $695 $5504 NA NA $2036 NA NA NA $372 45380 $3075 $2600 NA NA $4723 $3527 $3012 $1757 $4215 $2285 NA NA $5298 NA NA $3268 NA NA NA $627 59400 $6160 NA NA NA NA $5100 NA $1851 NA NA NA $1304 $9035 NA NA $3427 $9116 $5150 NA $966 70553 $2985 NA $1153 NA $2182 NA $1192 $492 NA NA $803 $489 $1512 NA $985 $1187 NA NA NA $197 71020 $61 $69 $43 NA $113 $319 $307 NA $183 $59 $32 NA $213 $66 $40 NA $83 $53 NA NA 71250 $1837 $621 $989 NA $1490 $931 $755 NA NA $745 $401 NA $1067 $982 $616 NA NA $304 NA NA 73721 NA $1098 $1153 NA $2042 $1065 $1192 NA NA $998 $803 NA NA $1275 $985 NA NA $644 NA $178 74183 $2971 $1144 NA NA NA $1092 $1192 $6884 NA $1098 $803 NA $2960 $1197 $985 $5454 NA NA NA $7607 76700 $364 $247 $207 NA $427 $708 $614 $13267 $428 $214 $152 NA $747 $263 $189 $9139 NA $235 NA NA 77052 NA NA NA NA NA NA NA $4744 NA NA NA NA NA NA NA $3070 NA NA NA $5611 93306 $1220 $1117 NA NA $1877 $1657 $2100 $4605 $1433 $413 $945 NA $1336 $1434 $1951 $2931 NA $2399 NA $5472 G0202 $262 $187 NA NA $431 NA NA $4605 $292 NA NA NA $530 $281 NA $2931 $327 NA NA $5472
Provider Group 29881_6 29888_6 43239_6 43644_1 43775_1 45378_6 45380_6 59400_1 70553_2 71020_2 71250_2 73721_2 74183_2 76700_2 77052_2 77052_5 80053_8 88305_8 93306_2 99203_4 G0202_2 G0202_5 93017_2 Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Atlanta Gastroenterology Associates $2399 $536 348 $1628 $536 204 $2400 $536 348 Atlanta Medical Center $24889 $2266 999 $25897 $2502 935 $11449 $2240 411 $81927 $15300 435 $75815 $17800 326 $7317 $859 752 $7317 $859 752 $12821 $4688 173 $6581 $1052 526 $645 $72 796 $3265 $319 925 $3450 $557 519 $7398 $836 785 $1576 $133 1084 $73 $23 217 $635 $25 2440 $891 $232 285 $2967 $1157 156 $344 $168 105 $1265 $797 59 Atlanta Womens Health Physicians Group $29 $14 107 $40 $13 208 $396 $188 111 $278 $118 135 $450 $231 95 Gwinnett Hospital $11941 $3022 295 $21654 $10096 114 $3551 $1132 214 $34384 $10800 218 $56472 $13230 327 $3003 $1244 141 $3533 $1244 184 $8984 $4607 95 $3901 $967 303 $417 $279 49 $2247 $491 358 $4000 $967 314 $3755 $967 288 $1593 $195 717 $50 $15 233 $186 $56 233 $505 $152 233 $1750 $1173 49 $418 $294 42 $1396 $907 54 Northside Hospital $15482 $4185 270 $21651 $9557 127 $4885 $2539 92 $35176 $17000 107 $35233 $20815 69 $3883 $2805 38 $5256 $3071 71 $10911 $5730 90 $4856 $1468 231 $443 $266 67 $2379 $810 194 $3776 $1398 170 $5105 $1468 248 $942 $538 75 $167 $99 69 $379 $15 2427 $433 $307 41 $2252 $1566 44 $459 $328 40 $576 $432 33 Piedmont Hospital $14772 $3837 285 $35493 $5983 493 $5069 $2012 152 $38320 $17750 116 $37125 $12105 207 $3485 $2013 73 $4993 $2013 148 $10143 $4654 118 $5939 $1117 432 $542 $305 78 $2983 $505 491 $3410 $1042 227 $6067 $1106 449 $1364 $545 150 $75 $41 85 $231 $24 863 $657 $80 721 $2041 $1388 47 $490 $431 14 $1780 $1299 37 Piedmont Physicians Group $42 $22 87 $318 $179 78 $239 $159 50 Resurgens $8558 $2036 320 $9293 $2258 312 $4638 $2067 124 $4039 $2164 87 $4392 $2164 103 $2252 $1371 64 $459 $330 39 Wellstar Hospital $9330 $3729 150 $17479 $7519 132 $5261 $1565 236 $35794 $18200 97 $46780 $14600 220 $3707 $1972 88 $4928 $1972 150 $13549 $5855 131 $5054 $2805 80 $528 $375 41 $3222 $579 457 $3694 $925 299 $5495 $2805 96 $1355 $190 615 $66 $45 46 $73 $51 43 $133 $78 71 $1785 $1125 59 $599 $425 41 $1010 $717 41 Avg Mark UpProcedure Atlanta Medical Center 634 Gwinnett Hospital 223 Northside Hospital 233 Piedmont Hospital 259 Wellstar Hospital 155 Emory 105
Atlanta Gastroenterology Associates Atlanta Medical Center Atlanta Womens Health Gwinnett Hospital Northside Hospital Piedmont Hospital Piedmont Physicians Group Resurgens Wellstar Hospital CPT Code CPT Proc Cat Comp Avg Allow Allow Allow Allow Allow Allow Allow Allow Allow 29881 KNEE ARTHROSCOPYSURGERY 6 $3179 $2266 $3022 $4185 $3837 $2036 $3729 29888 KNEE ARTHROSCOPYSURGERY 6 $6319 $2502 $10096 $9557 $5983 $2258 $7519 43239 UPPER GI ENDOSCOPY BIOPSY 6 $1727 $536 $2240 $1132 $2539 $2012 $2067 $1565 43644 LAP GASTRIC BYPASSROUX-EN-Y 1 $15810 $15300 $10800 $17000 $17750 $18200 43775 LAP SLEEVE GASTRECTOMY 1 $17800 $13230 $20815 $12105 $14600 45378 DIAGNOSTIC COLONOSCOPY 6 $1656 $536 $859 $1244 $2805 $2013 $2164 $1972 45380 COLONOSCOPY AND BIOPSY 6 $1694 $536 $859 $1244 $3071 $2013 $2164 $1972 59400 OBSTETRICAL CARE 1 $5107 $4688 $4607 $5730 $4654 $5855 70553 MRI BRAIN WO amp WDYE 2 $1482 $1052 $967 $1468 $1117 $2805 71020 CHEST X-RAY 2 $259 $72 $279 $266 $305 $375 71250 CT THORAX WO DYE 2 $541 $319 $491 $810 $505 $579 73721 MRI JNT OF LWR EXTRE WO DYE 2 $978 $557 $967 $1398 $1042 $925 74183 MRI ABDOMEN WO amp WDYE 2 $1436 $836 $967 $1468 $1106 $2805 76700 US EXAM ABDOM COMPLETE 2 $320 $133 $195 $538 $545 $190 77052 COMP SCREEN MAMMOGRAM ADD-ON 2 $45 $23 $15 $99 $41 $45 77052 COMP SCREEN MAMMOGRAM ADD-ON 5 $14 $14 80053 COMPREHEN METABOLIC PANEL 8 $29 $25 $13 $56 $15 $24 $22 $51 88305 TISSUE EXAM BY PATHOLOGIST 8 $174 $232 $188 $152 $307 $80 $179 $78 93306 TTE WDOPPLER COMPLETE 2 $1297 $1157 $1173 $1566 $1388 $1371 $1125 93017 STRESS TEST 5 $830 $797 $907 $432 $1299 $717 99203 OFFICEOUTPATIENT VISIT NEW 4 $139 $118 $159 G0202 Screeningmammographydigital 2 $329 $168 $294 $328 $431 $330 $425 G0202 Screeningmammographydigital 5 $231 $231
Service Line Procedure CPT Code Emory Atlanta Gastroenterology Associates Resurgens Atlanta Womens Health Piedmont Physicians Group Orthopedics (ASC) Knee Arthroscopy 29881 $3467 $2036 Arthroscopy Ligament Repair 29888 $3386 $2258 GI (ASC) Upper GI Endoscopy 43239 $2758 $536 Diagnostic Colonoscopy 45378 $2348 $536 Colonoscopy and biopsy 45380 $2181 $536 Radiology Mammogram Screening G0202 $164 $231 Computer Detection Add-on 77052 $93 $14 Lab Comp Metabolic Panel 80053 $53 $13 $22 Tissue Exam by Pathologist 88305 $277 $188 $179 EampM (TEC) Office Visit new pt 99203 $269 $118 $159
Service Line Procedure CPT CodeDRG Memorial Hospital Beta Hosptial Charlie Hospital Delta Hospital Echo Hospital Alpha Medical Center Atlanta Gastroenterology Associates Resurgens Atlanta Womens Health Piedmont Physicians Group Market Avg Emory abovebelow Orthopedics Arthroscopy Ligament Repair 29888 $ 5062 $ 9557 $ 5983 $ 10096 $ 7519 $ 2502 $ 2258 $ 6319 -20 Knee Arthroscopy 29881 6 $ 5069 $ 4185 $ 3837 $ 3022 $ 3729 $ 2266 $ 2036 $ 3179 59 GI Upper GI Endoscopy 43239 6 $ 3075 $ 2539 $ 2012 $ 1132 $ 1565 $ 2240 $ 536 $ 1671 84 Lap Sleeve Gastrectomy DRG 621 $ 20421 $ 20815 $ 12105 $ 13230 $ 14600 $ 17800 $ 15710 30 Colonoscopy and biopsy 45380 $ 3075 $ 3071 $ 2013 $ 1244 $ 1972 $ 859 $ 536 $ 1616 90 Diagnostic Colonoscopy 45378 6 $ 3075 $ 2805 $ 2013 $ 1244 $ 1972 $ 859 $ 536 $ 1572 96 Radiology MRI Brain w amp wo dye 70553 2 $ 1238 $ 1468 $ 1117 $ 967 $ 2805 $ 1052 $ 1482 -16 MRI Joint of Lower Extremity wo dye 73721 2 $ 1238 $ 1398 $ 1042 $ 967 $ 925 $ 557 $ 978 27 MRI Abdomen w amp wo dye 74183 2 $ 1238 $ 1468 $ 1106 $ 967 $ 2805 $ 836 $ 1436 -14 X-ray Chest 71020 $ 115 $ 266 $ 305 $ 279 $ 375 $ 72 $ 259 -56 CT Thorax wo dye 71250 $ 882 $ 810 $ 505 $ 491 $ 579 $ 319 $ 541 63 Ultrasound Abdomen Complete 76700 $ 397 $ 538 $ 545 $ 195 $ 190 $ 168 $ 327 21 Mammogram Screening G0202 2 $ 141 $ 328 $ 431 $ 294 $ 425 $ 168 $ 231 $ 313 -55 Computer Detection Add-on 77052 2 $ 112 $ 99 $ 41 $ 15 $ 45 $ 23 $ 14 $ 39 183 Lab Comp Metabolic Panel 80053 8 $ 56 $ 15 $ 24 $ 56 $ 51 $ 25 $ 13 $ 22 $ 29 88 Tissue Exam by Pathologist 88305 8 $ 236 $ 307 $ 80 $ 152 $ 78 $ 232 $ 188 $ 179 $ 174 36 Medical Cardiology Cardiovascular Stress Test 93017 $ 383 $ 432 $ 1299 $ 907 $ 717 $ 797 $ 830 -54 TTE w Doppler 93306 2 $ 960 $ 1566 $ 1388 $ 1173 $ 1125 $ 1157 $ 1282 -25 Obstetrics Vaginal Delivery DRG 755 $ 7290 $ 5730 $ 4654 $ 4607 $ 5855 $ 4688 $ 5107 43 EampM Office Visit new pt 99203 4 $ 248 $ 118 $ 159 $ 139 78 Colonoscopy and biopsy (HOSPITAL ONLY) 45380 Surg 2530 $ 307591 Diagnostic colonoscopy (HOSPITAL ONLY) 45378 Surg 2255 $ 307591 Upper gi endoscopy biopsy (HOSPITAL ONLY) 43239 Surg 1787 $ 307591 Knee Arthroscopy (HOSPITAL ONLY) 29881 Surg 10900 $ 506893 Arthroscopy Ligament Repair (HOSPITAL ONLY) 29888 Surg 10900 $ 506200 Key 1 Facility - Inpatient 2 Facility - Imaging 3 Physician - Imaging 4 Physician 5 Global - Imaging 6 Facility - Outpatient 8 Lab 41 Physician - Primary Care 42 Physician - Specialist
Blue Cross United - EJCH EUH EUHM WW United - SJH Non Options United - SJH Options Aetna - ASC TEC (HMO) Cigna - ASC TEC (HMO) Aetna - EJCH ESJH ECHM WW Cigna - EJCH (HMO) Cigna - ESJH EUHM (HMO) List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract Description CPT Code Charge Average Final Price (all plans) Emory Mark Up Reimbursement Method ( of charge or fixed) - 1713 Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Cardiovascular stress test 93017 Cardio $543 $ 425 28 of Charge 70 $ 380 of Charge 65 $ 353 of Charge 60 $ 326 of Charge 70 $ 380 of Charge 70 $ 380 of charge 100 $ 543 of Charge 70 $ 380 of charge 100 $ 543 of charge 100 $ 543 TTE wDoppler complete 93306 Cardio $1226 $ 960 28 of Charge 70 $ 858 of Charge 65 $ 797 of Charge 60 $ 736 of Charge 70 $ 858 of Charge 70 $ 858 of charge 100 $ 1226 of Charge 70 $ 858 of charge 100 $ 1226 of charge 100 $ 1226 Colonoscopy and biopsy (HOSPITAL ONLY) 45380 Surg $2530 $ 3076 -18 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 of Charge 70 $ 1771 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Diagnostic colonoscopy (HOSPITAL ONLY) 45378 Surg $2255 $ 3076 -27 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 of Charge 70 $ 1579 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Upper gi endoscopy biopsy (HOSPITAL ONLY) 43239 Surg $1787 $ 3076 -42 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Knee Arthroscopy (HOSPITAL ONLY) 29881 Surg $10900 $ 5069 115 Fixed Rate SC 4 $ 3865 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 449300 $ 4493 Fixed Rate $ 654700 $ 6547 of Charge 70 $ 7630 Fixed Rate $ 401000 $ 4010 of Charge 70 $ 7630 Fixed Rate $ 398300 $ 3983 Fixed Rate $ 398100 $ 3981 Arthroscopy Ligament Repair (HOSPITAL ONLY) 29888 Surg $10900 $ 5062 115 Fixed Rate SC 3 $ 3121 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 556900 $ 5569 Fixed Rate $ 770100 $ 7701 of Charge 70 $ 7630 Fixed Rate $ 323900 $ 3239 of Charge 70 $ 7630 Fixed Rate $ 321700 $ 3217 Fixed Rate $ 321400 $ 3214 Comp Metabolic Panel 80053 Lab $132 $ 56 138 RBRVS Fee (100) $ 1437 of Charge 65 $ 86 of Charge 65 $ 86 of Charge 65 $ 86 of Charge 70 $ 92 RBRVS Fee (100) $ 1437 $ 14 of Charge 70 $ 92 RBRVS Fee (100) $ 1437 $ 14 RBRVS Fee (100) $ 1437 $ 14 Surgical Path Tissue Exam 88305 Lab $326 $ 236 38 of Charge 150 $ 51 of Charge 65 $ 212 of Charge 65 $ 212 of Charge 65 $ 212 of Charge 70 $ 228 of charge 100 $ 326 of Charge 70 $ 228 of charge 100 $ 326 of charge 100 $ 326 MRI Abdomen 74183 Radiology $6960 $ 1238 462 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 MRI Brain 70553 Radiology $6804 $ 1238 450 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 MRI Joint Lower Extremity 73721 Radiology $3067 $ 1238 148 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 CT Thorax wo contrast 71250 Radiology $2199 $ 882 149 Fixed Rate $ 771 Fixed Rate $ 47100 $ 471 Fixed Rate $ 81700 $ 817 Fixed Rate $ 116000 $ 1160 of Charge 70 $ 1539 Fixed Rate $ 80100 $ 801 Fixed Rate $ 79200 $ 792 Fixed Rate $ 79300 $ 793 Fixed Rate $ 79500 $ 795 X-ray Chest 71020 Radiology $280 $ 115 142 of Charge 150 $ 25 of Charge 65 $ 182 of Charge 60 $ 168 of Charge 70 $ 196 of Charge 70 $ 196 RBRVS Fee (150) $ 2534 $ 25 of Charge 70 $ 196 RBRVS Fee (150) $ 2534 $ 25 RBRVS Fee (150) $ 2534 $ 25 Screening mammography G0202 Radiology $279 $ 141 98 Fixed Rate $ 128 Fixed Rate $ 13100 $ 131 Fixed Rate $ 14300 $ 143 Fixed Rate $ 16100 $ 161 of Charge 70 $ 195 Fixed Rate $ 13300 $ 133 Fixed Rate $ 13500 $ 135 Fixed Rate $ 13000 $ 130 Fixed Rate $ 11200 $ 112 Mammo Computer Aided 77052 Radiology $75 $ 112 -33 Fixed Rate $ 9 Fixed Rate $ 13100 $ 131 Fixed Rate $ 14300 $ 143 Fixed Rate $ 16100 $ 161 of Charge 70 $ 53 Fixed Rate $ 13300 $ 133 Fixed Rate $ 13500 $ 135 Fixed Rate $ 13000 $ 130 Fixed Rate $ 11200 $ 112 US Abdomen Complete 76700 Radiology $917 $ 397 131 of Charge 150 $ 125 of Charge 65 $ 596 of Charge 60 $ 550 of Charge 70 $ 642 of Charge 70 $ 642 RBRVS Fee (150) $ 12519 $ 125 of Charge 70 $ 642 RBRVS Fee (150) $ 12519 $ 125 RBRVS Fee (150) $ 12519 $ 125 Officeoutpatient visit new pt 30 min (TEC) 99203 EampM $316 $ 248 28 of Charge 70 $ 221 of Charge 65 $ 205 of Charge 60 $ 190 of Charge 70 $ 221 of Charge 70 $ 221 of charge 100 $ 316 of Charge 70 $ 221 of charge 100 $ 316 of charge 100 $ 316 Vaginal delivery 59409 Surg $14484 $ 7290 99 Fixed Rate DRG - 775 $ 5437 2 Day Case Rate + LOC 561700 $ 5617 BaseCMS Weight 584741 $ 5847 BaseCMS Weight 726146 $ 7261 No IP Terms $ - 0 No IP BaseCMS Weight 659343 $ 6593 BaseContract Weight 479451 100 $ 14484 BaseCMS Weight 579110 $ 5791 Lap Sleeve Gastrectomy 43775 Surg $29961 $ 20421 47 Fixed Rate DRG - 621 $ 14872 BaseCMS Weight 1810697 $ 18107 BaseCMS Weight 1835178 $ 18352 BaseCMS Weight 2278911 $ 22789 No IP Terms $ - 0 No IP BaseCMS Weight 2069315 $ 20693 BaseCMS Weight 1730442 100 $ 29961 BaseCMS Weight 1817507 $ 18175 105 Colonoscopy and biopsy (ASC ONLY) Surg $ 219200 $ 2181 Diagnostic colonoscopy (ASC ONLY) Surg $ 267100 $ 2348 Upper gi endoscopy biopsy (ASC ONLY) Surg $ 207500 $ 2758 Knee Arthroscopy (ASC ONLY) Surg $ 417900 $ 3467 Arthroscopy Ligament Repair (ASC ONLY) Surg $ 504800 $ 3386
Cpt Code CPT Description Procedure Category Claims Min 25thNtile 50thNtile Emorys Rates 75thNtile 90thNtile Max 20 Below 50th Ntile 20 Above 50th Ntile 93017 CARDIOVASCULAR STRESS TEST 5 82 $80 $125 $321 $382 $568 $791 $930 $257 $386 71020 CHEST X-RAY 2 2638 $11 $45 $152 $115 $289 $373 $585 $122 $182 71020 CHEST X-RAY 5 8106 $25 $34 $38 $54 $57 $69 $30 $46 45380 COLONOSCOPY AND BIOPSY 6 1256 $541 $560 $572 $2877 $1000 $2024 $3289 $458 $686 77052 COMP SCREEN MAMMOGRAM ADD-ON 2 194 $13 $15 $25 $38 $47 $134 $20 $30 77052 COMP SCREEN MAMMOGRAM ADD-ON 5 2411 $13 $16 $20 $23 $26 $28 $16 $24 80053 COMPREHEN METABOLIC PANEL 8 13019 $9 $19 $23 $55 $24 $25 $69 $19 $28 71250 CT THORAX WO DYE 2 302 $165 $372 $545 $878 $1658 $2067 $436 $654 71250 CT THORAX WO DYE 5 209 $53 $127 $203 $289 $419 $534 $162 $244 45378 DIAGNOSTIC COLONOSCOPY 6 1479 $484 $515 $536 $2914 $831 $1971 $2828 $428 $643 29881 KNEE ARTHROSCOPYSURGERY 6 152 $1650 $1826 $2036 $5235 $3054 $4216 $6461 $1629 $2443 29888 KNEE ARTHROSCOPYSURGERY 6 82 $1682 $3615 $5081 $5145 $7553 $12924 $18532 $4065 $6097 43644 LAP GASTRIC BYPASSROUX-EN-Y 1 21 $11821 $13873 $17050 $18391 $25029 $31079 $13640 $20460 43775 LAP SLEEVE GASTRECTOMY 1 38 $4215 $8250 $13253 $20421 $19197 $21509 $24260 $10602 $15903 74183 MRI ABDOMEN WO amp WDYE 2 120 $919 $987 $1015 $1237 $1252 $2534 $3177 $812 $1218 74183 MRI ABDOMEN WO amp WDYE 5 112 $475 $490 $521 $1154 $1337 $1696 $417 $625 70553 MRI BRAIN WO amp WDYE 2 324 $633 $987 $1142 $1237 $1706 $2805 $3331 $914 $1370 70553 MRI BRAIN WO amp WDYE 5 467 $280 $539 $1023 $1277 $1363 $1726 $818 $1228 73721 MRI JNT OF LWR EXTRE WO DYE 2 304 $804 $859 $967 $1237 $1063 $1598 $2485 $774 $1160 73721 MRI JNT OF LWR EXTRE WO DYE 5 1130 $500 $520 $530 $628 $679 $859 $424 $636 59400 OBSTETRICAL CARE 1 494 $3699 $4402 $4969 $6655 $7307 $8613 $3975 $5963 99203 OFFICEOUTPATIENT VISIT NEW 4 6776 $88 $101 $112 $138 $155 $169 $90 $134 G0202 Screeningmammographydigital 2 7444 $123 $206 $285 $380 $425 $479 $228 $342 G0202 Screeningmammographydigital 5 2754 $117 $165 $195 $230 $247 $252 $156 $234 88305 TISSUE EXAM BY PATHOLOGIST 8 20834 $51 $74 $112 $235 $168 $261 $478 $90 $134 93306 TTE WDOPPLER COMPLETE 2 931 $194 $377 $739 $960 $1267 $1480 $1849 $591 $887 93306 TTE WDOPPLER COMPLETE 5 2299 $151 $296 $373 $538 $573 $834 $298 $448 43239 UPPER GI ENDOSCOPY BIOPSY 6 1264 $424 $514 $550 $800 $1838 $2833 $440 $660 76700 US EXAM ABDOM COMPLETE 2 321 $96 $165 $271 $509 $584 $857 $217 $325 76700 US EXAM ABDOM COMPLETE 5 444 $111 $129 $147 $156 $220 $279 $118 $176 Key 1 Facility - Inpatient 2 Facility - Imaging 3 Physician - Imaging 4 Physician 5 Global - Imaging 6 Facility - Outpatient 8 Lab 41 Physician - Primary Care 42 Physician - Specialist Cardiovascular stress test $ 38279 TTE wDoppler complete $ 96037 Colonoscopy and biopsy $ 287709 Diagnostic colonoscopy $ 291434 Upper gi endoscopy biopsy $ 300526 Knee Arthroscopy $ 523584 Arthroscopy Ligament Repair $ 514501 Comp Metabolic Panel $ 5552 Surgical Path Tissue Exam $ 23570 MRI Abdomen $ 123786 MRI Brain $ 123786 MRI Joint Lower Extremity $ 123786 CT Thorax wo contrast $ 88213 X-ray Chest $ 11548 Screening mammography $ 14098 Mammo Computer Aided $ 11179 US Abdomen Complete $ 39695 Officeoutpatient visit new pt 30 min $ 24753 Vaginal delivery $ 729025 Lap Sleeve Gastrectomy $ 2042124
Page 3
SOCIETY OF ACTUARIES Antitrust Compliance Guidelines
Active participation in the Society of Actuaries is an important aspect of membership While the positive contributions of professional societies and associations are well-recognized and encouraged association activities are vulnerable to close antitrust scrutiny By their very nature associations bring together industry competitors and other market participants
The United States antitrust laws aim to protect consumers by preserving the free economy and prohibiting anti-competitive business practices they promote competition There are both state and federal antitrust laws although state antitrust laws closely follow federal law The Sherman Act is the primary US antitrust law pertaining to association activities The Sherman Act prohibits every contract combination or conspiracy that places an unreasonable restraint on trade There are however some activities that are illegal under all circumstances such as price fixing market allocation and collusive bidding
There is no safe harbor under the antitrust law for professional association activities Therefore association meeting participants should refrain from discussing any activity that could potentially be construed as having an anti-competitive effect Discussions relating to product or service pricing market allocations membership restrictions product standardization or other conditions on trade could arguably be perceived as a restraint on trade and may expose the SOA and its members to antitrust enforcement procedures
While participating in all SOA in person meetings webinars teleconferences or side discussions you should avoid discussing competitively sensitive information with competitors and follow these guidelines
bull Do not discuss prices for services or products or anything else that might affect prices
bull Do not discuss what you or other entities plan to do in a particular geographic or product markets or with particular customers bull Do not speak on behalf of the SOA or any of its committees unless specifically authorized to do so
bull Do leave a meeting where any anticompetitive pricing or market allocation discussion occurs
bull Do alert SOA staff andor legal counsel to any concerning discussions bull Do consult with legal counsel before raising any matter or making a statement that may involve competitively sensitive information
Adherence to these guidelines involves not only avoidance of antitrust violations but avoidance of behavior which might be so construed These guidelines only provide an overview of prohibited activities SOA legal counsel reviews meeting agenda and materials as deemed appropriate and any discussion that departs from the formal agenda should be scrutinized carefully Antitrust compliance is everyonersquos responsibility however please seek legal counsel if you have any questions or concerns
2
Presentation Disclaimer
Presentations are intended for educational purposes only and do not replace independent professional judgment Statements of fact and opinions expressed are those of the participants individually and unless expressly stated to the contrary are not the opinion or position of the Society of Actuaries its cosponsors or its committees The Society of Actuaries does not endorse or approve and assumes no responsibility for the content accuracy or completeness of the information presented Attendees should note that the sessions are audio-recorded and may be published in various media including print audio and video formats without further notice
3
Employer to Provider Direct Contracting
Background discussion Jay Hazelrigs
Case Study 1 ndash Pop Health Approach Rob Nation
Case Study 2 ndash Larger Employer Rob Nation
Pitfalls and challenges from a health system perspective Kevin Dotson
Q amp A
4
Background Discussion
6
Stakeholder Landscape
Source Re-Igniting the Growth Engine Part 2 Winning Increased Share of Lucrative Patient Volumes Advisory Board
68 68 55 55
42 49
40 44 40 47 50
80 80 80
68 60 60 50
60 50
53 55
0
5
10
Health care trend after plan changes (total plan costs)
Health care trend before plan changes
Consumer Price Index for all urban consumers (CPI-U)Source Willis Towers Watson 23rd Annual Best Practices in Health Care Employer Survey
Hos
pita
ls Are experiencing a compression of margins due to lower revenue and higher expense trends
Seek improvement in market share and improved margins Em
ploy
ers Face unstainable year over year healthcare costs To
mitigate costs they are forced to implement annual benefit plan changes
Seek lower more predictable medical expenses and healthy productive employees
Direct Contacting Arrangement Types
7
Bundled Payments prospective payment which covers patientrsquos care from start to finish
Reference Based Pricing (RBP) plan pays up to fixed amount for procedure any excess is billed to member
bull PCP-centric bull Level of provider risk can vary from partial to full bull May be offered with other options or full replacement if adequate network
bull Promotes shopping for services via price transparency bull Most common for elective procedures ndash joint surgeries spine gastric bypass
bull Appropriate for high volume procedures bull Medical expense more predictable for these services may not be fixed price bull May result in lower provider revenue than FFS providers seek steerage volume
Center of Excellence (COE) designated provider identified for specific procedures that may require travel
bull Appropriate for high volume procedures bull Specialization amp operational efficiencies reduce utilization variations improves patient
experience amp improves outcomes (eg lower LOS return to work time) bull Members out-of-pocket often low to $0 including travelhotel not always lowest ldquopricerdquo
Accountable Care Organization (ACO) provider reimbursements are directly tied to quality and financial outcomes
Mos
t Com
mon
Ar
rang
emen
ts
On-site health education seminars
Wellness services
On-site clinic
Bundled payments
Employer liaison coordinator
On-site coaching Andor counseling
Care pathways
Direct contracting narrow networks
Source Re-Igniting the Growth Engine Part 2 Winning Increased Share of Lucrative Patient Volumes Advisory Board
Boeing 1UW Med 2Memorial Care 3Mercy MO 4Roper St Francis 5ProvSwedish
DART amp Baylor Scott and White Health
Intel amp 1 Presbyterian ACO 2 Arizona Care Network
Quallcom amp Scripps Health
Stanford Healthcare Alliance
General Motors amp Henry Ford Health
Disney amp 1Orlando Health 2Florida Hospital
Walmart amp 1 Banner 2 Emory 3 Memorial Hermann 4 Mercy AK 5Mercy OK 6 Mercy MO 7Oschner Health 8 Presbyterian 9 St Lukersquos 10 Unity Point 11 Cleveland Clinic 12 Geisinger Health 13Johns Hopkins 14Mayo Clinic AZ 15Mayo Clinic FL 16Mayo MN 17Mercy MO
1 2
3
4 5
6
8
7
9
10
1
3
4 2
1
2
1
Whole Foods amp Adventis Health
11 12 13
14
15
16
17
Emergence of Direct Contracting
8
DC with providers to secure improved pricing
COE through a carve-out provider
COE within the health plans
Source Willis Towers Watson 23rd Annual Best Practices in Health Care Employer Survey Full report and high-performance insights httpswwwwillistowerswatsoncom-mediaWTWPDFInsights201812willis-towers-watson-23rd-annual-best-practices-in-health-care-employer-survey-full-reportpdf 2018
Trends in Direct Contracting amp COE
According to Willis Towers Watsonrsquos survey employers are using COEs mostly through their health plans however direct contracting considerations are expected to grow considerably
6
7
48
2
2
7
14
13
20
0 20 40 60 80
Action taken or tactic used in 2018
Planning for 2019
Considering for 2020
bull Almost 50 use COEs in 18rsquo expected to rise to 2 out of 3 by 2020
bull Employers engaging employees in multiple ways to use COE bull Ongoing communications bull Reducing member cost share
to use bull Increasing member cost
share when not using bull Mandatory use
9
16
12
18
9
3
6
2
50
39
19
22
26
11
10
15
19
31
30
31
22
11
Transplants
Bariatric Surgery
Knees hips or spine
Cardiovascularcardiac
Cancer
Fertility
Other Procedures
Yes with incentives Yes but no incentives No but considering
10
A 2015 survey by the National Business Group on Health shows the status of large employersrsquo contracts with COEs (note reflects all COEs not specifically direct contracts)
Source Large Employersrsquo 2016 Health Plan Design Survey copy 2015 National Business Group on Health
Other centers of excellence programs include maternity NICU sleep apnea pancreas cornea and kidney
National Business Group on Healthrsquos Large Employers 2019 Health Care Strategy and Plan Design Survey showed DC arrangements between employers and bull Health systemsproviders will
increase from 3 in 2018 to 11 in 20191
bull COEs will increase from 12 in 2018 to 18 in 20191
bull Cancer cardiovascular and fertility COEs are experiencing the greatest growth
Source National Business Group on Health ldquoLarge US Employers Eye Changes to Health Care Delivery System as Cost to Provide Health Benefits Nears $15000 per Employeerdquo August 2018
10
Trends in Direct Contracting amp COE
Outcomes amp Benefits bull Employers with COE arrangements are seeing reduction in procedures
bull Walmart (15rsquo-18rsquo) 50+ of spine surgeries amp 20 of kneehip procedures recommended by local providers were determined lsquonot necessaryrsquo by COE (see table)
bull Employers like Walmart amp Boeing continue to sign new providers which suggest (employersrsquo) continued interest in pursuing DC arrangements2 However Boeing and Providence Swedish did end relationship due to inability to capture enoughright data to estimate cost of care3
bull John Hopkinsrsquo Bayview campus COE emerging metrics4
bull 121 referrals in the first three months
bull 352 referrals and 183 surgeries over 18 months
bull 23 of all joint replacement volumes at facility now attributed to travel program
bull 96 of patients said they would recommend this program to family friends coworkers
bull Bingham Memorial in Idaho direct contracting emerging metrics4
bull 17 companies participating covering over 5000 lives
bull +3000 new patients as of October 2018
bull +$3M Revenue from new patients
11
1 How Employers Are Fixing Health Care Harvard Business Review March 2019 2 httpswwwhealthleadersmediacomstrategywalmart-escalates-strategy-solve-employee-healthcare Health Leaders Media Nov 18rsquo 3 Do Providers Have the Data chops to Success with Direct Contract Modern Healthcare August 2018 4 Re-Igniting the Growth Engine Part 2 Winning Increased Share of Lucrative Patient Volumes Advisory Board 5 httpswwwautonewscomarticle20180806OEM180809831gm-signs-major-health-care-services-deal-for-salaried-employees
Walmart COE Programs1
Program Key Benefits
Spin
e Su
rger
y 2300 EEs 50 COE approved of those applied
bull 95 lower readmission bull 14 less time in hospital bull 1 COE vs 5 non-COE patients discharged to SNF bull Returned to work sooner reducing 20 of OOO
time bull More-effective less dangerous amp less expensive bull The COE surgery ldquopricerdquo is 8 higher but value in
earlier discharge lower readmission rates far less utilization of SNF faster return to work
Join
t
1836 EEs 18 COE approved of those applied
bull 32 less time in hospital bull 70 less likely to be readmitted than non-COE
patients bull Fewer postsurgical complications bull 0 COE vs 5 non-COE patients discharged to SNF bull COE patients returned to work a 15 weeks sooner bull Cost of surgery is 15 less at COE hospitals
Baria
tric
300+ EEs
bull Preliminary data suggests the weight loss from surgery reduces absenteeism or presentism (working while sick)
bull Dramatically cuts pharmacy amp medical costs Complications of obesity drop sharply as does the need for medication
bull GMrsquos direct contract benefit plans with Henry Ford allows it to offer similarly designed plans to that of Blue Cross with savings in monthly EE contributions ranging from $300-$19805
Walmartrsquos Travel (Surgery) Program
Mem
ber F
eedb
ack
12
Looking beyond traditional cost management techniques Walmart designed a program to address wild variations in cost and become directly in improving quality of care for its employees FIRST SELECTING PROVIDERS 1 Identify providers with high volume and high quality 2 Target regions in country to support Walmartrsquos employees 3Focus on Integrated Health Systems Hospitals within these systems were best aligned to Walmarts mission could take on risks associated with bundling 4 Eliminate systems unwilling to do bundled payments model were
PROVIDERS VALUE IN PARICIPATING
Build Bundles bull Define bundles and negotiate price (typically 10-15 below FFS ) bull Definitions of service limit disputes of what is covered vs not (covers
entryexit of facility SNF not part of bundle) bull Contract flexibility covers unforeseen testcosts and reinforces
Walmarthealth system partnership bull Warrantees if further treatment - can return in 30 days no
additional cost to Walmart bull Strict criteria and providers with track record of clinically sound
decisions are included to mitigate any incentivizing of volume Business bull 100 travelaccom brings
new volume of patients from outside of market
bull More stable payments for services (vs Medicare or commercial FFS)
bull Increased visibility and attract new business
Clinical bull lsquoHalorsquo effect ndash Building a highly
efficient multidiscipline program brings improvements throughout health system
bull Onsite collaboration among health systems allows sharing of outcomesbest practices
Source How Employers Are Fixing Health Care Harvard Business Review March 2019
5000 participants in the program
95 satisfiedvery satisfied
Denied by care because not deemed necessary by COE Treatment denied due to lifestyle weightsmoking
The Member Experience
13
Engagement begins when employee on clear
path to surgery
Patient contacts with COE TPA
TPA team triages and ensures basic criteria
met
Employee put in touch with nurse team
Car pick-up Flight Hotel all arranged by
TPA
Navigators and nurse coordinators help
throughout the stay
Patient visits to hospital to understand
exceptions of procedure and meet treatment
team
Surgery occurs typically next day
Stay length according to procedure typically a
few days
Discharged from facility Travel home COE team updates local
PCP and discuss follow up care
COE provider checks in with local physician
frequently Revert back to standard coverage
Source How Employers Are Fixing Health Care Harvard Business Review March 2019
Case Study 1
Case study 1 ndash Pop Health Approach bull ProblemCircumstance Large multi-employer group needs to
evaluate benefit design disease prevalence health spend and utilization to manage their population
bull ConsiderationsValue Prop Unique industry and geography drive chronic conditions and utilization patterns
bull Solution Provide opportunity assessment comparing this population to other benchmarks to understand where to target intervention and management as well as assess efforts already taken
15
Market Comparison Preference Sensitive Procedures
16
Legend vs
Mt States vs
National gt120 gt110
110-120 105-110 lt80 lt90
Source Multi-payer commercial benchmark Results are weighted by AgeGender Broader market area includes multi-payer data from the mountain regions
Preference Sensitive Procedures Benchmark Comparison
Dartmouth Atlas Preference Sensitive Procedures
IP allowed dollars ALOS Employer vs
Mt States Employer
vs National FY 2017 FY 2018 FY 2017 FY 2018
Hysterectomy for Uterine Fibroids Rate $569354 $436932 45 54 124 140 CABG Rate $1800260 $2400608 53 60 218 130 Cholycystectomy Rate $832675 $755565 68 39 92 120 C-Section Rate 116 110 HighTech Radiology Rate 103 101 PCIPTCA Rate $934486 $1133708 37 55 82 80 Back Surgery Rate $3237613 $4003212 39 57 52 70 Knee Replacement Rate $3086693 $2177334 41 48 50 64 Total Hip Replacement Rate $1023675 $747491 45 64 37 34
Strengths (+)
Employer compares favorably for orthopedic procedures (back hip knee)
Opportunity (-)
Employer has higher than expected rates for CABG and hysterectomy (Note Low PTCA rate combined with high CABG rate may suggest provider practice patterns favoring CABG)
0 50 100 150 200 250
Total Hip Replacement
Knee Replacement
Back Surgery
PCIPTCA
Cholycystectomy
HighTech Radiology
C-Section
CABG
Culinary VsNational
Culinary Vs MtStates
Employer vs Mt States
Employer vs National
Market Comparison Condition Prevalence
17 Source Multi-payer commercial benchmark Results are weighted by AgeGender Broader market area includes multi-payer data from the mountain regions
Condition Prevalence Benchmark Comparison
Condition Employer vs
Mt States Employer vs
National Prevalence Diabetes Rate 229 219 Prevalence Hyperlipidemia Rate 259 207 Prevalence Kidney Disease Rate 143 174 Prevalence Migraine Rate 166 164 Prevalence Low Back Pain Rate 136 139 Prevalence Hypertension Rate 156 134 Prevalence Asthma Rate 146 128 Prevalence CAD Rate 175 115 Prevalence Pregnancy Rate 110 109 Prevalence Adult Preventive Screening Rate 114 91 Prevalence Depression Rate 63 60
Strengths (+)
Rate of depression is low (Note May be due to incomplete behavioral health claims)
Opportunity (-)
Employer has a higher prevalence of most chronic conditions including asthma CAD diabetes hypertension hyperlipidemia Kidney Disease LBP and migraines
0
100
200
300Hyperlipidemia
Diabetes
CAD
Migraine
Hypertension
AsthmaKidney Disease
Low Back Pain
Pregnancy
Depression
Employer vsMt States
Employer vsNational Legend
vs Mt States
vs National
gt120 gt110 110-120 105-110
lt80 lt90
Market Comparison Utilization Rates
18
A higher preventive office visit rate is better Source Multi-payer commercial benchmark Results are weighted by AgeGender Broader market area includes multi-payer data from the mountain regions
Strengths (+)
Lower than average utilization of ED and high dollar patient rate
Opportunity (-)
Higher LOS lengthy admits avoidable admits and readmissions which all drive significantly more spend
Utilization Benchmark Comparison
Condition Employer vs
Mt States Employer vs
National Avoidable Admit Rate 142 144 Lengthy Admit Rate 175 136 Outpatient Problem Focused Office Rate 146 131 Readmission Rate (readmitadmit) 135 126 Average LOS 125 116 One Day Admit Rate 76 103 Office Visit Rate 106 96 Acute Admit Rate 80 95 Avoidable ED Rate 68 86 ED Rate 54 69 Preventive Office Rate 95 68 High Dollar Patient Rate 49 51 Frequent ED User (gt3 times) Rate 24 36
Legend vs
Mt States vs
National gt120 gt110
110-120 105-110 lt80 lt90
0 50 100 150 200
Frequent ED User (gt3 times)
High Dollar Patient
Preventive Office
ED
Avoidable ED
Acute Admit
Office Visit
One Day Admit
Average LOS
Readmissionhellip
Outpt Problem Focusedhellip
Lengthy Admit
Avoidable Admit
Employer vsNational
Employer vsMt States
ED and Avoidable ED
19
Potentially Avoidable ED - Trend View Overall ED
Period Change FY 2017 FY 2018 Count Rate
Measure Mbrs Rate Mbrs Rate Overall ED 16394 12626 13820 10745 -16 -15 FREQUENT ED UTILIZER (mbr1k) 1581 1218 1468 1141 -7 -6 AVOIDABLE ED 6371 4907 5288 4111 -17 -16 Potentially Avoidable ED
Period Change FY 2017 FY 2018 Count Rate
Avoid ED Condition Mbrs Rate Mbrs Rate ABDOMINAL_PAIN 1092 841 895 696 -18 -17 ENT_INFECTION 854 658 742 577 -13 -12 FEVER 715 551 700 544 -2 -1 URINARY 650 501 468 364 -28 -27 HEADACHE 558 430 434 337 -22 -21 BACK_PAIN 414 319 423 329 2 3 NAUSEA 394 303 271 211 -31 -31 ASTHMA 294 226 209 162 -29 -28 CELLULITIS 210 162 198 154 -6 -5 GASTROENTERITIS 254 196 171 133 -33 -32 OTITIS_MEDIA 201 155 160 124 -20 -20 COPD 132 102 108 084 -18 -17 DIABETES 123 095 91 071 -26 -25 BACT_PNEUMONIA 111 085 86 067 -23 -22 DENTAL 93 072 83 065 -11 -10 DEHYDRATION 98 075 81 063 -17 -17 HYPERTENSION 16 012 24 019 50 51 CHF 4 003 3 002 -25 -24 ANGINA 8 006 3 002 -63 -62 IMMUNIZATION_RELATED 2 002 0 000 -100 -100 Grand Total 6371 4907 5288 4111 -17 -16
AHRQ avoidable ED visits are based on the logic for ambulatory care sensitive ED visits from AHRQ and diagnosis code driven
696
577
544 364
337
329
211 162
154 133 ABDOMINAL_PAIN
ENT_INFECTION
FEVER
URINARY
HEADACHE
BACK_PAIN
NAUSEA
- 200 400 600 800
1000 1200
2017 Members 2018 Members
Top Ten 2018 Conditions by Rate
Top Ten Conditions by Member Count
ED Avoidable ED and the impact of new on-site clinic
20
0
1000
2000
3000
4000
5000
6000
0200400600800
10001200140016001800
Clinic Visits ED Visits
Avoidable ED VisitsED Visits (non-avoidable)Clinic EampM Visits
0
500000
1000000
1500000
2000000
2500000
3000000
3500000
$s
Clinic EampM Profess DollarsAvoidable ED Dollars
bull Clinic visits have a clear impact on ED and avoidable ED use and spend
bull Combined ED visits are down on average 157 in FY 18 from FY 17
bull Combined ED spend is down 128 in FY 18 from FY 17
Clinic Live 62017
Pitfalls and Challenges bull Face many of the challenges similar to startup health
plan bull Critical to determine how you will deliver value and
communicate the value to potential customers and brokersconsultants
bull Care management bull Network
21
Considerations in Offering Development bull Care Management Model
bull Traditional care model bull Case management bull Utilization management bull Disease management
bull Longitudinal care model with value based care philosophy bull Primary care driven bull Local care management
bull Predictive analytics and risk stratification model bull Claims history and ongoing data bull EMR data
22
Case Study 2
Case study 2 ndash Large Employer bull Business Problem Large employer wants to contract
directly with 2 major hospital systems developing professional fee schedules
bull ConsiderationsValue Prop Fee schedule should be competitive but also nuanced to minimize gap relative to current reimbursement at physician level
bull Solution Data-driven approach using current market-wide reimbursement distinguished by service level
24
Evaluate Provider Spend Top 25 Service Lines by Allowable Spend
Evaluate Provider Spend Top 20 Professional CPTs by Total Spend
Understand relative market pricing position
27
21
-1
-28
14 10
28
-22
-11 -13
24
3
20 21
8
-20
13
3 9
-39
56
-26
4
-42
60
MRI Colonoscopy Cardiac Cath Lab - OrganPanel
Memorial Hospital Beta Hospital Delta Hospital Charlie Hospital Echo Hospital Alpha Medical Center
ndash25 5 -15 10 0 39
State Charges as a Percent of Peer Average Weighted Averages for MRI Colonoscopy Cardiology and Lab
Total Percent Above Below Market Average2
Memorial Hospital Beta Hospital Delta Hospital Charlie Hospital Echo Hospital Alpha Medical Center
Develop fee schedule relative to market
28
Service Line Procedure CPT CodeDRG
Memorial Hospital
Beta Hosptial
Charlie Hospital
Delta Hospital
Echo Hospital
Alpha Medical Center
Arthroscopy Ligament Repair 29888 $ 5062 $ 9557 $ 5983 $ 10096 $ 7519 $ 2502 Knee Arthroscopy 29881 $ 5069 $ 4185 $ 3837 $ 3022 $ 3729 $ 2266 Upper GI Endoscopy 43239 $ 3075 $ 2539 $ 2012 $ 1132 $ 1565 $ 2240 Lap Sleeve Gastrectomy DRG 621 $ 20421 $ 20815 $ 12105 $ 13230 $ 14600 $ 17800 Colonoscopy and biopsy 45380 $ 3075 $ 3071 $ 2013 $ 1244 $ 1972 $ 859 Diagnostic Colonoscopy 45378 $ 3075 $ 2805 $ 2013 $ 1244 $ 1972 $ 859 MRI Brain w amp wo dye 70553 $ 1238 $ 1468 $ 1117 $ 967 $ 2805 $ 1052 MRI Joint of Lower Extremity wo dye 73721 $ 1238 $ 1398 $ 1042 $ 967 $ 925 $ 557 MRI Abdomen w amp wo dye 74183 $ 1238 $ 1468 $ 1106 $ 967 $ 2805 $ 836 X-ray Chest 71020 $ 115 $ 266 $ 305 $ 279 $ 375 $ 72 CT Thorax wo dye 71250 $ 882 $ 810 $ 505 $ 491 $ 579 $ 319 Ultrasound Abdomen Complete 76700 $ 397 $ 538 $ 545 $ 195 $ 190 $ 168 Mammogram Screening G0202 $ 141 $ 328 $ 431 $ 294 $ 425 $ 168 Computer Detection Add-on 77052 $ 112 $ 99 $ 41 $ 15 $ 45 $ 23 Comp Metabolic Panel 80053 $ 56 $ 15 $ 24 $ 56 $ 51 $ 25 Tissue Exam by Pathologist 88305 $ 236 $ 307 $ 80 $ 152 $ 78 $ 232 Cardiovascular Stress Test 93017 $ 383 $ 432 $ 1299 $ 907 $ 717 $ 797 TTE w Doppler 93306 $ 960 $ 1566 $ 1388 $ 1173 $ 1125 $ 1157
Obstetrics Vaginal Delivery DRG 755 7290$ 5730$ 4654$ 4607$ 5855$ 4688$
GI
Lab
Radiology
Medical Cardiology
Orthopedics
KEY OBSERVA TIONS bull Potential exposure on GI bull Opportunity to align price and acuity in MRI bull Opportunity to raise rates on chest x-ray and mammogram
Percentile Bands Emory Allowables Heatmap TEC ASC Heatmap Allowable Comp Analysis Portal Pricing Sheet1 image1png A few words on Bundled Payments bull Bundled payments are growing as a type of direct contracting bull In some cases third parties match-make between employers
and providers bull Contracts may vary in definitions prepost admission
coverage duration readmission cause (ie all-cause vs medically related) outlier provisions LOS caps andor per diems
bull Providers need to be strategic in pricing to enable profitable growth of market share
29
Considerations in Offering Development bull Network Development
bull Build off existing structure eg health system employee plan network bull How does this fit into your broader value based care strategy bull Employed and independent physicians bull How do you want to approach the buildout of high performance
network bull Quality focus bull Cost efficiency
bull Integrated behavioral health bull Wrap network for other markets
30
Considerations in Offering Development bull Target Market
bull Consideration of employer profile in market bull Fully-insured vs ASO bull Total cost of care vs bundled services
bull Distribution bull Direct marketing bull Brokerconsultant community
bull Plan designs bull Standard designs vs flexible ndash Dependent on target market
bull Claims administration bull Data sharing amp analytics
31
Considerations in Offering Development bull Other components of comprehensive offering
bull Pharmacy bull Preventive health bull Onsite clinics bull Wellness programs bull Technology platform
32
Sample Bundle Analysis
33
Cover page Dotson Hazelrigs Nation Mainly of charge of fixed Cardiovascular stress test TTE wDoppler complete Colonoscopy and biopsy (Combined) Diagnostic colonoscopy (Combined) Upper gi endoscopy biopsy (Combined) Knee Arthroscopy (Combined) Arthroscopy Ligament Repair Comp Metabolic Panel Surgical Path Tissue Exam MRI Abdomen MRI Brain MRI Joint Lower Extremity CT Thorax wo contrast X-ray Chest Screening mammography Mammo Computer Aided US Abdomen Complete Officeoutpatient visit new pt 30 min Vaginal delivery Lap Sleeve Gastrectomy
Piedmont Piedmont Piedmont Piedmont Northside Northside Northside Northside Gwinnett Gwinnett Gwinnett Gwinnett WellStar WellStar WellStar WellStar AMC - Tenet AMC - Tenet AMC - Tenet AMC - Tenet CPT Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing 29881 $11312 $10872 NA NA $7476 $9338 NA $23655 $11856 $3668 NA $17871 $12253 NA NA $15645 $5490 NA NA $23039 29888 NA NA NA NA NA NA NA $23784 NA $8261 NA $18000 NA NA NA $15774 NA NA NA $23168 43239 NA $4408 NA NA NA NA $5997 $8852 NA $3304 NA $7424 $1267 NA NA $9230 NA $2458 NA $8274 43644 $26468 NA NA NA $3382 $12050 NA $1861 NA NA NA $1316 $7841 NA NA $3444 $18892 $27950 NA $979 43775 NA NA NA NA NA NA NA $352 NA NA NA $302 NA NA NA $413 NA NA NA $83 45378 $2705 $2530 NA NA $4381 $3676 $4496 $1022 $2938 $2138 NA $695 $5504 NA NA $2036 NA NA NA $372 45380 $3075 $2600 NA NA $4723 $3527 $3012 $1757 $4215 $2285 NA NA $5298 NA NA $3268 NA NA NA $627 59400 $6160 NA NA NA NA $5100 NA $1851 NA NA NA $1304 $9035 NA NA $3427 $9116 $5150 NA $966 70553 $2985 NA $1153 NA $2182 NA $1192 $492 NA NA $803 $489 $1512 NA $985 $1187 NA NA NA $197 71020 $61 $69 $43 NA $113 $319 $307 NA $183 $59 $32 NA $213 $66 $40 NA $83 $53 NA NA 71250 $1837 $621 $989 NA $1490 $931 $755 NA NA $745 $401 NA $1067 $982 $616 NA NA $304 NA NA 73721 NA $1098 $1153 NA $2042 $1065 $1192 NA NA $998 $803 NA NA $1275 $985 NA NA $644 NA $178 74183 $2971 $1144 NA NA NA $1092 $1192 $6884 NA $1098 $803 NA $2960 $1197 $985 $5454 NA NA NA $7607 76700 $364 $247 $207 NA $427 $708 $614 $13267 $428 $214 $152 NA $747 $263 $189 $9139 NA $235 NA NA 77052 NA NA NA NA NA NA NA $4744 NA NA NA NA NA NA NA $3070 NA NA NA $5611 93306 $1220 $1117 NA NA $1877 $1657 $2100 $4605 $1433 $413 $945 NA $1336 $1434 $1951 $2931 NA $2399 NA $5472 G0202 $262 $187 NA NA $431 NA NA $4605 $292 NA NA NA $530 $281 NA $2931 $327 NA NA $5472
Provider Group 29881_6 29888_6 43239_6 43644_1 43775_1 45378_6 45380_6 59400_1 70553_2 71020_2 71250_2 73721_2 74183_2 76700_2 77052_2 77052_5 80053_8 88305_8 93306_2 99203_4 G0202_2 G0202_5 93017_2 Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Atlanta Gastroenterology Associates $2399 $536 348 $1628 $536 204 $2400 $536 348 Atlanta Medical Center $24889 $2266 999 $25897 $2502 935 $11449 $2240 411 $81927 $15300 435 $75815 $17800 326 $7317 $859 752 $7317 $859 752 $12821 $4688 173 $6581 $1052 526 $645 $72 796 $3265 $319 925 $3450 $557 519 $7398 $836 785 $1576 $133 1084 $73 $23 217 $635 $25 2440 $891 $232 285 $2967 $1157 156 $344 $168 105 $1265 $797 59 Atlanta Womens Health Physicians Group $29 $14 107 $40 $13 208 $396 $188 111 $278 $118 135 $450 $231 95 Gwinnett Hospital $11941 $3022 295 $21654 $10096 114 $3551 $1132 214 $34384 $10800 218 $56472 $13230 327 $3003 $1244 141 $3533 $1244 184 $8984 $4607 95 $3901 $967 303 $417 $279 49 $2247 $491 358 $4000 $967 314 $3755 $967 288 $1593 $195 717 $50 $15 233 $186 $56 233 $505 $152 233 $1750 $1173 49 $418 $294 42 $1396 $907 54 Northside Hospital $15482 $4185 270 $21651 $9557 127 $4885 $2539 92 $35176 $17000 107 $35233 $20815 69 $3883 $2805 38 $5256 $3071 71 $10911 $5730 90 $4856 $1468 231 $443 $266 67 $2379 $810 194 $3776 $1398 170 $5105 $1468 248 $942 $538 75 $167 $99 69 $379 $15 2427 $433 $307 41 $2252 $1566 44 $459 $328 40 $576 $432 33 Piedmont Hospital $14772 $3837 285 $35493 $5983 493 $5069 $2012 152 $38320 $17750 116 $37125 $12105 207 $3485 $2013 73 $4993 $2013 148 $10143 $4654 118 $5939 $1117 432 $542 $305 78 $2983 $505 491 $3410 $1042 227 $6067 $1106 449 $1364 $545 150 $75 $41 85 $231 $24 863 $657 $80 721 $2041 $1388 47 $490 $431 14 $1780 $1299 37 Piedmont Physicians Group $42 $22 87 $318 $179 78 $239 $159 50 Resurgens $8558 $2036 320 $9293 $2258 312 $4638 $2067 124 $4039 $2164 87 $4392 $2164 103 $2252 $1371 64 $459 $330 39 Wellstar Hospital $9330 $3729 150 $17479 $7519 132 $5261 $1565 236 $35794 $18200 97 $46780 $14600 220 $3707 $1972 88 $4928 $1972 150 $13549 $5855 131 $5054 $2805 80 $528 $375 41 $3222 $579 457 $3694 $925 299 $5495 $2805 96 $1355 $190 615 $66 $45 46 $73 $51 43 $133 $78 71 $1785 $1125 59 $599 $425 41 $1010 $717 41 Avg Mark UpProcedure Atlanta Medical Center 634 Gwinnett Hospital 223 Northside Hospital 233 Piedmont Hospital 259 Wellstar Hospital 155 Emory 105
Atlanta Gastroenterology Associates Atlanta Medical Center Atlanta Womens Health Gwinnett Hospital Northside Hospital Piedmont Hospital Piedmont Physicians Group Resurgens Wellstar Hospital CPT Code CPT Proc Cat Comp Avg Allow Allow Allow Allow Allow Allow Allow Allow Allow 29881 KNEE ARTHROSCOPYSURGERY 6 $3179 $2266 $3022 $4185 $3837 $2036 $3729 29888 KNEE ARTHROSCOPYSURGERY 6 $6319 $2502 $10096 $9557 $5983 $2258 $7519 43239 UPPER GI ENDOSCOPY BIOPSY 6 $1727 $536 $2240 $1132 $2539 $2012 $2067 $1565 43644 LAP GASTRIC BYPASSROUX-EN-Y 1 $15810 $15300 $10800 $17000 $17750 $18200 43775 LAP SLEEVE GASTRECTOMY 1 $17800 $13230 $20815 $12105 $14600 45378 DIAGNOSTIC COLONOSCOPY 6 $1656 $536 $859 $1244 $2805 $2013 $2164 $1972 45380 COLONOSCOPY AND BIOPSY 6 $1694 $536 $859 $1244 $3071 $2013 $2164 $1972 59400 OBSTETRICAL CARE 1 $5107 $4688 $4607 $5730 $4654 $5855 70553 MRI BRAIN WO amp WDYE 2 $1482 $1052 $967 $1468 $1117 $2805 71020 CHEST X-RAY 2 $259 $72 $279 $266 $305 $375 71250 CT THORAX WO DYE 2 $541 $319 $491 $810 $505 $579 73721 MRI JNT OF LWR EXTRE WO DYE 2 $978 $557 $967 $1398 $1042 $925 74183 MRI ABDOMEN WO amp WDYE 2 $1436 $836 $967 $1468 $1106 $2805 76700 US EXAM ABDOM COMPLETE 2 $320 $133 $195 $538 $545 $190 77052 COMP SCREEN MAMMOGRAM ADD-ON 2 $45 $23 $15 $99 $41 $45 77052 COMP SCREEN MAMMOGRAM ADD-ON 5 $14 $14 80053 COMPREHEN METABOLIC PANEL 8 $29 $25 $13 $56 $15 $24 $22 $51 88305 TISSUE EXAM BY PATHOLOGIST 8 $174 $232 $188 $152 $307 $80 $179 $78 93306 TTE WDOPPLER COMPLETE 2 $1297 $1157 $1173 $1566 $1388 $1371 $1125 93017 STRESS TEST 5 $830 $797 $907 $432 $1299 $717 99203 OFFICEOUTPATIENT VISIT NEW 4 $139 $118 $159 G0202 Screeningmammographydigital 2 $329 $168 $294 $328 $431 $330 $425 G0202 Screeningmammographydigital 5 $231 $231
Service Line Procedure CPT Code Emory Atlanta Gastroenterology Associates Resurgens Atlanta Womens Health Piedmont Physicians Group Orthopedics (ASC) Knee Arthroscopy 29881 $3467 $2036 Arthroscopy Ligament Repair 29888 $3386 $2258 GI (ASC) Upper GI Endoscopy 43239 $2758 $536 Diagnostic Colonoscopy 45378 $2348 $536 Colonoscopy and biopsy 45380 $2181 $536 Radiology Mammogram Screening G0202 $164 $231 Computer Detection Add-on 77052 $93 $14 Lab Comp Metabolic Panel 80053 $53 $13 $22 Tissue Exam by Pathologist 88305 $277 $188 $179 EampM (TEC) Office Visit new pt 99203 $269 $118 $159
Service Line Procedure CPT CodeDRG Memorial Hospital Beta Hosptial Charlie Hospital Delta Hospital Echo Hospital Alpha Medical Center Atlanta Gastroenterology Associates Resurgens Atlanta Womens Health Piedmont Physicians Group Market Avg Emory abovebelow Orthopedics Arthroscopy Ligament Repair 29888 $ 5062 $ 9557 $ 5983 $ 10096 $ 7519 $ 2502 $ 2258 $ 6319 -20 Knee Arthroscopy 29881 6 $ 5069 $ 4185 $ 3837 $ 3022 $ 3729 $ 2266 $ 2036 $ 3179 59 GI Upper GI Endoscopy 43239 6 $ 3075 $ 2539 $ 2012 $ 1132 $ 1565 $ 2240 $ 536 $ 1671 84 Lap Sleeve Gastrectomy DRG 621 $ 20421 $ 20815 $ 12105 $ 13230 $ 14600 $ 17800 $ 15710 30 Colonoscopy and biopsy 45380 $ 3075 $ 3071 $ 2013 $ 1244 $ 1972 $ 859 $ 536 $ 1616 90 Diagnostic Colonoscopy 45378 6 $ 3075 $ 2805 $ 2013 $ 1244 $ 1972 $ 859 $ 536 $ 1572 96 Radiology MRI Brain w amp wo dye 70553 2 $ 1238 $ 1468 $ 1117 $ 967 $ 2805 $ 1052 $ 1482 -16 MRI Joint of Lower Extremity wo dye 73721 2 $ 1238 $ 1398 $ 1042 $ 967 $ 925 $ 557 $ 978 27 MRI Abdomen w amp wo dye 74183 2 $ 1238 $ 1468 $ 1106 $ 967 $ 2805 $ 836 $ 1436 -14 X-ray Chest 71020 $ 115 $ 266 $ 305 $ 279 $ 375 $ 72 $ 259 -56 CT Thorax wo dye 71250 $ 882 $ 810 $ 505 $ 491 $ 579 $ 319 $ 541 63 Ultrasound Abdomen Complete 76700 $ 397 $ 538 $ 545 $ 195 $ 190 $ 168 $ 327 21 Mammogram Screening G0202 2 $ 141 $ 328 $ 431 $ 294 $ 425 $ 168 $ 231 $ 313 -55 Computer Detection Add-on 77052 2 $ 112 $ 99 $ 41 $ 15 $ 45 $ 23 $ 14 $ 39 183 Lab Comp Metabolic Panel 80053 8 $ 56 $ 15 $ 24 $ 56 $ 51 $ 25 $ 13 $ 22 $ 29 88 Tissue Exam by Pathologist 88305 8 $ 236 $ 307 $ 80 $ 152 $ 78 $ 232 $ 188 $ 179 $ 174 36 Medical Cardiology Cardiovascular Stress Test 93017 $ 383 $ 432 $ 1299 $ 907 $ 717 $ 797 $ 830 -54 TTE w Doppler 93306 2 $ 960 $ 1566 $ 1388 $ 1173 $ 1125 $ 1157 $ 1282 -25 Obstetrics Vaginal Delivery DRG 755 $ 7290 $ 5730 $ 4654 $ 4607 $ 5855 $ 4688 $ 5107 43 EampM Office Visit new pt 99203 4 $ 248 $ 118 $ 159 $ 139 78 Colonoscopy and biopsy (HOSPITAL ONLY) 45380 Surg 2530 $ 307591 Diagnostic colonoscopy (HOSPITAL ONLY) 45378 Surg 2255 $ 307591 Upper gi endoscopy biopsy (HOSPITAL ONLY) 43239 Surg 1787 $ 307591 Knee Arthroscopy (HOSPITAL ONLY) 29881 Surg 10900 $ 506893 Arthroscopy Ligament Repair (HOSPITAL ONLY) 29888 Surg 10900 $ 506200 Key 1 Facility - Inpatient 2 Facility - Imaging 3 Physician - Imaging 4 Physician 5 Global - Imaging 6 Facility - Outpatient 8 Lab 41 Physician - Primary Care 42 Physician - Specialist
Blue Cross United - EJCH EUH EUHM WW United - SJH Non Options United - SJH Options Aetna - ASC TEC (HMO) Cigna - ASC TEC (HMO) Aetna - EJCH ESJH ECHM WW Cigna - EJCH (HMO) Cigna - ESJH EUHM (HMO) List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract Description CPT Code Charge Average Final Price (all plans) Emory Mark Up Reimbursement Method ( of charge or fixed) - 1713 Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Cardiovascular stress test 93017 Cardio $543 $ 425 28 of Charge 70 $ 380 of Charge 65 $ 353 of Charge 60 $ 326 of Charge 70 $ 380 of Charge 70 $ 380 of charge 100 $ 543 of Charge 70 $ 380 of charge 100 $ 543 of charge 100 $ 543 TTE wDoppler complete 93306 Cardio $1226 $ 960 28 of Charge 70 $ 858 of Charge 65 $ 797 of Charge 60 $ 736 of Charge 70 $ 858 of Charge 70 $ 858 of charge 100 $ 1226 of Charge 70 $ 858 of charge 100 $ 1226 of charge 100 $ 1226 Colonoscopy and biopsy (HOSPITAL ONLY) 45380 Surg $2530 $ 3076 -18 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 of Charge 70 $ 1771 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Diagnostic colonoscopy (HOSPITAL ONLY) 45378 Surg $2255 $ 3076 -27 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 of Charge 70 $ 1579 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Upper gi endoscopy biopsy (HOSPITAL ONLY) 43239 Surg $1787 $ 3076 -42 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Knee Arthroscopy (HOSPITAL ONLY) 29881 Surg $10900 $ 5069 115 Fixed Rate SC 4 $ 3865 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 449300 $ 4493 Fixed Rate $ 654700 $ 6547 of Charge 70 $ 7630 Fixed Rate $ 401000 $ 4010 of Charge 70 $ 7630 Fixed Rate $ 398300 $ 3983 Fixed Rate $ 398100 $ 3981 Arthroscopy Ligament Repair (HOSPITAL ONLY) 29888 Surg $10900 $ 5062 115 Fixed Rate SC 3 $ 3121 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 556900 $ 5569 Fixed Rate $ 770100 $ 7701 of Charge 70 $ 7630 Fixed Rate $ 323900 $ 3239 of Charge 70 $ 7630 Fixed Rate $ 321700 $ 3217 Fixed Rate $ 321400 $ 3214 Comp Metabolic Panel 80053 Lab $132 $ 56 138 RBRVS Fee (100) $ 1437 of Charge 65 $ 86 of Charge 65 $ 86 of Charge 65 $ 86 of Charge 70 $ 92 RBRVS Fee (100) $ 1437 $ 14 of Charge 70 $ 92 RBRVS Fee (100) $ 1437 $ 14 RBRVS Fee (100) $ 1437 $ 14 Surgical Path Tissue Exam 88305 Lab $326 $ 236 38 of Charge 150 $ 51 of Charge 65 $ 212 of Charge 65 $ 212 of Charge 65 $ 212 of Charge 70 $ 228 of charge 100 $ 326 of Charge 70 $ 228 of charge 100 $ 326 of charge 100 $ 326 MRI Abdomen 74183 Radiology $6960 $ 1238 462 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 MRI Brain 70553 Radiology $6804 $ 1238 450 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 MRI Joint Lower Extremity 73721 Radiology $3067 $ 1238 148 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 CT Thorax wo contrast 71250 Radiology $2199 $ 882 149 Fixed Rate $ 771 Fixed Rate $ 47100 $ 471 Fixed Rate $ 81700 $ 817 Fixed Rate $ 116000 $ 1160 of Charge 70 $ 1539 Fixed Rate $ 80100 $ 801 Fixed Rate $ 79200 $ 792 Fixed Rate $ 79300 $ 793 Fixed Rate $ 79500 $ 795 X-ray Chest 71020 Radiology $280 $ 115 142 of Charge 150 $ 25 of Charge 65 $ 182 of Charge 60 $ 168 of Charge 70 $ 196 of Charge 70 $ 196 RBRVS Fee (150) $ 2534 $ 25 of Charge 70 $ 196 RBRVS Fee (150) $ 2534 $ 25 RBRVS Fee (150) $ 2534 $ 25 Screening mammography G0202 Radiology $279 $ 141 98 Fixed Rate $ 128 Fixed Rate $ 13100 $ 131 Fixed Rate $ 14300 $ 143 Fixed Rate $ 16100 $ 161 of Charge 70 $ 195 Fixed Rate $ 13300 $ 133 Fixed Rate $ 13500 $ 135 Fixed Rate $ 13000 $ 130 Fixed Rate $ 11200 $ 112 Mammo Computer Aided 77052 Radiology $75 $ 112 -33 Fixed Rate $ 9 Fixed Rate $ 13100 $ 131 Fixed Rate $ 14300 $ 143 Fixed Rate $ 16100 $ 161 of Charge 70 $ 53 Fixed Rate $ 13300 $ 133 Fixed Rate $ 13500 $ 135 Fixed Rate $ 13000 $ 130 Fixed Rate $ 11200 $ 112 US Abdomen Complete 76700 Radiology $917 $ 397 131 of Charge 150 $ 125 of Charge 65 $ 596 of Charge 60 $ 550 of Charge 70 $ 642 of Charge 70 $ 642 RBRVS Fee (150) $ 12519 $ 125 of Charge 70 $ 642 RBRVS Fee (150) $ 12519 $ 125 RBRVS Fee (150) $ 12519 $ 125 Officeoutpatient visit new pt 30 min (TEC) 99203 EampM $316 $ 248 28 of Charge 70 $ 221 of Charge 65 $ 205 of Charge 60 $ 190 of Charge 70 $ 221 of Charge 70 $ 221 of charge 100 $ 316 of Charge 70 $ 221 of charge 100 $ 316 of charge 100 $ 316 Vaginal delivery 59409 Surg $14484 $ 7290 99 Fixed Rate DRG - 775 $ 5437 2 Day Case Rate + LOC 561700 $ 5617 BaseCMS Weight 584741 $ 5847 BaseCMS Weight 726146 $ 7261 No IP Terms $ - 0 No IP BaseCMS Weight 659343 $ 6593 BaseContract Weight 479451 100 $ 14484 BaseCMS Weight 579110 $ 5791 Lap Sleeve Gastrectomy 43775 Surg $29961 $ 20421 47 Fixed Rate DRG - 621 $ 14872 BaseCMS Weight 1810697 $ 18107 BaseCMS Weight 1835178 $ 18352 BaseCMS Weight 2278911 $ 22789 No IP Terms $ - 0 No IP BaseCMS Weight 2069315 $ 20693 BaseCMS Weight 1730442 100 $ 29961 BaseCMS Weight 1817507 $ 18175 105 Colonoscopy and biopsy (ASC ONLY) Surg $ 219200 $ 2181 Diagnostic colonoscopy (ASC ONLY) Surg $ 267100 $ 2348 Upper gi endoscopy biopsy (ASC ONLY) Surg $ 207500 $ 2758 Knee Arthroscopy (ASC ONLY) Surg $ 417900 $ 3467 Arthroscopy Ligament Repair (ASC ONLY) Surg $ 504800 $ 3386
Cpt Code CPT Description Procedure Category Claims Min 25thNtile 50thNtile Emorys Rates 75thNtile 90thNtile Max 20 Below 50th Ntile 20 Above 50th Ntile 93017 CARDIOVASCULAR STRESS TEST 5 82 $80 $125 $321 $382 $568 $791 $930 $257 $386 71020 CHEST X-RAY 2 2638 $11 $45 $152 $115 $289 $373 $585 $122 $182 71020 CHEST X-RAY 5 8106 $25 $34 $38 $54 $57 $69 $30 $46 45380 COLONOSCOPY AND BIOPSY 6 1256 $541 $560 $572 $2877 $1000 $2024 $3289 $458 $686 77052 COMP SCREEN MAMMOGRAM ADD-ON 2 194 $13 $15 $25 $38 $47 $134 $20 $30 77052 COMP SCREEN MAMMOGRAM ADD-ON 5 2411 $13 $16 $20 $23 $26 $28 $16 $24 80053 COMPREHEN METABOLIC PANEL 8 13019 $9 $19 $23 $55 $24 $25 $69 $19 $28 71250 CT THORAX WO DYE 2 302 $165 $372 $545 $878 $1658 $2067 $436 $654 71250 CT THORAX WO DYE 5 209 $53 $127 $203 $289 $419 $534 $162 $244 45378 DIAGNOSTIC COLONOSCOPY 6 1479 $484 $515 $536 $2914 $831 $1971 $2828 $428 $643 29881 KNEE ARTHROSCOPYSURGERY 6 152 $1650 $1826 $2036 $5235 $3054 $4216 $6461 $1629 $2443 29888 KNEE ARTHROSCOPYSURGERY 6 82 $1682 $3615 $5081 $5145 $7553 $12924 $18532 $4065 $6097 43644 LAP GASTRIC BYPASSROUX-EN-Y 1 21 $11821 $13873 $17050 $18391 $25029 $31079 $13640 $20460 43775 LAP SLEEVE GASTRECTOMY 1 38 $4215 $8250 $13253 $20421 $19197 $21509 $24260 $10602 $15903 74183 MRI ABDOMEN WO amp WDYE 2 120 $919 $987 $1015 $1237 $1252 $2534 $3177 $812 $1218 74183 MRI ABDOMEN WO amp WDYE 5 112 $475 $490 $521 $1154 $1337 $1696 $417 $625 70553 MRI BRAIN WO amp WDYE 2 324 $633 $987 $1142 $1237 $1706 $2805 $3331 $914 $1370 70553 MRI BRAIN WO amp WDYE 5 467 $280 $539 $1023 $1277 $1363 $1726 $818 $1228 73721 MRI JNT OF LWR EXTRE WO DYE 2 304 $804 $859 $967 $1237 $1063 $1598 $2485 $774 $1160 73721 MRI JNT OF LWR EXTRE WO DYE 5 1130 $500 $520 $530 $628 $679 $859 $424 $636 59400 OBSTETRICAL CARE 1 494 $3699 $4402 $4969 $6655 $7307 $8613 $3975 $5963 99203 OFFICEOUTPATIENT VISIT NEW 4 6776 $88 $101 $112 $138 $155 $169 $90 $134 G0202 Screeningmammographydigital 2 7444 $123 $206 $285 $380 $425 $479 $228 $342 G0202 Screeningmammographydigital 5 2754 $117 $165 $195 $230 $247 $252 $156 $234 88305 TISSUE EXAM BY PATHOLOGIST 8 20834 $51 $74 $112 $235 $168 $261 $478 $90 $134 93306 TTE WDOPPLER COMPLETE 2 931 $194 $377 $739 $960 $1267 $1480 $1849 $591 $887 93306 TTE WDOPPLER COMPLETE 5 2299 $151 $296 $373 $538 $573 $834 $298 $448 43239 UPPER GI ENDOSCOPY BIOPSY 6 1264 $424 $514 $550 $800 $1838 $2833 $440 $660 76700 US EXAM ABDOM COMPLETE 2 321 $96 $165 $271 $509 $584 $857 $217 $325 76700 US EXAM ABDOM COMPLETE 5 444 $111 $129 $147 $156 $220 $279 $118 $176 Key 1 Facility - Inpatient 2 Facility - Imaging 3 Physician - Imaging 4 Physician 5 Global - Imaging 6 Facility - Outpatient 8 Lab 41 Physician - Primary Care 42 Physician - Specialist Cardiovascular stress test $ 38279 TTE wDoppler complete $ 96037 Colonoscopy and biopsy $ 287709 Diagnostic colonoscopy $ 291434 Upper gi endoscopy biopsy $ 300526 Knee Arthroscopy $ 523584 Arthroscopy Ligament Repair $ 514501 Comp Metabolic Panel $ 5552 Surgical Path Tissue Exam $ 23570 MRI Abdomen $ 123786 MRI Brain $ 123786 MRI Joint Lower Extremity $ 123786 CT Thorax wo contrast $ 88213 X-ray Chest $ 11548 Screening mammography $ 14098 Mammo Computer Aided $ 11179 US Abdomen Complete $ 39695 Officeoutpatient visit new pt 30 min $ 24753 Vaginal delivery $ 729025 Lap Sleeve Gastrectomy $ 2042124
Page 4
Presentation Disclaimer
Presentations are intended for educational purposes only and do not replace independent professional judgment Statements of fact and opinions expressed are those of the participants individually and unless expressly stated to the contrary are not the opinion or position of the Society of Actuaries its cosponsors or its committees The Society of Actuaries does not endorse or approve and assumes no responsibility for the content accuracy or completeness of the information presented Attendees should note that the sessions are audio-recorded and may be published in various media including print audio and video formats without further notice
3
Employer to Provider Direct Contracting
Background discussion Jay Hazelrigs
Case Study 1 ndash Pop Health Approach Rob Nation
Case Study 2 ndash Larger Employer Rob Nation
Pitfalls and challenges from a health system perspective Kevin Dotson
Q amp A
4
Background Discussion
6
Stakeholder Landscape
Source Re-Igniting the Growth Engine Part 2 Winning Increased Share of Lucrative Patient Volumes Advisory Board
68 68 55 55
42 49
40 44 40 47 50
80 80 80
68 60 60 50
60 50
53 55
0
5
10
Health care trend after plan changes (total plan costs)
Health care trend before plan changes
Consumer Price Index for all urban consumers (CPI-U)Source Willis Towers Watson 23rd Annual Best Practices in Health Care Employer Survey
Hos
pita
ls Are experiencing a compression of margins due to lower revenue and higher expense trends
Seek improvement in market share and improved margins Em
ploy
ers Face unstainable year over year healthcare costs To
mitigate costs they are forced to implement annual benefit plan changes
Seek lower more predictable medical expenses and healthy productive employees
Direct Contacting Arrangement Types
7
Bundled Payments prospective payment which covers patientrsquos care from start to finish
Reference Based Pricing (RBP) plan pays up to fixed amount for procedure any excess is billed to member
bull PCP-centric bull Level of provider risk can vary from partial to full bull May be offered with other options or full replacement if adequate network
bull Promotes shopping for services via price transparency bull Most common for elective procedures ndash joint surgeries spine gastric bypass
bull Appropriate for high volume procedures bull Medical expense more predictable for these services may not be fixed price bull May result in lower provider revenue than FFS providers seek steerage volume
Center of Excellence (COE) designated provider identified for specific procedures that may require travel
bull Appropriate for high volume procedures bull Specialization amp operational efficiencies reduce utilization variations improves patient
experience amp improves outcomes (eg lower LOS return to work time) bull Members out-of-pocket often low to $0 including travelhotel not always lowest ldquopricerdquo
Accountable Care Organization (ACO) provider reimbursements are directly tied to quality and financial outcomes
Mos
t Com
mon
Ar
rang
emen
ts
On-site health education seminars
Wellness services
On-site clinic
Bundled payments
Employer liaison coordinator
On-site coaching Andor counseling
Care pathways
Direct contracting narrow networks
Source Re-Igniting the Growth Engine Part 2 Winning Increased Share of Lucrative Patient Volumes Advisory Board
Boeing 1UW Med 2Memorial Care 3Mercy MO 4Roper St Francis 5ProvSwedish
DART amp Baylor Scott and White Health
Intel amp 1 Presbyterian ACO 2 Arizona Care Network
Quallcom amp Scripps Health
Stanford Healthcare Alliance
General Motors amp Henry Ford Health
Disney amp 1Orlando Health 2Florida Hospital
Walmart amp 1 Banner 2 Emory 3 Memorial Hermann 4 Mercy AK 5Mercy OK 6 Mercy MO 7Oschner Health 8 Presbyterian 9 St Lukersquos 10 Unity Point 11 Cleveland Clinic 12 Geisinger Health 13Johns Hopkins 14Mayo Clinic AZ 15Mayo Clinic FL 16Mayo MN 17Mercy MO
1 2
3
4 5
6
8
7
9
10
1
3
4 2
1
2
1
Whole Foods amp Adventis Health
11 12 13
14
15
16
17
Emergence of Direct Contracting
8
DC with providers to secure improved pricing
COE through a carve-out provider
COE within the health plans
Source Willis Towers Watson 23rd Annual Best Practices in Health Care Employer Survey Full report and high-performance insights httpswwwwillistowerswatsoncom-mediaWTWPDFInsights201812willis-towers-watson-23rd-annual-best-practices-in-health-care-employer-survey-full-reportpdf 2018
Trends in Direct Contracting amp COE
According to Willis Towers Watsonrsquos survey employers are using COEs mostly through their health plans however direct contracting considerations are expected to grow considerably
6
7
48
2
2
7
14
13
20
0 20 40 60 80
Action taken or tactic used in 2018
Planning for 2019
Considering for 2020
bull Almost 50 use COEs in 18rsquo expected to rise to 2 out of 3 by 2020
bull Employers engaging employees in multiple ways to use COE bull Ongoing communications bull Reducing member cost share
to use bull Increasing member cost
share when not using bull Mandatory use
9
16
12
18
9
3
6
2
50
39
19
22
26
11
10
15
19
31
30
31
22
11
Transplants
Bariatric Surgery
Knees hips or spine
Cardiovascularcardiac
Cancer
Fertility
Other Procedures
Yes with incentives Yes but no incentives No but considering
10
A 2015 survey by the National Business Group on Health shows the status of large employersrsquo contracts with COEs (note reflects all COEs not specifically direct contracts)
Source Large Employersrsquo 2016 Health Plan Design Survey copy 2015 National Business Group on Health
Other centers of excellence programs include maternity NICU sleep apnea pancreas cornea and kidney
National Business Group on Healthrsquos Large Employers 2019 Health Care Strategy and Plan Design Survey showed DC arrangements between employers and bull Health systemsproviders will
increase from 3 in 2018 to 11 in 20191
bull COEs will increase from 12 in 2018 to 18 in 20191
bull Cancer cardiovascular and fertility COEs are experiencing the greatest growth
Source National Business Group on Health ldquoLarge US Employers Eye Changes to Health Care Delivery System as Cost to Provide Health Benefits Nears $15000 per Employeerdquo August 2018
10
Trends in Direct Contracting amp COE
Outcomes amp Benefits bull Employers with COE arrangements are seeing reduction in procedures
bull Walmart (15rsquo-18rsquo) 50+ of spine surgeries amp 20 of kneehip procedures recommended by local providers were determined lsquonot necessaryrsquo by COE (see table)
bull Employers like Walmart amp Boeing continue to sign new providers which suggest (employersrsquo) continued interest in pursuing DC arrangements2 However Boeing and Providence Swedish did end relationship due to inability to capture enoughright data to estimate cost of care3
bull John Hopkinsrsquo Bayview campus COE emerging metrics4
bull 121 referrals in the first three months
bull 352 referrals and 183 surgeries over 18 months
bull 23 of all joint replacement volumes at facility now attributed to travel program
bull 96 of patients said they would recommend this program to family friends coworkers
bull Bingham Memorial in Idaho direct contracting emerging metrics4
bull 17 companies participating covering over 5000 lives
bull +3000 new patients as of October 2018
bull +$3M Revenue from new patients
11
1 How Employers Are Fixing Health Care Harvard Business Review March 2019 2 httpswwwhealthleadersmediacomstrategywalmart-escalates-strategy-solve-employee-healthcare Health Leaders Media Nov 18rsquo 3 Do Providers Have the Data chops to Success with Direct Contract Modern Healthcare August 2018 4 Re-Igniting the Growth Engine Part 2 Winning Increased Share of Lucrative Patient Volumes Advisory Board 5 httpswwwautonewscomarticle20180806OEM180809831gm-signs-major-health-care-services-deal-for-salaried-employees
Walmart COE Programs1
Program Key Benefits
Spin
e Su
rger
y 2300 EEs 50 COE approved of those applied
bull 95 lower readmission bull 14 less time in hospital bull 1 COE vs 5 non-COE patients discharged to SNF bull Returned to work sooner reducing 20 of OOO
time bull More-effective less dangerous amp less expensive bull The COE surgery ldquopricerdquo is 8 higher but value in
earlier discharge lower readmission rates far less utilization of SNF faster return to work
Join
t
1836 EEs 18 COE approved of those applied
bull 32 less time in hospital bull 70 less likely to be readmitted than non-COE
patients bull Fewer postsurgical complications bull 0 COE vs 5 non-COE patients discharged to SNF bull COE patients returned to work a 15 weeks sooner bull Cost of surgery is 15 less at COE hospitals
Baria
tric
300+ EEs
bull Preliminary data suggests the weight loss from surgery reduces absenteeism or presentism (working while sick)
bull Dramatically cuts pharmacy amp medical costs Complications of obesity drop sharply as does the need for medication
bull GMrsquos direct contract benefit plans with Henry Ford allows it to offer similarly designed plans to that of Blue Cross with savings in monthly EE contributions ranging from $300-$19805
Walmartrsquos Travel (Surgery) Program
Mem
ber F
eedb
ack
12
Looking beyond traditional cost management techniques Walmart designed a program to address wild variations in cost and become directly in improving quality of care for its employees FIRST SELECTING PROVIDERS 1 Identify providers with high volume and high quality 2 Target regions in country to support Walmartrsquos employees 3Focus on Integrated Health Systems Hospitals within these systems were best aligned to Walmarts mission could take on risks associated with bundling 4 Eliminate systems unwilling to do bundled payments model were
PROVIDERS VALUE IN PARICIPATING
Build Bundles bull Define bundles and negotiate price (typically 10-15 below FFS ) bull Definitions of service limit disputes of what is covered vs not (covers
entryexit of facility SNF not part of bundle) bull Contract flexibility covers unforeseen testcosts and reinforces
Walmarthealth system partnership bull Warrantees if further treatment - can return in 30 days no
additional cost to Walmart bull Strict criteria and providers with track record of clinically sound
decisions are included to mitigate any incentivizing of volume Business bull 100 travelaccom brings
new volume of patients from outside of market
bull More stable payments for services (vs Medicare or commercial FFS)
bull Increased visibility and attract new business
Clinical bull lsquoHalorsquo effect ndash Building a highly
efficient multidiscipline program brings improvements throughout health system
bull Onsite collaboration among health systems allows sharing of outcomesbest practices
Source How Employers Are Fixing Health Care Harvard Business Review March 2019
5000 participants in the program
95 satisfiedvery satisfied
Denied by care because not deemed necessary by COE Treatment denied due to lifestyle weightsmoking
The Member Experience
13
Engagement begins when employee on clear
path to surgery
Patient contacts with COE TPA
TPA team triages and ensures basic criteria
met
Employee put in touch with nurse team
Car pick-up Flight Hotel all arranged by
TPA
Navigators and nurse coordinators help
throughout the stay
Patient visits to hospital to understand
exceptions of procedure and meet treatment
team
Surgery occurs typically next day
Stay length according to procedure typically a
few days
Discharged from facility Travel home COE team updates local
PCP and discuss follow up care
COE provider checks in with local physician
frequently Revert back to standard coverage
Source How Employers Are Fixing Health Care Harvard Business Review March 2019
Case Study 1
Case study 1 ndash Pop Health Approach bull ProblemCircumstance Large multi-employer group needs to
evaluate benefit design disease prevalence health spend and utilization to manage their population
bull ConsiderationsValue Prop Unique industry and geography drive chronic conditions and utilization patterns
bull Solution Provide opportunity assessment comparing this population to other benchmarks to understand where to target intervention and management as well as assess efforts already taken
15
Market Comparison Preference Sensitive Procedures
16
Legend vs
Mt States vs
National gt120 gt110
110-120 105-110 lt80 lt90
Source Multi-payer commercial benchmark Results are weighted by AgeGender Broader market area includes multi-payer data from the mountain regions
Preference Sensitive Procedures Benchmark Comparison
Dartmouth Atlas Preference Sensitive Procedures
IP allowed dollars ALOS Employer vs
Mt States Employer
vs National FY 2017 FY 2018 FY 2017 FY 2018
Hysterectomy for Uterine Fibroids Rate $569354 $436932 45 54 124 140 CABG Rate $1800260 $2400608 53 60 218 130 Cholycystectomy Rate $832675 $755565 68 39 92 120 C-Section Rate 116 110 HighTech Radiology Rate 103 101 PCIPTCA Rate $934486 $1133708 37 55 82 80 Back Surgery Rate $3237613 $4003212 39 57 52 70 Knee Replacement Rate $3086693 $2177334 41 48 50 64 Total Hip Replacement Rate $1023675 $747491 45 64 37 34
Strengths (+)
Employer compares favorably for orthopedic procedures (back hip knee)
Opportunity (-)
Employer has higher than expected rates for CABG and hysterectomy (Note Low PTCA rate combined with high CABG rate may suggest provider practice patterns favoring CABG)
0 50 100 150 200 250
Total Hip Replacement
Knee Replacement
Back Surgery
PCIPTCA
Cholycystectomy
HighTech Radiology
C-Section
CABG
Culinary VsNational
Culinary Vs MtStates
Employer vs Mt States
Employer vs National
Market Comparison Condition Prevalence
17 Source Multi-payer commercial benchmark Results are weighted by AgeGender Broader market area includes multi-payer data from the mountain regions
Condition Prevalence Benchmark Comparison
Condition Employer vs
Mt States Employer vs
National Prevalence Diabetes Rate 229 219 Prevalence Hyperlipidemia Rate 259 207 Prevalence Kidney Disease Rate 143 174 Prevalence Migraine Rate 166 164 Prevalence Low Back Pain Rate 136 139 Prevalence Hypertension Rate 156 134 Prevalence Asthma Rate 146 128 Prevalence CAD Rate 175 115 Prevalence Pregnancy Rate 110 109 Prevalence Adult Preventive Screening Rate 114 91 Prevalence Depression Rate 63 60
Strengths (+)
Rate of depression is low (Note May be due to incomplete behavioral health claims)
Opportunity (-)
Employer has a higher prevalence of most chronic conditions including asthma CAD diabetes hypertension hyperlipidemia Kidney Disease LBP and migraines
0
100
200
300Hyperlipidemia
Diabetes
CAD
Migraine
Hypertension
AsthmaKidney Disease
Low Back Pain
Pregnancy
Depression
Employer vsMt States
Employer vsNational Legend
vs Mt States
vs National
gt120 gt110 110-120 105-110
lt80 lt90
Market Comparison Utilization Rates
18
A higher preventive office visit rate is better Source Multi-payer commercial benchmark Results are weighted by AgeGender Broader market area includes multi-payer data from the mountain regions
Strengths (+)
Lower than average utilization of ED and high dollar patient rate
Opportunity (-)
Higher LOS lengthy admits avoidable admits and readmissions which all drive significantly more spend
Utilization Benchmark Comparison
Condition Employer vs
Mt States Employer vs
National Avoidable Admit Rate 142 144 Lengthy Admit Rate 175 136 Outpatient Problem Focused Office Rate 146 131 Readmission Rate (readmitadmit) 135 126 Average LOS 125 116 One Day Admit Rate 76 103 Office Visit Rate 106 96 Acute Admit Rate 80 95 Avoidable ED Rate 68 86 ED Rate 54 69 Preventive Office Rate 95 68 High Dollar Patient Rate 49 51 Frequent ED User (gt3 times) Rate 24 36
Legend vs
Mt States vs
National gt120 gt110
110-120 105-110 lt80 lt90
0 50 100 150 200
Frequent ED User (gt3 times)
High Dollar Patient
Preventive Office
ED
Avoidable ED
Acute Admit
Office Visit
One Day Admit
Average LOS
Readmissionhellip
Outpt Problem Focusedhellip
Lengthy Admit
Avoidable Admit
Employer vsNational
Employer vsMt States
ED and Avoidable ED
19
Potentially Avoidable ED - Trend View Overall ED
Period Change FY 2017 FY 2018 Count Rate
Measure Mbrs Rate Mbrs Rate Overall ED 16394 12626 13820 10745 -16 -15 FREQUENT ED UTILIZER (mbr1k) 1581 1218 1468 1141 -7 -6 AVOIDABLE ED 6371 4907 5288 4111 -17 -16 Potentially Avoidable ED
Period Change FY 2017 FY 2018 Count Rate
Avoid ED Condition Mbrs Rate Mbrs Rate ABDOMINAL_PAIN 1092 841 895 696 -18 -17 ENT_INFECTION 854 658 742 577 -13 -12 FEVER 715 551 700 544 -2 -1 URINARY 650 501 468 364 -28 -27 HEADACHE 558 430 434 337 -22 -21 BACK_PAIN 414 319 423 329 2 3 NAUSEA 394 303 271 211 -31 -31 ASTHMA 294 226 209 162 -29 -28 CELLULITIS 210 162 198 154 -6 -5 GASTROENTERITIS 254 196 171 133 -33 -32 OTITIS_MEDIA 201 155 160 124 -20 -20 COPD 132 102 108 084 -18 -17 DIABETES 123 095 91 071 -26 -25 BACT_PNEUMONIA 111 085 86 067 -23 -22 DENTAL 93 072 83 065 -11 -10 DEHYDRATION 98 075 81 063 -17 -17 HYPERTENSION 16 012 24 019 50 51 CHF 4 003 3 002 -25 -24 ANGINA 8 006 3 002 -63 -62 IMMUNIZATION_RELATED 2 002 0 000 -100 -100 Grand Total 6371 4907 5288 4111 -17 -16
AHRQ avoidable ED visits are based on the logic for ambulatory care sensitive ED visits from AHRQ and diagnosis code driven
696
577
544 364
337
329
211 162
154 133 ABDOMINAL_PAIN
ENT_INFECTION
FEVER
URINARY
HEADACHE
BACK_PAIN
NAUSEA
- 200 400 600 800
1000 1200
2017 Members 2018 Members
Top Ten 2018 Conditions by Rate
Top Ten Conditions by Member Count
ED Avoidable ED and the impact of new on-site clinic
20
0
1000
2000
3000
4000
5000
6000
0200400600800
10001200140016001800
Clinic Visits ED Visits
Avoidable ED VisitsED Visits (non-avoidable)Clinic EampM Visits
0
500000
1000000
1500000
2000000
2500000
3000000
3500000
$s
Clinic EampM Profess DollarsAvoidable ED Dollars
bull Clinic visits have a clear impact on ED and avoidable ED use and spend
bull Combined ED visits are down on average 157 in FY 18 from FY 17
bull Combined ED spend is down 128 in FY 18 from FY 17
Clinic Live 62017
Pitfalls and Challenges bull Face many of the challenges similar to startup health
plan bull Critical to determine how you will deliver value and
communicate the value to potential customers and brokersconsultants
bull Care management bull Network
21
Considerations in Offering Development bull Care Management Model
bull Traditional care model bull Case management bull Utilization management bull Disease management
bull Longitudinal care model with value based care philosophy bull Primary care driven bull Local care management
bull Predictive analytics and risk stratification model bull Claims history and ongoing data bull EMR data
22
Case Study 2
Case study 2 ndash Large Employer bull Business Problem Large employer wants to contract
directly with 2 major hospital systems developing professional fee schedules
bull ConsiderationsValue Prop Fee schedule should be competitive but also nuanced to minimize gap relative to current reimbursement at physician level
bull Solution Data-driven approach using current market-wide reimbursement distinguished by service level
24
Evaluate Provider Spend Top 25 Service Lines by Allowable Spend
Evaluate Provider Spend Top 20 Professional CPTs by Total Spend
Understand relative market pricing position
27
21
-1
-28
14 10
28
-22
-11 -13
24
3
20 21
8
-20
13
3 9
-39
56
-26
4
-42
60
MRI Colonoscopy Cardiac Cath Lab - OrganPanel
Memorial Hospital Beta Hospital Delta Hospital Charlie Hospital Echo Hospital Alpha Medical Center
ndash25 5 -15 10 0 39
State Charges as a Percent of Peer Average Weighted Averages for MRI Colonoscopy Cardiology and Lab
Total Percent Above Below Market Average2
Memorial Hospital Beta Hospital Delta Hospital Charlie Hospital Echo Hospital Alpha Medical Center
Develop fee schedule relative to market
28
Service Line Procedure CPT CodeDRG
Memorial Hospital
Beta Hosptial
Charlie Hospital
Delta Hospital
Echo Hospital
Alpha Medical Center
Arthroscopy Ligament Repair 29888 $ 5062 $ 9557 $ 5983 $ 10096 $ 7519 $ 2502 Knee Arthroscopy 29881 $ 5069 $ 4185 $ 3837 $ 3022 $ 3729 $ 2266 Upper GI Endoscopy 43239 $ 3075 $ 2539 $ 2012 $ 1132 $ 1565 $ 2240 Lap Sleeve Gastrectomy DRG 621 $ 20421 $ 20815 $ 12105 $ 13230 $ 14600 $ 17800 Colonoscopy and biopsy 45380 $ 3075 $ 3071 $ 2013 $ 1244 $ 1972 $ 859 Diagnostic Colonoscopy 45378 $ 3075 $ 2805 $ 2013 $ 1244 $ 1972 $ 859 MRI Brain w amp wo dye 70553 $ 1238 $ 1468 $ 1117 $ 967 $ 2805 $ 1052 MRI Joint of Lower Extremity wo dye 73721 $ 1238 $ 1398 $ 1042 $ 967 $ 925 $ 557 MRI Abdomen w amp wo dye 74183 $ 1238 $ 1468 $ 1106 $ 967 $ 2805 $ 836 X-ray Chest 71020 $ 115 $ 266 $ 305 $ 279 $ 375 $ 72 CT Thorax wo dye 71250 $ 882 $ 810 $ 505 $ 491 $ 579 $ 319 Ultrasound Abdomen Complete 76700 $ 397 $ 538 $ 545 $ 195 $ 190 $ 168 Mammogram Screening G0202 $ 141 $ 328 $ 431 $ 294 $ 425 $ 168 Computer Detection Add-on 77052 $ 112 $ 99 $ 41 $ 15 $ 45 $ 23 Comp Metabolic Panel 80053 $ 56 $ 15 $ 24 $ 56 $ 51 $ 25 Tissue Exam by Pathologist 88305 $ 236 $ 307 $ 80 $ 152 $ 78 $ 232 Cardiovascular Stress Test 93017 $ 383 $ 432 $ 1299 $ 907 $ 717 $ 797 TTE w Doppler 93306 $ 960 $ 1566 $ 1388 $ 1173 $ 1125 $ 1157
Obstetrics Vaginal Delivery DRG 755 7290$ 5730$ 4654$ 4607$ 5855$ 4688$
GI
Lab
Radiology
Medical Cardiology
Orthopedics
KEY OBSERVA TIONS bull Potential exposure on GI bull Opportunity to align price and acuity in MRI bull Opportunity to raise rates on chest x-ray and mammogram
Percentile Bands Emory Allowables Heatmap TEC ASC Heatmap Allowable Comp Analysis Portal Pricing Sheet1 image1png A few words on Bundled Payments bull Bundled payments are growing as a type of direct contracting bull In some cases third parties match-make between employers
and providers bull Contracts may vary in definitions prepost admission
coverage duration readmission cause (ie all-cause vs medically related) outlier provisions LOS caps andor per diems
bull Providers need to be strategic in pricing to enable profitable growth of market share
29
Considerations in Offering Development bull Network Development
bull Build off existing structure eg health system employee plan network bull How does this fit into your broader value based care strategy bull Employed and independent physicians bull How do you want to approach the buildout of high performance
network bull Quality focus bull Cost efficiency
bull Integrated behavioral health bull Wrap network for other markets
30
Considerations in Offering Development bull Target Market
bull Consideration of employer profile in market bull Fully-insured vs ASO bull Total cost of care vs bundled services
bull Distribution bull Direct marketing bull Brokerconsultant community
bull Plan designs bull Standard designs vs flexible ndash Dependent on target market
bull Claims administration bull Data sharing amp analytics
31
Considerations in Offering Development bull Other components of comprehensive offering
bull Pharmacy bull Preventive health bull Onsite clinics bull Wellness programs bull Technology platform
32
Sample Bundle Analysis
33
Cover page Dotson Hazelrigs Nation Mainly of charge of fixed Cardiovascular stress test TTE wDoppler complete Colonoscopy and biopsy (Combined) Diagnostic colonoscopy (Combined) Upper gi endoscopy biopsy (Combined) Knee Arthroscopy (Combined) Arthroscopy Ligament Repair Comp Metabolic Panel Surgical Path Tissue Exam MRI Abdomen MRI Brain MRI Joint Lower Extremity CT Thorax wo contrast X-ray Chest Screening mammography Mammo Computer Aided US Abdomen Complete Officeoutpatient visit new pt 30 min Vaginal delivery Lap Sleeve Gastrectomy
Piedmont Piedmont Piedmont Piedmont Northside Northside Northside Northside Gwinnett Gwinnett Gwinnett Gwinnett WellStar WellStar WellStar WellStar AMC - Tenet AMC - Tenet AMC - Tenet AMC - Tenet CPT Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing 29881 $11312 $10872 NA NA $7476 $9338 NA $23655 $11856 $3668 NA $17871 $12253 NA NA $15645 $5490 NA NA $23039 29888 NA NA NA NA NA NA NA $23784 NA $8261 NA $18000 NA NA NA $15774 NA NA NA $23168 43239 NA $4408 NA NA NA NA $5997 $8852 NA $3304 NA $7424 $1267 NA NA $9230 NA $2458 NA $8274 43644 $26468 NA NA NA $3382 $12050 NA $1861 NA NA NA $1316 $7841 NA NA $3444 $18892 $27950 NA $979 43775 NA NA NA NA NA NA NA $352 NA NA NA $302 NA NA NA $413 NA NA NA $83 45378 $2705 $2530 NA NA $4381 $3676 $4496 $1022 $2938 $2138 NA $695 $5504 NA NA $2036 NA NA NA $372 45380 $3075 $2600 NA NA $4723 $3527 $3012 $1757 $4215 $2285 NA NA $5298 NA NA $3268 NA NA NA $627 59400 $6160 NA NA NA NA $5100 NA $1851 NA NA NA $1304 $9035 NA NA $3427 $9116 $5150 NA $966 70553 $2985 NA $1153 NA $2182 NA $1192 $492 NA NA $803 $489 $1512 NA $985 $1187 NA NA NA $197 71020 $61 $69 $43 NA $113 $319 $307 NA $183 $59 $32 NA $213 $66 $40 NA $83 $53 NA NA 71250 $1837 $621 $989 NA $1490 $931 $755 NA NA $745 $401 NA $1067 $982 $616 NA NA $304 NA NA 73721 NA $1098 $1153 NA $2042 $1065 $1192 NA NA $998 $803 NA NA $1275 $985 NA NA $644 NA $178 74183 $2971 $1144 NA NA NA $1092 $1192 $6884 NA $1098 $803 NA $2960 $1197 $985 $5454 NA NA NA $7607 76700 $364 $247 $207 NA $427 $708 $614 $13267 $428 $214 $152 NA $747 $263 $189 $9139 NA $235 NA NA 77052 NA NA NA NA NA NA NA $4744 NA NA NA NA NA NA NA $3070 NA NA NA $5611 93306 $1220 $1117 NA NA $1877 $1657 $2100 $4605 $1433 $413 $945 NA $1336 $1434 $1951 $2931 NA $2399 NA $5472 G0202 $262 $187 NA NA $431 NA NA $4605 $292 NA NA NA $530 $281 NA $2931 $327 NA NA $5472
Provider Group 29881_6 29888_6 43239_6 43644_1 43775_1 45378_6 45380_6 59400_1 70553_2 71020_2 71250_2 73721_2 74183_2 76700_2 77052_2 77052_5 80053_8 88305_8 93306_2 99203_4 G0202_2 G0202_5 93017_2 Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Atlanta Gastroenterology Associates $2399 $536 348 $1628 $536 204 $2400 $536 348 Atlanta Medical Center $24889 $2266 999 $25897 $2502 935 $11449 $2240 411 $81927 $15300 435 $75815 $17800 326 $7317 $859 752 $7317 $859 752 $12821 $4688 173 $6581 $1052 526 $645 $72 796 $3265 $319 925 $3450 $557 519 $7398 $836 785 $1576 $133 1084 $73 $23 217 $635 $25 2440 $891 $232 285 $2967 $1157 156 $344 $168 105 $1265 $797 59 Atlanta Womens Health Physicians Group $29 $14 107 $40 $13 208 $396 $188 111 $278 $118 135 $450 $231 95 Gwinnett Hospital $11941 $3022 295 $21654 $10096 114 $3551 $1132 214 $34384 $10800 218 $56472 $13230 327 $3003 $1244 141 $3533 $1244 184 $8984 $4607 95 $3901 $967 303 $417 $279 49 $2247 $491 358 $4000 $967 314 $3755 $967 288 $1593 $195 717 $50 $15 233 $186 $56 233 $505 $152 233 $1750 $1173 49 $418 $294 42 $1396 $907 54 Northside Hospital $15482 $4185 270 $21651 $9557 127 $4885 $2539 92 $35176 $17000 107 $35233 $20815 69 $3883 $2805 38 $5256 $3071 71 $10911 $5730 90 $4856 $1468 231 $443 $266 67 $2379 $810 194 $3776 $1398 170 $5105 $1468 248 $942 $538 75 $167 $99 69 $379 $15 2427 $433 $307 41 $2252 $1566 44 $459 $328 40 $576 $432 33 Piedmont Hospital $14772 $3837 285 $35493 $5983 493 $5069 $2012 152 $38320 $17750 116 $37125 $12105 207 $3485 $2013 73 $4993 $2013 148 $10143 $4654 118 $5939 $1117 432 $542 $305 78 $2983 $505 491 $3410 $1042 227 $6067 $1106 449 $1364 $545 150 $75 $41 85 $231 $24 863 $657 $80 721 $2041 $1388 47 $490 $431 14 $1780 $1299 37 Piedmont Physicians Group $42 $22 87 $318 $179 78 $239 $159 50 Resurgens $8558 $2036 320 $9293 $2258 312 $4638 $2067 124 $4039 $2164 87 $4392 $2164 103 $2252 $1371 64 $459 $330 39 Wellstar Hospital $9330 $3729 150 $17479 $7519 132 $5261 $1565 236 $35794 $18200 97 $46780 $14600 220 $3707 $1972 88 $4928 $1972 150 $13549 $5855 131 $5054 $2805 80 $528 $375 41 $3222 $579 457 $3694 $925 299 $5495 $2805 96 $1355 $190 615 $66 $45 46 $73 $51 43 $133 $78 71 $1785 $1125 59 $599 $425 41 $1010 $717 41 Avg Mark UpProcedure Atlanta Medical Center 634 Gwinnett Hospital 223 Northside Hospital 233 Piedmont Hospital 259 Wellstar Hospital 155 Emory 105
Atlanta Gastroenterology Associates Atlanta Medical Center Atlanta Womens Health Gwinnett Hospital Northside Hospital Piedmont Hospital Piedmont Physicians Group Resurgens Wellstar Hospital CPT Code CPT Proc Cat Comp Avg Allow Allow Allow Allow Allow Allow Allow Allow Allow 29881 KNEE ARTHROSCOPYSURGERY 6 $3179 $2266 $3022 $4185 $3837 $2036 $3729 29888 KNEE ARTHROSCOPYSURGERY 6 $6319 $2502 $10096 $9557 $5983 $2258 $7519 43239 UPPER GI ENDOSCOPY BIOPSY 6 $1727 $536 $2240 $1132 $2539 $2012 $2067 $1565 43644 LAP GASTRIC BYPASSROUX-EN-Y 1 $15810 $15300 $10800 $17000 $17750 $18200 43775 LAP SLEEVE GASTRECTOMY 1 $17800 $13230 $20815 $12105 $14600 45378 DIAGNOSTIC COLONOSCOPY 6 $1656 $536 $859 $1244 $2805 $2013 $2164 $1972 45380 COLONOSCOPY AND BIOPSY 6 $1694 $536 $859 $1244 $3071 $2013 $2164 $1972 59400 OBSTETRICAL CARE 1 $5107 $4688 $4607 $5730 $4654 $5855 70553 MRI BRAIN WO amp WDYE 2 $1482 $1052 $967 $1468 $1117 $2805 71020 CHEST X-RAY 2 $259 $72 $279 $266 $305 $375 71250 CT THORAX WO DYE 2 $541 $319 $491 $810 $505 $579 73721 MRI JNT OF LWR EXTRE WO DYE 2 $978 $557 $967 $1398 $1042 $925 74183 MRI ABDOMEN WO amp WDYE 2 $1436 $836 $967 $1468 $1106 $2805 76700 US EXAM ABDOM COMPLETE 2 $320 $133 $195 $538 $545 $190 77052 COMP SCREEN MAMMOGRAM ADD-ON 2 $45 $23 $15 $99 $41 $45 77052 COMP SCREEN MAMMOGRAM ADD-ON 5 $14 $14 80053 COMPREHEN METABOLIC PANEL 8 $29 $25 $13 $56 $15 $24 $22 $51 88305 TISSUE EXAM BY PATHOLOGIST 8 $174 $232 $188 $152 $307 $80 $179 $78 93306 TTE WDOPPLER COMPLETE 2 $1297 $1157 $1173 $1566 $1388 $1371 $1125 93017 STRESS TEST 5 $830 $797 $907 $432 $1299 $717 99203 OFFICEOUTPATIENT VISIT NEW 4 $139 $118 $159 G0202 Screeningmammographydigital 2 $329 $168 $294 $328 $431 $330 $425 G0202 Screeningmammographydigital 5 $231 $231
Service Line Procedure CPT Code Emory Atlanta Gastroenterology Associates Resurgens Atlanta Womens Health Piedmont Physicians Group Orthopedics (ASC) Knee Arthroscopy 29881 $3467 $2036 Arthroscopy Ligament Repair 29888 $3386 $2258 GI (ASC) Upper GI Endoscopy 43239 $2758 $536 Diagnostic Colonoscopy 45378 $2348 $536 Colonoscopy and biopsy 45380 $2181 $536 Radiology Mammogram Screening G0202 $164 $231 Computer Detection Add-on 77052 $93 $14 Lab Comp Metabolic Panel 80053 $53 $13 $22 Tissue Exam by Pathologist 88305 $277 $188 $179 EampM (TEC) Office Visit new pt 99203 $269 $118 $159
Service Line Procedure CPT CodeDRG Memorial Hospital Beta Hosptial Charlie Hospital Delta Hospital Echo Hospital Alpha Medical Center Atlanta Gastroenterology Associates Resurgens Atlanta Womens Health Piedmont Physicians Group Market Avg Emory abovebelow Orthopedics Arthroscopy Ligament Repair 29888 $ 5062 $ 9557 $ 5983 $ 10096 $ 7519 $ 2502 $ 2258 $ 6319 -20 Knee Arthroscopy 29881 6 $ 5069 $ 4185 $ 3837 $ 3022 $ 3729 $ 2266 $ 2036 $ 3179 59 GI Upper GI Endoscopy 43239 6 $ 3075 $ 2539 $ 2012 $ 1132 $ 1565 $ 2240 $ 536 $ 1671 84 Lap Sleeve Gastrectomy DRG 621 $ 20421 $ 20815 $ 12105 $ 13230 $ 14600 $ 17800 $ 15710 30 Colonoscopy and biopsy 45380 $ 3075 $ 3071 $ 2013 $ 1244 $ 1972 $ 859 $ 536 $ 1616 90 Diagnostic Colonoscopy 45378 6 $ 3075 $ 2805 $ 2013 $ 1244 $ 1972 $ 859 $ 536 $ 1572 96 Radiology MRI Brain w amp wo dye 70553 2 $ 1238 $ 1468 $ 1117 $ 967 $ 2805 $ 1052 $ 1482 -16 MRI Joint of Lower Extremity wo dye 73721 2 $ 1238 $ 1398 $ 1042 $ 967 $ 925 $ 557 $ 978 27 MRI Abdomen w amp wo dye 74183 2 $ 1238 $ 1468 $ 1106 $ 967 $ 2805 $ 836 $ 1436 -14 X-ray Chest 71020 $ 115 $ 266 $ 305 $ 279 $ 375 $ 72 $ 259 -56 CT Thorax wo dye 71250 $ 882 $ 810 $ 505 $ 491 $ 579 $ 319 $ 541 63 Ultrasound Abdomen Complete 76700 $ 397 $ 538 $ 545 $ 195 $ 190 $ 168 $ 327 21 Mammogram Screening G0202 2 $ 141 $ 328 $ 431 $ 294 $ 425 $ 168 $ 231 $ 313 -55 Computer Detection Add-on 77052 2 $ 112 $ 99 $ 41 $ 15 $ 45 $ 23 $ 14 $ 39 183 Lab Comp Metabolic Panel 80053 8 $ 56 $ 15 $ 24 $ 56 $ 51 $ 25 $ 13 $ 22 $ 29 88 Tissue Exam by Pathologist 88305 8 $ 236 $ 307 $ 80 $ 152 $ 78 $ 232 $ 188 $ 179 $ 174 36 Medical Cardiology Cardiovascular Stress Test 93017 $ 383 $ 432 $ 1299 $ 907 $ 717 $ 797 $ 830 -54 TTE w Doppler 93306 2 $ 960 $ 1566 $ 1388 $ 1173 $ 1125 $ 1157 $ 1282 -25 Obstetrics Vaginal Delivery DRG 755 $ 7290 $ 5730 $ 4654 $ 4607 $ 5855 $ 4688 $ 5107 43 EampM Office Visit new pt 99203 4 $ 248 $ 118 $ 159 $ 139 78 Colonoscopy and biopsy (HOSPITAL ONLY) 45380 Surg 2530 $ 307591 Diagnostic colonoscopy (HOSPITAL ONLY) 45378 Surg 2255 $ 307591 Upper gi endoscopy biopsy (HOSPITAL ONLY) 43239 Surg 1787 $ 307591 Knee Arthroscopy (HOSPITAL ONLY) 29881 Surg 10900 $ 506893 Arthroscopy Ligament Repair (HOSPITAL ONLY) 29888 Surg 10900 $ 506200 Key 1 Facility - Inpatient 2 Facility - Imaging 3 Physician - Imaging 4 Physician 5 Global - Imaging 6 Facility - Outpatient 8 Lab 41 Physician - Primary Care 42 Physician - Specialist
Blue Cross United - EJCH EUH EUHM WW United - SJH Non Options United - SJH Options Aetna - ASC TEC (HMO) Cigna - ASC TEC (HMO) Aetna - EJCH ESJH ECHM WW Cigna - EJCH (HMO) Cigna - ESJH EUHM (HMO) List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract Description CPT Code Charge Average Final Price (all plans) Emory Mark Up Reimbursement Method ( of charge or fixed) - 1713 Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Cardiovascular stress test 93017 Cardio $543 $ 425 28 of Charge 70 $ 380 of Charge 65 $ 353 of Charge 60 $ 326 of Charge 70 $ 380 of Charge 70 $ 380 of charge 100 $ 543 of Charge 70 $ 380 of charge 100 $ 543 of charge 100 $ 543 TTE wDoppler complete 93306 Cardio $1226 $ 960 28 of Charge 70 $ 858 of Charge 65 $ 797 of Charge 60 $ 736 of Charge 70 $ 858 of Charge 70 $ 858 of charge 100 $ 1226 of Charge 70 $ 858 of charge 100 $ 1226 of charge 100 $ 1226 Colonoscopy and biopsy (HOSPITAL ONLY) 45380 Surg $2530 $ 3076 -18 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 of Charge 70 $ 1771 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Diagnostic colonoscopy (HOSPITAL ONLY) 45378 Surg $2255 $ 3076 -27 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 of Charge 70 $ 1579 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Upper gi endoscopy biopsy (HOSPITAL ONLY) 43239 Surg $1787 $ 3076 -42 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Knee Arthroscopy (HOSPITAL ONLY) 29881 Surg $10900 $ 5069 115 Fixed Rate SC 4 $ 3865 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 449300 $ 4493 Fixed Rate $ 654700 $ 6547 of Charge 70 $ 7630 Fixed Rate $ 401000 $ 4010 of Charge 70 $ 7630 Fixed Rate $ 398300 $ 3983 Fixed Rate $ 398100 $ 3981 Arthroscopy Ligament Repair (HOSPITAL ONLY) 29888 Surg $10900 $ 5062 115 Fixed Rate SC 3 $ 3121 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 556900 $ 5569 Fixed Rate $ 770100 $ 7701 of Charge 70 $ 7630 Fixed Rate $ 323900 $ 3239 of Charge 70 $ 7630 Fixed Rate $ 321700 $ 3217 Fixed Rate $ 321400 $ 3214 Comp Metabolic Panel 80053 Lab $132 $ 56 138 RBRVS Fee (100) $ 1437 of Charge 65 $ 86 of Charge 65 $ 86 of Charge 65 $ 86 of Charge 70 $ 92 RBRVS Fee (100) $ 1437 $ 14 of Charge 70 $ 92 RBRVS Fee (100) $ 1437 $ 14 RBRVS Fee (100) $ 1437 $ 14 Surgical Path Tissue Exam 88305 Lab $326 $ 236 38 of Charge 150 $ 51 of Charge 65 $ 212 of Charge 65 $ 212 of Charge 65 $ 212 of Charge 70 $ 228 of charge 100 $ 326 of Charge 70 $ 228 of charge 100 $ 326 of charge 100 $ 326 MRI Abdomen 74183 Radiology $6960 $ 1238 462 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 MRI Brain 70553 Radiology $6804 $ 1238 450 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 MRI Joint Lower Extremity 73721 Radiology $3067 $ 1238 148 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 CT Thorax wo contrast 71250 Radiology $2199 $ 882 149 Fixed Rate $ 771 Fixed Rate $ 47100 $ 471 Fixed Rate $ 81700 $ 817 Fixed Rate $ 116000 $ 1160 of Charge 70 $ 1539 Fixed Rate $ 80100 $ 801 Fixed Rate $ 79200 $ 792 Fixed Rate $ 79300 $ 793 Fixed Rate $ 79500 $ 795 X-ray Chest 71020 Radiology $280 $ 115 142 of Charge 150 $ 25 of Charge 65 $ 182 of Charge 60 $ 168 of Charge 70 $ 196 of Charge 70 $ 196 RBRVS Fee (150) $ 2534 $ 25 of Charge 70 $ 196 RBRVS Fee (150) $ 2534 $ 25 RBRVS Fee (150) $ 2534 $ 25 Screening mammography G0202 Radiology $279 $ 141 98 Fixed Rate $ 128 Fixed Rate $ 13100 $ 131 Fixed Rate $ 14300 $ 143 Fixed Rate $ 16100 $ 161 of Charge 70 $ 195 Fixed Rate $ 13300 $ 133 Fixed Rate $ 13500 $ 135 Fixed Rate $ 13000 $ 130 Fixed Rate $ 11200 $ 112 Mammo Computer Aided 77052 Radiology $75 $ 112 -33 Fixed Rate $ 9 Fixed Rate $ 13100 $ 131 Fixed Rate $ 14300 $ 143 Fixed Rate $ 16100 $ 161 of Charge 70 $ 53 Fixed Rate $ 13300 $ 133 Fixed Rate $ 13500 $ 135 Fixed Rate $ 13000 $ 130 Fixed Rate $ 11200 $ 112 US Abdomen Complete 76700 Radiology $917 $ 397 131 of Charge 150 $ 125 of Charge 65 $ 596 of Charge 60 $ 550 of Charge 70 $ 642 of Charge 70 $ 642 RBRVS Fee (150) $ 12519 $ 125 of Charge 70 $ 642 RBRVS Fee (150) $ 12519 $ 125 RBRVS Fee (150) $ 12519 $ 125 Officeoutpatient visit new pt 30 min (TEC) 99203 EampM $316 $ 248 28 of Charge 70 $ 221 of Charge 65 $ 205 of Charge 60 $ 190 of Charge 70 $ 221 of Charge 70 $ 221 of charge 100 $ 316 of Charge 70 $ 221 of charge 100 $ 316 of charge 100 $ 316 Vaginal delivery 59409 Surg $14484 $ 7290 99 Fixed Rate DRG - 775 $ 5437 2 Day Case Rate + LOC 561700 $ 5617 BaseCMS Weight 584741 $ 5847 BaseCMS Weight 726146 $ 7261 No IP Terms $ - 0 No IP BaseCMS Weight 659343 $ 6593 BaseContract Weight 479451 100 $ 14484 BaseCMS Weight 579110 $ 5791 Lap Sleeve Gastrectomy 43775 Surg $29961 $ 20421 47 Fixed Rate DRG - 621 $ 14872 BaseCMS Weight 1810697 $ 18107 BaseCMS Weight 1835178 $ 18352 BaseCMS Weight 2278911 $ 22789 No IP Terms $ - 0 No IP BaseCMS Weight 2069315 $ 20693 BaseCMS Weight 1730442 100 $ 29961 BaseCMS Weight 1817507 $ 18175 105 Colonoscopy and biopsy (ASC ONLY) Surg $ 219200 $ 2181 Diagnostic colonoscopy (ASC ONLY) Surg $ 267100 $ 2348 Upper gi endoscopy biopsy (ASC ONLY) Surg $ 207500 $ 2758 Knee Arthroscopy (ASC ONLY) Surg $ 417900 $ 3467 Arthroscopy Ligament Repair (ASC ONLY) Surg $ 504800 $ 3386
Cpt Code CPT Description Procedure Category Claims Min 25thNtile 50thNtile Emorys Rates 75thNtile 90thNtile Max 20 Below 50th Ntile 20 Above 50th Ntile 93017 CARDIOVASCULAR STRESS TEST 5 82 $80 $125 $321 $382 $568 $791 $930 $257 $386 71020 CHEST X-RAY 2 2638 $11 $45 $152 $115 $289 $373 $585 $122 $182 71020 CHEST X-RAY 5 8106 $25 $34 $38 $54 $57 $69 $30 $46 45380 COLONOSCOPY AND BIOPSY 6 1256 $541 $560 $572 $2877 $1000 $2024 $3289 $458 $686 77052 COMP SCREEN MAMMOGRAM ADD-ON 2 194 $13 $15 $25 $38 $47 $134 $20 $30 77052 COMP SCREEN MAMMOGRAM ADD-ON 5 2411 $13 $16 $20 $23 $26 $28 $16 $24 80053 COMPREHEN METABOLIC PANEL 8 13019 $9 $19 $23 $55 $24 $25 $69 $19 $28 71250 CT THORAX WO DYE 2 302 $165 $372 $545 $878 $1658 $2067 $436 $654 71250 CT THORAX WO DYE 5 209 $53 $127 $203 $289 $419 $534 $162 $244 45378 DIAGNOSTIC COLONOSCOPY 6 1479 $484 $515 $536 $2914 $831 $1971 $2828 $428 $643 29881 KNEE ARTHROSCOPYSURGERY 6 152 $1650 $1826 $2036 $5235 $3054 $4216 $6461 $1629 $2443 29888 KNEE ARTHROSCOPYSURGERY 6 82 $1682 $3615 $5081 $5145 $7553 $12924 $18532 $4065 $6097 43644 LAP GASTRIC BYPASSROUX-EN-Y 1 21 $11821 $13873 $17050 $18391 $25029 $31079 $13640 $20460 43775 LAP SLEEVE GASTRECTOMY 1 38 $4215 $8250 $13253 $20421 $19197 $21509 $24260 $10602 $15903 74183 MRI ABDOMEN WO amp WDYE 2 120 $919 $987 $1015 $1237 $1252 $2534 $3177 $812 $1218 74183 MRI ABDOMEN WO amp WDYE 5 112 $475 $490 $521 $1154 $1337 $1696 $417 $625 70553 MRI BRAIN WO amp WDYE 2 324 $633 $987 $1142 $1237 $1706 $2805 $3331 $914 $1370 70553 MRI BRAIN WO amp WDYE 5 467 $280 $539 $1023 $1277 $1363 $1726 $818 $1228 73721 MRI JNT OF LWR EXTRE WO DYE 2 304 $804 $859 $967 $1237 $1063 $1598 $2485 $774 $1160 73721 MRI JNT OF LWR EXTRE WO DYE 5 1130 $500 $520 $530 $628 $679 $859 $424 $636 59400 OBSTETRICAL CARE 1 494 $3699 $4402 $4969 $6655 $7307 $8613 $3975 $5963 99203 OFFICEOUTPATIENT VISIT NEW 4 6776 $88 $101 $112 $138 $155 $169 $90 $134 G0202 Screeningmammographydigital 2 7444 $123 $206 $285 $380 $425 $479 $228 $342 G0202 Screeningmammographydigital 5 2754 $117 $165 $195 $230 $247 $252 $156 $234 88305 TISSUE EXAM BY PATHOLOGIST 8 20834 $51 $74 $112 $235 $168 $261 $478 $90 $134 93306 TTE WDOPPLER COMPLETE 2 931 $194 $377 $739 $960 $1267 $1480 $1849 $591 $887 93306 TTE WDOPPLER COMPLETE 5 2299 $151 $296 $373 $538 $573 $834 $298 $448 43239 UPPER GI ENDOSCOPY BIOPSY 6 1264 $424 $514 $550 $800 $1838 $2833 $440 $660 76700 US EXAM ABDOM COMPLETE 2 321 $96 $165 $271 $509 $584 $857 $217 $325 76700 US EXAM ABDOM COMPLETE 5 444 $111 $129 $147 $156 $220 $279 $118 $176 Key 1 Facility - Inpatient 2 Facility - Imaging 3 Physician - Imaging 4 Physician 5 Global - Imaging 6 Facility - Outpatient 8 Lab 41 Physician - Primary Care 42 Physician - Specialist Cardiovascular stress test $ 38279 TTE wDoppler complete $ 96037 Colonoscopy and biopsy $ 287709 Diagnostic colonoscopy $ 291434 Upper gi endoscopy biopsy $ 300526 Knee Arthroscopy $ 523584 Arthroscopy Ligament Repair $ 514501 Comp Metabolic Panel $ 5552 Surgical Path Tissue Exam $ 23570 MRI Abdomen $ 123786 MRI Brain $ 123786 MRI Joint Lower Extremity $ 123786 CT Thorax wo contrast $ 88213 X-ray Chest $ 11548 Screening mammography $ 14098 Mammo Computer Aided $ 11179 US Abdomen Complete $ 39695 Officeoutpatient visit new pt 30 min $ 24753 Vaginal delivery $ 729025 Lap Sleeve Gastrectomy $ 2042124
Page 5
Employer to Provider Direct Contracting
Background discussion Jay Hazelrigs
Case Study 1 ndash Pop Health Approach Rob Nation
Case Study 2 ndash Larger Employer Rob Nation
Pitfalls and challenges from a health system perspective Kevin Dotson
Q amp A
4
Background Discussion
6
Stakeholder Landscape
Source Re-Igniting the Growth Engine Part 2 Winning Increased Share of Lucrative Patient Volumes Advisory Board
68 68 55 55
42 49
40 44 40 47 50
80 80 80
68 60 60 50
60 50
53 55
0
5
10
Health care trend after plan changes (total plan costs)
Health care trend before plan changes
Consumer Price Index for all urban consumers (CPI-U)Source Willis Towers Watson 23rd Annual Best Practices in Health Care Employer Survey
Hos
pita
ls Are experiencing a compression of margins due to lower revenue and higher expense trends
Seek improvement in market share and improved margins Em
ploy
ers Face unstainable year over year healthcare costs To
mitigate costs they are forced to implement annual benefit plan changes
Seek lower more predictable medical expenses and healthy productive employees
Direct Contacting Arrangement Types
7
Bundled Payments prospective payment which covers patientrsquos care from start to finish
Reference Based Pricing (RBP) plan pays up to fixed amount for procedure any excess is billed to member
bull PCP-centric bull Level of provider risk can vary from partial to full bull May be offered with other options or full replacement if adequate network
bull Promotes shopping for services via price transparency bull Most common for elective procedures ndash joint surgeries spine gastric bypass
bull Appropriate for high volume procedures bull Medical expense more predictable for these services may not be fixed price bull May result in lower provider revenue than FFS providers seek steerage volume
Center of Excellence (COE) designated provider identified for specific procedures that may require travel
bull Appropriate for high volume procedures bull Specialization amp operational efficiencies reduce utilization variations improves patient
experience amp improves outcomes (eg lower LOS return to work time) bull Members out-of-pocket often low to $0 including travelhotel not always lowest ldquopricerdquo
Accountable Care Organization (ACO) provider reimbursements are directly tied to quality and financial outcomes
Mos
t Com
mon
Ar
rang
emen
ts
On-site health education seminars
Wellness services
On-site clinic
Bundled payments
Employer liaison coordinator
On-site coaching Andor counseling
Care pathways
Direct contracting narrow networks
Source Re-Igniting the Growth Engine Part 2 Winning Increased Share of Lucrative Patient Volumes Advisory Board
Boeing 1UW Med 2Memorial Care 3Mercy MO 4Roper St Francis 5ProvSwedish
DART amp Baylor Scott and White Health
Intel amp 1 Presbyterian ACO 2 Arizona Care Network
Quallcom amp Scripps Health
Stanford Healthcare Alliance
General Motors amp Henry Ford Health
Disney amp 1Orlando Health 2Florida Hospital
Walmart amp 1 Banner 2 Emory 3 Memorial Hermann 4 Mercy AK 5Mercy OK 6 Mercy MO 7Oschner Health 8 Presbyterian 9 St Lukersquos 10 Unity Point 11 Cleveland Clinic 12 Geisinger Health 13Johns Hopkins 14Mayo Clinic AZ 15Mayo Clinic FL 16Mayo MN 17Mercy MO
1 2
3
4 5
6
8
7
9
10
1
3
4 2
1
2
1
Whole Foods amp Adventis Health
11 12 13
14
15
16
17
Emergence of Direct Contracting
8
DC with providers to secure improved pricing
COE through a carve-out provider
COE within the health plans
Source Willis Towers Watson 23rd Annual Best Practices in Health Care Employer Survey Full report and high-performance insights httpswwwwillistowerswatsoncom-mediaWTWPDFInsights201812willis-towers-watson-23rd-annual-best-practices-in-health-care-employer-survey-full-reportpdf 2018
Trends in Direct Contracting amp COE
According to Willis Towers Watsonrsquos survey employers are using COEs mostly through their health plans however direct contracting considerations are expected to grow considerably
6
7
48
2
2
7
14
13
20
0 20 40 60 80
Action taken or tactic used in 2018
Planning for 2019
Considering for 2020
bull Almost 50 use COEs in 18rsquo expected to rise to 2 out of 3 by 2020
bull Employers engaging employees in multiple ways to use COE bull Ongoing communications bull Reducing member cost share
to use bull Increasing member cost
share when not using bull Mandatory use
9
16
12
18
9
3
6
2
50
39
19
22
26
11
10
15
19
31
30
31
22
11
Transplants
Bariatric Surgery
Knees hips or spine
Cardiovascularcardiac
Cancer
Fertility
Other Procedures
Yes with incentives Yes but no incentives No but considering
10
A 2015 survey by the National Business Group on Health shows the status of large employersrsquo contracts with COEs (note reflects all COEs not specifically direct contracts)
Source Large Employersrsquo 2016 Health Plan Design Survey copy 2015 National Business Group on Health
Other centers of excellence programs include maternity NICU sleep apnea pancreas cornea and kidney
National Business Group on Healthrsquos Large Employers 2019 Health Care Strategy and Plan Design Survey showed DC arrangements between employers and bull Health systemsproviders will
increase from 3 in 2018 to 11 in 20191
bull COEs will increase from 12 in 2018 to 18 in 20191
bull Cancer cardiovascular and fertility COEs are experiencing the greatest growth
Source National Business Group on Health ldquoLarge US Employers Eye Changes to Health Care Delivery System as Cost to Provide Health Benefits Nears $15000 per Employeerdquo August 2018
10
Trends in Direct Contracting amp COE
Outcomes amp Benefits bull Employers with COE arrangements are seeing reduction in procedures
bull Walmart (15rsquo-18rsquo) 50+ of spine surgeries amp 20 of kneehip procedures recommended by local providers were determined lsquonot necessaryrsquo by COE (see table)
bull Employers like Walmart amp Boeing continue to sign new providers which suggest (employersrsquo) continued interest in pursuing DC arrangements2 However Boeing and Providence Swedish did end relationship due to inability to capture enoughright data to estimate cost of care3
bull John Hopkinsrsquo Bayview campus COE emerging metrics4
bull 121 referrals in the first three months
bull 352 referrals and 183 surgeries over 18 months
bull 23 of all joint replacement volumes at facility now attributed to travel program
bull 96 of patients said they would recommend this program to family friends coworkers
bull Bingham Memorial in Idaho direct contracting emerging metrics4
bull 17 companies participating covering over 5000 lives
bull +3000 new patients as of October 2018
bull +$3M Revenue from new patients
11
1 How Employers Are Fixing Health Care Harvard Business Review March 2019 2 httpswwwhealthleadersmediacomstrategywalmart-escalates-strategy-solve-employee-healthcare Health Leaders Media Nov 18rsquo 3 Do Providers Have the Data chops to Success with Direct Contract Modern Healthcare August 2018 4 Re-Igniting the Growth Engine Part 2 Winning Increased Share of Lucrative Patient Volumes Advisory Board 5 httpswwwautonewscomarticle20180806OEM180809831gm-signs-major-health-care-services-deal-for-salaried-employees
Walmart COE Programs1
Program Key Benefits
Spin
e Su
rger
y 2300 EEs 50 COE approved of those applied
bull 95 lower readmission bull 14 less time in hospital bull 1 COE vs 5 non-COE patients discharged to SNF bull Returned to work sooner reducing 20 of OOO
time bull More-effective less dangerous amp less expensive bull The COE surgery ldquopricerdquo is 8 higher but value in
earlier discharge lower readmission rates far less utilization of SNF faster return to work
Join
t
1836 EEs 18 COE approved of those applied
bull 32 less time in hospital bull 70 less likely to be readmitted than non-COE
patients bull Fewer postsurgical complications bull 0 COE vs 5 non-COE patients discharged to SNF bull COE patients returned to work a 15 weeks sooner bull Cost of surgery is 15 less at COE hospitals
Baria
tric
300+ EEs
bull Preliminary data suggests the weight loss from surgery reduces absenteeism or presentism (working while sick)
bull Dramatically cuts pharmacy amp medical costs Complications of obesity drop sharply as does the need for medication
bull GMrsquos direct contract benefit plans with Henry Ford allows it to offer similarly designed plans to that of Blue Cross with savings in monthly EE contributions ranging from $300-$19805
Walmartrsquos Travel (Surgery) Program
Mem
ber F
eedb
ack
12
Looking beyond traditional cost management techniques Walmart designed a program to address wild variations in cost and become directly in improving quality of care for its employees FIRST SELECTING PROVIDERS 1 Identify providers with high volume and high quality 2 Target regions in country to support Walmartrsquos employees 3Focus on Integrated Health Systems Hospitals within these systems were best aligned to Walmarts mission could take on risks associated with bundling 4 Eliminate systems unwilling to do bundled payments model were
PROVIDERS VALUE IN PARICIPATING
Build Bundles bull Define bundles and negotiate price (typically 10-15 below FFS ) bull Definitions of service limit disputes of what is covered vs not (covers
entryexit of facility SNF not part of bundle) bull Contract flexibility covers unforeseen testcosts and reinforces
Walmarthealth system partnership bull Warrantees if further treatment - can return in 30 days no
additional cost to Walmart bull Strict criteria and providers with track record of clinically sound
decisions are included to mitigate any incentivizing of volume Business bull 100 travelaccom brings
new volume of patients from outside of market
bull More stable payments for services (vs Medicare or commercial FFS)
bull Increased visibility and attract new business
Clinical bull lsquoHalorsquo effect ndash Building a highly
efficient multidiscipline program brings improvements throughout health system
bull Onsite collaboration among health systems allows sharing of outcomesbest practices
Source How Employers Are Fixing Health Care Harvard Business Review March 2019
5000 participants in the program
95 satisfiedvery satisfied
Denied by care because not deemed necessary by COE Treatment denied due to lifestyle weightsmoking
The Member Experience
13
Engagement begins when employee on clear
path to surgery
Patient contacts with COE TPA
TPA team triages and ensures basic criteria
met
Employee put in touch with nurse team
Car pick-up Flight Hotel all arranged by
TPA
Navigators and nurse coordinators help
throughout the stay
Patient visits to hospital to understand
exceptions of procedure and meet treatment
team
Surgery occurs typically next day
Stay length according to procedure typically a
few days
Discharged from facility Travel home COE team updates local
PCP and discuss follow up care
COE provider checks in with local physician
frequently Revert back to standard coverage
Source How Employers Are Fixing Health Care Harvard Business Review March 2019
Case Study 1
Case study 1 ndash Pop Health Approach bull ProblemCircumstance Large multi-employer group needs to
evaluate benefit design disease prevalence health spend and utilization to manage their population
bull ConsiderationsValue Prop Unique industry and geography drive chronic conditions and utilization patterns
bull Solution Provide opportunity assessment comparing this population to other benchmarks to understand where to target intervention and management as well as assess efforts already taken
15
Market Comparison Preference Sensitive Procedures
16
Legend vs
Mt States vs
National gt120 gt110
110-120 105-110 lt80 lt90
Source Multi-payer commercial benchmark Results are weighted by AgeGender Broader market area includes multi-payer data from the mountain regions
Preference Sensitive Procedures Benchmark Comparison
Dartmouth Atlas Preference Sensitive Procedures
IP allowed dollars ALOS Employer vs
Mt States Employer
vs National FY 2017 FY 2018 FY 2017 FY 2018
Hysterectomy for Uterine Fibroids Rate $569354 $436932 45 54 124 140 CABG Rate $1800260 $2400608 53 60 218 130 Cholycystectomy Rate $832675 $755565 68 39 92 120 C-Section Rate 116 110 HighTech Radiology Rate 103 101 PCIPTCA Rate $934486 $1133708 37 55 82 80 Back Surgery Rate $3237613 $4003212 39 57 52 70 Knee Replacement Rate $3086693 $2177334 41 48 50 64 Total Hip Replacement Rate $1023675 $747491 45 64 37 34
Strengths (+)
Employer compares favorably for orthopedic procedures (back hip knee)
Opportunity (-)
Employer has higher than expected rates for CABG and hysterectomy (Note Low PTCA rate combined with high CABG rate may suggest provider practice patterns favoring CABG)
0 50 100 150 200 250
Total Hip Replacement
Knee Replacement
Back Surgery
PCIPTCA
Cholycystectomy
HighTech Radiology
C-Section
CABG
Culinary VsNational
Culinary Vs MtStates
Employer vs Mt States
Employer vs National
Market Comparison Condition Prevalence
17 Source Multi-payer commercial benchmark Results are weighted by AgeGender Broader market area includes multi-payer data from the mountain regions
Condition Prevalence Benchmark Comparison
Condition Employer vs
Mt States Employer vs
National Prevalence Diabetes Rate 229 219 Prevalence Hyperlipidemia Rate 259 207 Prevalence Kidney Disease Rate 143 174 Prevalence Migraine Rate 166 164 Prevalence Low Back Pain Rate 136 139 Prevalence Hypertension Rate 156 134 Prevalence Asthma Rate 146 128 Prevalence CAD Rate 175 115 Prevalence Pregnancy Rate 110 109 Prevalence Adult Preventive Screening Rate 114 91 Prevalence Depression Rate 63 60
Strengths (+)
Rate of depression is low (Note May be due to incomplete behavioral health claims)
Opportunity (-)
Employer has a higher prevalence of most chronic conditions including asthma CAD diabetes hypertension hyperlipidemia Kidney Disease LBP and migraines
0
100
200
300Hyperlipidemia
Diabetes
CAD
Migraine
Hypertension
AsthmaKidney Disease
Low Back Pain
Pregnancy
Depression
Employer vsMt States
Employer vsNational Legend
vs Mt States
vs National
gt120 gt110 110-120 105-110
lt80 lt90
Market Comparison Utilization Rates
18
A higher preventive office visit rate is better Source Multi-payer commercial benchmark Results are weighted by AgeGender Broader market area includes multi-payer data from the mountain regions
Strengths (+)
Lower than average utilization of ED and high dollar patient rate
Opportunity (-)
Higher LOS lengthy admits avoidable admits and readmissions which all drive significantly more spend
Utilization Benchmark Comparison
Condition Employer vs
Mt States Employer vs
National Avoidable Admit Rate 142 144 Lengthy Admit Rate 175 136 Outpatient Problem Focused Office Rate 146 131 Readmission Rate (readmitadmit) 135 126 Average LOS 125 116 One Day Admit Rate 76 103 Office Visit Rate 106 96 Acute Admit Rate 80 95 Avoidable ED Rate 68 86 ED Rate 54 69 Preventive Office Rate 95 68 High Dollar Patient Rate 49 51 Frequent ED User (gt3 times) Rate 24 36
Legend vs
Mt States vs
National gt120 gt110
110-120 105-110 lt80 lt90
0 50 100 150 200
Frequent ED User (gt3 times)
High Dollar Patient
Preventive Office
ED
Avoidable ED
Acute Admit
Office Visit
One Day Admit
Average LOS
Readmissionhellip
Outpt Problem Focusedhellip
Lengthy Admit
Avoidable Admit
Employer vsNational
Employer vsMt States
ED and Avoidable ED
19
Potentially Avoidable ED - Trend View Overall ED
Period Change FY 2017 FY 2018 Count Rate
Measure Mbrs Rate Mbrs Rate Overall ED 16394 12626 13820 10745 -16 -15 FREQUENT ED UTILIZER (mbr1k) 1581 1218 1468 1141 -7 -6 AVOIDABLE ED 6371 4907 5288 4111 -17 -16 Potentially Avoidable ED
Period Change FY 2017 FY 2018 Count Rate
Avoid ED Condition Mbrs Rate Mbrs Rate ABDOMINAL_PAIN 1092 841 895 696 -18 -17 ENT_INFECTION 854 658 742 577 -13 -12 FEVER 715 551 700 544 -2 -1 URINARY 650 501 468 364 -28 -27 HEADACHE 558 430 434 337 -22 -21 BACK_PAIN 414 319 423 329 2 3 NAUSEA 394 303 271 211 -31 -31 ASTHMA 294 226 209 162 -29 -28 CELLULITIS 210 162 198 154 -6 -5 GASTROENTERITIS 254 196 171 133 -33 -32 OTITIS_MEDIA 201 155 160 124 -20 -20 COPD 132 102 108 084 -18 -17 DIABETES 123 095 91 071 -26 -25 BACT_PNEUMONIA 111 085 86 067 -23 -22 DENTAL 93 072 83 065 -11 -10 DEHYDRATION 98 075 81 063 -17 -17 HYPERTENSION 16 012 24 019 50 51 CHF 4 003 3 002 -25 -24 ANGINA 8 006 3 002 -63 -62 IMMUNIZATION_RELATED 2 002 0 000 -100 -100 Grand Total 6371 4907 5288 4111 -17 -16
AHRQ avoidable ED visits are based on the logic for ambulatory care sensitive ED visits from AHRQ and diagnosis code driven
696
577
544 364
337
329
211 162
154 133 ABDOMINAL_PAIN
ENT_INFECTION
FEVER
URINARY
HEADACHE
BACK_PAIN
NAUSEA
- 200 400 600 800
1000 1200
2017 Members 2018 Members
Top Ten 2018 Conditions by Rate
Top Ten Conditions by Member Count
ED Avoidable ED and the impact of new on-site clinic
20
0
1000
2000
3000
4000
5000
6000
0200400600800
10001200140016001800
Clinic Visits ED Visits
Avoidable ED VisitsED Visits (non-avoidable)Clinic EampM Visits
0
500000
1000000
1500000
2000000
2500000
3000000
3500000
$s
Clinic EampM Profess DollarsAvoidable ED Dollars
bull Clinic visits have a clear impact on ED and avoidable ED use and spend
bull Combined ED visits are down on average 157 in FY 18 from FY 17
bull Combined ED spend is down 128 in FY 18 from FY 17
Clinic Live 62017
Pitfalls and Challenges bull Face many of the challenges similar to startup health
plan bull Critical to determine how you will deliver value and
communicate the value to potential customers and brokersconsultants
bull Care management bull Network
21
Considerations in Offering Development bull Care Management Model
bull Traditional care model bull Case management bull Utilization management bull Disease management
bull Longitudinal care model with value based care philosophy bull Primary care driven bull Local care management
bull Predictive analytics and risk stratification model bull Claims history and ongoing data bull EMR data
22
Case Study 2
Case study 2 ndash Large Employer bull Business Problem Large employer wants to contract
directly with 2 major hospital systems developing professional fee schedules
bull ConsiderationsValue Prop Fee schedule should be competitive but also nuanced to minimize gap relative to current reimbursement at physician level
bull Solution Data-driven approach using current market-wide reimbursement distinguished by service level
24
Evaluate Provider Spend Top 25 Service Lines by Allowable Spend
Evaluate Provider Spend Top 20 Professional CPTs by Total Spend
Understand relative market pricing position
27
21
-1
-28
14 10
28
-22
-11 -13
24
3
20 21
8
-20
13
3 9
-39
56
-26
4
-42
60
MRI Colonoscopy Cardiac Cath Lab - OrganPanel
Memorial Hospital Beta Hospital Delta Hospital Charlie Hospital Echo Hospital Alpha Medical Center
ndash25 5 -15 10 0 39
State Charges as a Percent of Peer Average Weighted Averages for MRI Colonoscopy Cardiology and Lab
Total Percent Above Below Market Average2
Memorial Hospital Beta Hospital Delta Hospital Charlie Hospital Echo Hospital Alpha Medical Center
Develop fee schedule relative to market
28
Service Line Procedure CPT CodeDRG
Memorial Hospital
Beta Hosptial
Charlie Hospital
Delta Hospital
Echo Hospital
Alpha Medical Center
Arthroscopy Ligament Repair 29888 $ 5062 $ 9557 $ 5983 $ 10096 $ 7519 $ 2502 Knee Arthroscopy 29881 $ 5069 $ 4185 $ 3837 $ 3022 $ 3729 $ 2266 Upper GI Endoscopy 43239 $ 3075 $ 2539 $ 2012 $ 1132 $ 1565 $ 2240 Lap Sleeve Gastrectomy DRG 621 $ 20421 $ 20815 $ 12105 $ 13230 $ 14600 $ 17800 Colonoscopy and biopsy 45380 $ 3075 $ 3071 $ 2013 $ 1244 $ 1972 $ 859 Diagnostic Colonoscopy 45378 $ 3075 $ 2805 $ 2013 $ 1244 $ 1972 $ 859 MRI Brain w amp wo dye 70553 $ 1238 $ 1468 $ 1117 $ 967 $ 2805 $ 1052 MRI Joint of Lower Extremity wo dye 73721 $ 1238 $ 1398 $ 1042 $ 967 $ 925 $ 557 MRI Abdomen w amp wo dye 74183 $ 1238 $ 1468 $ 1106 $ 967 $ 2805 $ 836 X-ray Chest 71020 $ 115 $ 266 $ 305 $ 279 $ 375 $ 72 CT Thorax wo dye 71250 $ 882 $ 810 $ 505 $ 491 $ 579 $ 319 Ultrasound Abdomen Complete 76700 $ 397 $ 538 $ 545 $ 195 $ 190 $ 168 Mammogram Screening G0202 $ 141 $ 328 $ 431 $ 294 $ 425 $ 168 Computer Detection Add-on 77052 $ 112 $ 99 $ 41 $ 15 $ 45 $ 23 Comp Metabolic Panel 80053 $ 56 $ 15 $ 24 $ 56 $ 51 $ 25 Tissue Exam by Pathologist 88305 $ 236 $ 307 $ 80 $ 152 $ 78 $ 232 Cardiovascular Stress Test 93017 $ 383 $ 432 $ 1299 $ 907 $ 717 $ 797 TTE w Doppler 93306 $ 960 $ 1566 $ 1388 $ 1173 $ 1125 $ 1157
Obstetrics Vaginal Delivery DRG 755 7290$ 5730$ 4654$ 4607$ 5855$ 4688$
GI
Lab
Radiology
Medical Cardiology
Orthopedics
KEY OBSERVA TIONS bull Potential exposure on GI bull Opportunity to align price and acuity in MRI bull Opportunity to raise rates on chest x-ray and mammogram
Percentile Bands Emory Allowables Heatmap TEC ASC Heatmap Allowable Comp Analysis Portal Pricing Sheet1 image1png A few words on Bundled Payments bull Bundled payments are growing as a type of direct contracting bull In some cases third parties match-make between employers
and providers bull Contracts may vary in definitions prepost admission
coverage duration readmission cause (ie all-cause vs medically related) outlier provisions LOS caps andor per diems
bull Providers need to be strategic in pricing to enable profitable growth of market share
29
Considerations in Offering Development bull Network Development
bull Build off existing structure eg health system employee plan network bull How does this fit into your broader value based care strategy bull Employed and independent physicians bull How do you want to approach the buildout of high performance
network bull Quality focus bull Cost efficiency
bull Integrated behavioral health bull Wrap network for other markets
30
Considerations in Offering Development bull Target Market
bull Consideration of employer profile in market bull Fully-insured vs ASO bull Total cost of care vs bundled services
bull Distribution bull Direct marketing bull Brokerconsultant community
bull Plan designs bull Standard designs vs flexible ndash Dependent on target market
bull Claims administration bull Data sharing amp analytics
31
Considerations in Offering Development bull Other components of comprehensive offering
bull Pharmacy bull Preventive health bull Onsite clinics bull Wellness programs bull Technology platform
32
Sample Bundle Analysis
33
Cover page Dotson Hazelrigs Nation Mainly of charge of fixed Cardiovascular stress test TTE wDoppler complete Colonoscopy and biopsy (Combined) Diagnostic colonoscopy (Combined) Upper gi endoscopy biopsy (Combined) Knee Arthroscopy (Combined) Arthroscopy Ligament Repair Comp Metabolic Panel Surgical Path Tissue Exam MRI Abdomen MRI Brain MRI Joint Lower Extremity CT Thorax wo contrast X-ray Chest Screening mammography Mammo Computer Aided US Abdomen Complete Officeoutpatient visit new pt 30 min Vaginal delivery Lap Sleeve Gastrectomy
Piedmont Piedmont Piedmont Piedmont Northside Northside Northside Northside Gwinnett Gwinnett Gwinnett Gwinnett WellStar WellStar WellStar WellStar AMC - Tenet AMC - Tenet AMC - Tenet AMC - Tenet CPT Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing 29881 $11312 $10872 NA NA $7476 $9338 NA $23655 $11856 $3668 NA $17871 $12253 NA NA $15645 $5490 NA NA $23039 29888 NA NA NA NA NA NA NA $23784 NA $8261 NA $18000 NA NA NA $15774 NA NA NA $23168 43239 NA $4408 NA NA NA NA $5997 $8852 NA $3304 NA $7424 $1267 NA NA $9230 NA $2458 NA $8274 43644 $26468 NA NA NA $3382 $12050 NA $1861 NA NA NA $1316 $7841 NA NA $3444 $18892 $27950 NA $979 43775 NA NA NA NA NA NA NA $352 NA NA NA $302 NA NA NA $413 NA NA NA $83 45378 $2705 $2530 NA NA $4381 $3676 $4496 $1022 $2938 $2138 NA $695 $5504 NA NA $2036 NA NA NA $372 45380 $3075 $2600 NA NA $4723 $3527 $3012 $1757 $4215 $2285 NA NA $5298 NA NA $3268 NA NA NA $627 59400 $6160 NA NA NA NA $5100 NA $1851 NA NA NA $1304 $9035 NA NA $3427 $9116 $5150 NA $966 70553 $2985 NA $1153 NA $2182 NA $1192 $492 NA NA $803 $489 $1512 NA $985 $1187 NA NA NA $197 71020 $61 $69 $43 NA $113 $319 $307 NA $183 $59 $32 NA $213 $66 $40 NA $83 $53 NA NA 71250 $1837 $621 $989 NA $1490 $931 $755 NA NA $745 $401 NA $1067 $982 $616 NA NA $304 NA NA 73721 NA $1098 $1153 NA $2042 $1065 $1192 NA NA $998 $803 NA NA $1275 $985 NA NA $644 NA $178 74183 $2971 $1144 NA NA NA $1092 $1192 $6884 NA $1098 $803 NA $2960 $1197 $985 $5454 NA NA NA $7607 76700 $364 $247 $207 NA $427 $708 $614 $13267 $428 $214 $152 NA $747 $263 $189 $9139 NA $235 NA NA 77052 NA NA NA NA NA NA NA $4744 NA NA NA NA NA NA NA $3070 NA NA NA $5611 93306 $1220 $1117 NA NA $1877 $1657 $2100 $4605 $1433 $413 $945 NA $1336 $1434 $1951 $2931 NA $2399 NA $5472 G0202 $262 $187 NA NA $431 NA NA $4605 $292 NA NA NA $530 $281 NA $2931 $327 NA NA $5472
Provider Group 29881_6 29888_6 43239_6 43644_1 43775_1 45378_6 45380_6 59400_1 70553_2 71020_2 71250_2 73721_2 74183_2 76700_2 77052_2 77052_5 80053_8 88305_8 93306_2 99203_4 G0202_2 G0202_5 93017_2 Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Atlanta Gastroenterology Associates $2399 $536 348 $1628 $536 204 $2400 $536 348 Atlanta Medical Center $24889 $2266 999 $25897 $2502 935 $11449 $2240 411 $81927 $15300 435 $75815 $17800 326 $7317 $859 752 $7317 $859 752 $12821 $4688 173 $6581 $1052 526 $645 $72 796 $3265 $319 925 $3450 $557 519 $7398 $836 785 $1576 $133 1084 $73 $23 217 $635 $25 2440 $891 $232 285 $2967 $1157 156 $344 $168 105 $1265 $797 59 Atlanta Womens Health Physicians Group $29 $14 107 $40 $13 208 $396 $188 111 $278 $118 135 $450 $231 95 Gwinnett Hospital $11941 $3022 295 $21654 $10096 114 $3551 $1132 214 $34384 $10800 218 $56472 $13230 327 $3003 $1244 141 $3533 $1244 184 $8984 $4607 95 $3901 $967 303 $417 $279 49 $2247 $491 358 $4000 $967 314 $3755 $967 288 $1593 $195 717 $50 $15 233 $186 $56 233 $505 $152 233 $1750 $1173 49 $418 $294 42 $1396 $907 54 Northside Hospital $15482 $4185 270 $21651 $9557 127 $4885 $2539 92 $35176 $17000 107 $35233 $20815 69 $3883 $2805 38 $5256 $3071 71 $10911 $5730 90 $4856 $1468 231 $443 $266 67 $2379 $810 194 $3776 $1398 170 $5105 $1468 248 $942 $538 75 $167 $99 69 $379 $15 2427 $433 $307 41 $2252 $1566 44 $459 $328 40 $576 $432 33 Piedmont Hospital $14772 $3837 285 $35493 $5983 493 $5069 $2012 152 $38320 $17750 116 $37125 $12105 207 $3485 $2013 73 $4993 $2013 148 $10143 $4654 118 $5939 $1117 432 $542 $305 78 $2983 $505 491 $3410 $1042 227 $6067 $1106 449 $1364 $545 150 $75 $41 85 $231 $24 863 $657 $80 721 $2041 $1388 47 $490 $431 14 $1780 $1299 37 Piedmont Physicians Group $42 $22 87 $318 $179 78 $239 $159 50 Resurgens $8558 $2036 320 $9293 $2258 312 $4638 $2067 124 $4039 $2164 87 $4392 $2164 103 $2252 $1371 64 $459 $330 39 Wellstar Hospital $9330 $3729 150 $17479 $7519 132 $5261 $1565 236 $35794 $18200 97 $46780 $14600 220 $3707 $1972 88 $4928 $1972 150 $13549 $5855 131 $5054 $2805 80 $528 $375 41 $3222 $579 457 $3694 $925 299 $5495 $2805 96 $1355 $190 615 $66 $45 46 $73 $51 43 $133 $78 71 $1785 $1125 59 $599 $425 41 $1010 $717 41 Avg Mark UpProcedure Atlanta Medical Center 634 Gwinnett Hospital 223 Northside Hospital 233 Piedmont Hospital 259 Wellstar Hospital 155 Emory 105
Atlanta Gastroenterology Associates Atlanta Medical Center Atlanta Womens Health Gwinnett Hospital Northside Hospital Piedmont Hospital Piedmont Physicians Group Resurgens Wellstar Hospital CPT Code CPT Proc Cat Comp Avg Allow Allow Allow Allow Allow Allow Allow Allow Allow 29881 KNEE ARTHROSCOPYSURGERY 6 $3179 $2266 $3022 $4185 $3837 $2036 $3729 29888 KNEE ARTHROSCOPYSURGERY 6 $6319 $2502 $10096 $9557 $5983 $2258 $7519 43239 UPPER GI ENDOSCOPY BIOPSY 6 $1727 $536 $2240 $1132 $2539 $2012 $2067 $1565 43644 LAP GASTRIC BYPASSROUX-EN-Y 1 $15810 $15300 $10800 $17000 $17750 $18200 43775 LAP SLEEVE GASTRECTOMY 1 $17800 $13230 $20815 $12105 $14600 45378 DIAGNOSTIC COLONOSCOPY 6 $1656 $536 $859 $1244 $2805 $2013 $2164 $1972 45380 COLONOSCOPY AND BIOPSY 6 $1694 $536 $859 $1244 $3071 $2013 $2164 $1972 59400 OBSTETRICAL CARE 1 $5107 $4688 $4607 $5730 $4654 $5855 70553 MRI BRAIN WO amp WDYE 2 $1482 $1052 $967 $1468 $1117 $2805 71020 CHEST X-RAY 2 $259 $72 $279 $266 $305 $375 71250 CT THORAX WO DYE 2 $541 $319 $491 $810 $505 $579 73721 MRI JNT OF LWR EXTRE WO DYE 2 $978 $557 $967 $1398 $1042 $925 74183 MRI ABDOMEN WO amp WDYE 2 $1436 $836 $967 $1468 $1106 $2805 76700 US EXAM ABDOM COMPLETE 2 $320 $133 $195 $538 $545 $190 77052 COMP SCREEN MAMMOGRAM ADD-ON 2 $45 $23 $15 $99 $41 $45 77052 COMP SCREEN MAMMOGRAM ADD-ON 5 $14 $14 80053 COMPREHEN METABOLIC PANEL 8 $29 $25 $13 $56 $15 $24 $22 $51 88305 TISSUE EXAM BY PATHOLOGIST 8 $174 $232 $188 $152 $307 $80 $179 $78 93306 TTE WDOPPLER COMPLETE 2 $1297 $1157 $1173 $1566 $1388 $1371 $1125 93017 STRESS TEST 5 $830 $797 $907 $432 $1299 $717 99203 OFFICEOUTPATIENT VISIT NEW 4 $139 $118 $159 G0202 Screeningmammographydigital 2 $329 $168 $294 $328 $431 $330 $425 G0202 Screeningmammographydigital 5 $231 $231
Service Line Procedure CPT Code Emory Atlanta Gastroenterology Associates Resurgens Atlanta Womens Health Piedmont Physicians Group Orthopedics (ASC) Knee Arthroscopy 29881 $3467 $2036 Arthroscopy Ligament Repair 29888 $3386 $2258 GI (ASC) Upper GI Endoscopy 43239 $2758 $536 Diagnostic Colonoscopy 45378 $2348 $536 Colonoscopy and biopsy 45380 $2181 $536 Radiology Mammogram Screening G0202 $164 $231 Computer Detection Add-on 77052 $93 $14 Lab Comp Metabolic Panel 80053 $53 $13 $22 Tissue Exam by Pathologist 88305 $277 $188 $179 EampM (TEC) Office Visit new pt 99203 $269 $118 $159
Service Line Procedure CPT CodeDRG Memorial Hospital Beta Hosptial Charlie Hospital Delta Hospital Echo Hospital Alpha Medical Center Atlanta Gastroenterology Associates Resurgens Atlanta Womens Health Piedmont Physicians Group Market Avg Emory abovebelow Orthopedics Arthroscopy Ligament Repair 29888 $ 5062 $ 9557 $ 5983 $ 10096 $ 7519 $ 2502 $ 2258 $ 6319 -20 Knee Arthroscopy 29881 6 $ 5069 $ 4185 $ 3837 $ 3022 $ 3729 $ 2266 $ 2036 $ 3179 59 GI Upper GI Endoscopy 43239 6 $ 3075 $ 2539 $ 2012 $ 1132 $ 1565 $ 2240 $ 536 $ 1671 84 Lap Sleeve Gastrectomy DRG 621 $ 20421 $ 20815 $ 12105 $ 13230 $ 14600 $ 17800 $ 15710 30 Colonoscopy and biopsy 45380 $ 3075 $ 3071 $ 2013 $ 1244 $ 1972 $ 859 $ 536 $ 1616 90 Diagnostic Colonoscopy 45378 6 $ 3075 $ 2805 $ 2013 $ 1244 $ 1972 $ 859 $ 536 $ 1572 96 Radiology MRI Brain w amp wo dye 70553 2 $ 1238 $ 1468 $ 1117 $ 967 $ 2805 $ 1052 $ 1482 -16 MRI Joint of Lower Extremity wo dye 73721 2 $ 1238 $ 1398 $ 1042 $ 967 $ 925 $ 557 $ 978 27 MRI Abdomen w amp wo dye 74183 2 $ 1238 $ 1468 $ 1106 $ 967 $ 2805 $ 836 $ 1436 -14 X-ray Chest 71020 $ 115 $ 266 $ 305 $ 279 $ 375 $ 72 $ 259 -56 CT Thorax wo dye 71250 $ 882 $ 810 $ 505 $ 491 $ 579 $ 319 $ 541 63 Ultrasound Abdomen Complete 76700 $ 397 $ 538 $ 545 $ 195 $ 190 $ 168 $ 327 21 Mammogram Screening G0202 2 $ 141 $ 328 $ 431 $ 294 $ 425 $ 168 $ 231 $ 313 -55 Computer Detection Add-on 77052 2 $ 112 $ 99 $ 41 $ 15 $ 45 $ 23 $ 14 $ 39 183 Lab Comp Metabolic Panel 80053 8 $ 56 $ 15 $ 24 $ 56 $ 51 $ 25 $ 13 $ 22 $ 29 88 Tissue Exam by Pathologist 88305 8 $ 236 $ 307 $ 80 $ 152 $ 78 $ 232 $ 188 $ 179 $ 174 36 Medical Cardiology Cardiovascular Stress Test 93017 $ 383 $ 432 $ 1299 $ 907 $ 717 $ 797 $ 830 -54 TTE w Doppler 93306 2 $ 960 $ 1566 $ 1388 $ 1173 $ 1125 $ 1157 $ 1282 -25 Obstetrics Vaginal Delivery DRG 755 $ 7290 $ 5730 $ 4654 $ 4607 $ 5855 $ 4688 $ 5107 43 EampM Office Visit new pt 99203 4 $ 248 $ 118 $ 159 $ 139 78 Colonoscopy and biopsy (HOSPITAL ONLY) 45380 Surg 2530 $ 307591 Diagnostic colonoscopy (HOSPITAL ONLY) 45378 Surg 2255 $ 307591 Upper gi endoscopy biopsy (HOSPITAL ONLY) 43239 Surg 1787 $ 307591 Knee Arthroscopy (HOSPITAL ONLY) 29881 Surg 10900 $ 506893 Arthroscopy Ligament Repair (HOSPITAL ONLY) 29888 Surg 10900 $ 506200 Key 1 Facility - Inpatient 2 Facility - Imaging 3 Physician - Imaging 4 Physician 5 Global - Imaging 6 Facility - Outpatient 8 Lab 41 Physician - Primary Care 42 Physician - Specialist
Blue Cross United - EJCH EUH EUHM WW United - SJH Non Options United - SJH Options Aetna - ASC TEC (HMO) Cigna - ASC TEC (HMO) Aetna - EJCH ESJH ECHM WW Cigna - EJCH (HMO) Cigna - ESJH EUHM (HMO) List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract Description CPT Code Charge Average Final Price (all plans) Emory Mark Up Reimbursement Method ( of charge or fixed) - 1713 Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Cardiovascular stress test 93017 Cardio $543 $ 425 28 of Charge 70 $ 380 of Charge 65 $ 353 of Charge 60 $ 326 of Charge 70 $ 380 of Charge 70 $ 380 of charge 100 $ 543 of Charge 70 $ 380 of charge 100 $ 543 of charge 100 $ 543 TTE wDoppler complete 93306 Cardio $1226 $ 960 28 of Charge 70 $ 858 of Charge 65 $ 797 of Charge 60 $ 736 of Charge 70 $ 858 of Charge 70 $ 858 of charge 100 $ 1226 of Charge 70 $ 858 of charge 100 $ 1226 of charge 100 $ 1226 Colonoscopy and biopsy (HOSPITAL ONLY) 45380 Surg $2530 $ 3076 -18 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 of Charge 70 $ 1771 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Diagnostic colonoscopy (HOSPITAL ONLY) 45378 Surg $2255 $ 3076 -27 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 of Charge 70 $ 1579 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Upper gi endoscopy biopsy (HOSPITAL ONLY) 43239 Surg $1787 $ 3076 -42 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Knee Arthroscopy (HOSPITAL ONLY) 29881 Surg $10900 $ 5069 115 Fixed Rate SC 4 $ 3865 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 449300 $ 4493 Fixed Rate $ 654700 $ 6547 of Charge 70 $ 7630 Fixed Rate $ 401000 $ 4010 of Charge 70 $ 7630 Fixed Rate $ 398300 $ 3983 Fixed Rate $ 398100 $ 3981 Arthroscopy Ligament Repair (HOSPITAL ONLY) 29888 Surg $10900 $ 5062 115 Fixed Rate SC 3 $ 3121 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 556900 $ 5569 Fixed Rate $ 770100 $ 7701 of Charge 70 $ 7630 Fixed Rate $ 323900 $ 3239 of Charge 70 $ 7630 Fixed Rate $ 321700 $ 3217 Fixed Rate $ 321400 $ 3214 Comp Metabolic Panel 80053 Lab $132 $ 56 138 RBRVS Fee (100) $ 1437 of Charge 65 $ 86 of Charge 65 $ 86 of Charge 65 $ 86 of Charge 70 $ 92 RBRVS Fee (100) $ 1437 $ 14 of Charge 70 $ 92 RBRVS Fee (100) $ 1437 $ 14 RBRVS Fee (100) $ 1437 $ 14 Surgical Path Tissue Exam 88305 Lab $326 $ 236 38 of Charge 150 $ 51 of Charge 65 $ 212 of Charge 65 $ 212 of Charge 65 $ 212 of Charge 70 $ 228 of charge 100 $ 326 of Charge 70 $ 228 of charge 100 $ 326 of charge 100 $ 326 MRI Abdomen 74183 Radiology $6960 $ 1238 462 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 MRI Brain 70553 Radiology $6804 $ 1238 450 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 MRI Joint Lower Extremity 73721 Radiology $3067 $ 1238 148 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 CT Thorax wo contrast 71250 Radiology $2199 $ 882 149 Fixed Rate $ 771 Fixed Rate $ 47100 $ 471 Fixed Rate $ 81700 $ 817 Fixed Rate $ 116000 $ 1160 of Charge 70 $ 1539 Fixed Rate $ 80100 $ 801 Fixed Rate $ 79200 $ 792 Fixed Rate $ 79300 $ 793 Fixed Rate $ 79500 $ 795 X-ray Chest 71020 Radiology $280 $ 115 142 of Charge 150 $ 25 of Charge 65 $ 182 of Charge 60 $ 168 of Charge 70 $ 196 of Charge 70 $ 196 RBRVS Fee (150) $ 2534 $ 25 of Charge 70 $ 196 RBRVS Fee (150) $ 2534 $ 25 RBRVS Fee (150) $ 2534 $ 25 Screening mammography G0202 Radiology $279 $ 141 98 Fixed Rate $ 128 Fixed Rate $ 13100 $ 131 Fixed Rate $ 14300 $ 143 Fixed Rate $ 16100 $ 161 of Charge 70 $ 195 Fixed Rate $ 13300 $ 133 Fixed Rate $ 13500 $ 135 Fixed Rate $ 13000 $ 130 Fixed Rate $ 11200 $ 112 Mammo Computer Aided 77052 Radiology $75 $ 112 -33 Fixed Rate $ 9 Fixed Rate $ 13100 $ 131 Fixed Rate $ 14300 $ 143 Fixed Rate $ 16100 $ 161 of Charge 70 $ 53 Fixed Rate $ 13300 $ 133 Fixed Rate $ 13500 $ 135 Fixed Rate $ 13000 $ 130 Fixed Rate $ 11200 $ 112 US Abdomen Complete 76700 Radiology $917 $ 397 131 of Charge 150 $ 125 of Charge 65 $ 596 of Charge 60 $ 550 of Charge 70 $ 642 of Charge 70 $ 642 RBRVS Fee (150) $ 12519 $ 125 of Charge 70 $ 642 RBRVS Fee (150) $ 12519 $ 125 RBRVS Fee (150) $ 12519 $ 125 Officeoutpatient visit new pt 30 min (TEC) 99203 EampM $316 $ 248 28 of Charge 70 $ 221 of Charge 65 $ 205 of Charge 60 $ 190 of Charge 70 $ 221 of Charge 70 $ 221 of charge 100 $ 316 of Charge 70 $ 221 of charge 100 $ 316 of charge 100 $ 316 Vaginal delivery 59409 Surg $14484 $ 7290 99 Fixed Rate DRG - 775 $ 5437 2 Day Case Rate + LOC 561700 $ 5617 BaseCMS Weight 584741 $ 5847 BaseCMS Weight 726146 $ 7261 No IP Terms $ - 0 No IP BaseCMS Weight 659343 $ 6593 BaseContract Weight 479451 100 $ 14484 BaseCMS Weight 579110 $ 5791 Lap Sleeve Gastrectomy 43775 Surg $29961 $ 20421 47 Fixed Rate DRG - 621 $ 14872 BaseCMS Weight 1810697 $ 18107 BaseCMS Weight 1835178 $ 18352 BaseCMS Weight 2278911 $ 22789 No IP Terms $ - 0 No IP BaseCMS Weight 2069315 $ 20693 BaseCMS Weight 1730442 100 $ 29961 BaseCMS Weight 1817507 $ 18175 105 Colonoscopy and biopsy (ASC ONLY) Surg $ 219200 $ 2181 Diagnostic colonoscopy (ASC ONLY) Surg $ 267100 $ 2348 Upper gi endoscopy biopsy (ASC ONLY) Surg $ 207500 $ 2758 Knee Arthroscopy (ASC ONLY) Surg $ 417900 $ 3467 Arthroscopy Ligament Repair (ASC ONLY) Surg $ 504800 $ 3386
Cpt Code CPT Description Procedure Category Claims Min 25thNtile 50thNtile Emorys Rates 75thNtile 90thNtile Max 20 Below 50th Ntile 20 Above 50th Ntile 93017 CARDIOVASCULAR STRESS TEST 5 82 $80 $125 $321 $382 $568 $791 $930 $257 $386 71020 CHEST X-RAY 2 2638 $11 $45 $152 $115 $289 $373 $585 $122 $182 71020 CHEST X-RAY 5 8106 $25 $34 $38 $54 $57 $69 $30 $46 45380 COLONOSCOPY AND BIOPSY 6 1256 $541 $560 $572 $2877 $1000 $2024 $3289 $458 $686 77052 COMP SCREEN MAMMOGRAM ADD-ON 2 194 $13 $15 $25 $38 $47 $134 $20 $30 77052 COMP SCREEN MAMMOGRAM ADD-ON 5 2411 $13 $16 $20 $23 $26 $28 $16 $24 80053 COMPREHEN METABOLIC PANEL 8 13019 $9 $19 $23 $55 $24 $25 $69 $19 $28 71250 CT THORAX WO DYE 2 302 $165 $372 $545 $878 $1658 $2067 $436 $654 71250 CT THORAX WO DYE 5 209 $53 $127 $203 $289 $419 $534 $162 $244 45378 DIAGNOSTIC COLONOSCOPY 6 1479 $484 $515 $536 $2914 $831 $1971 $2828 $428 $643 29881 KNEE ARTHROSCOPYSURGERY 6 152 $1650 $1826 $2036 $5235 $3054 $4216 $6461 $1629 $2443 29888 KNEE ARTHROSCOPYSURGERY 6 82 $1682 $3615 $5081 $5145 $7553 $12924 $18532 $4065 $6097 43644 LAP GASTRIC BYPASSROUX-EN-Y 1 21 $11821 $13873 $17050 $18391 $25029 $31079 $13640 $20460 43775 LAP SLEEVE GASTRECTOMY 1 38 $4215 $8250 $13253 $20421 $19197 $21509 $24260 $10602 $15903 74183 MRI ABDOMEN WO amp WDYE 2 120 $919 $987 $1015 $1237 $1252 $2534 $3177 $812 $1218 74183 MRI ABDOMEN WO amp WDYE 5 112 $475 $490 $521 $1154 $1337 $1696 $417 $625 70553 MRI BRAIN WO amp WDYE 2 324 $633 $987 $1142 $1237 $1706 $2805 $3331 $914 $1370 70553 MRI BRAIN WO amp WDYE 5 467 $280 $539 $1023 $1277 $1363 $1726 $818 $1228 73721 MRI JNT OF LWR EXTRE WO DYE 2 304 $804 $859 $967 $1237 $1063 $1598 $2485 $774 $1160 73721 MRI JNT OF LWR EXTRE WO DYE 5 1130 $500 $520 $530 $628 $679 $859 $424 $636 59400 OBSTETRICAL CARE 1 494 $3699 $4402 $4969 $6655 $7307 $8613 $3975 $5963 99203 OFFICEOUTPATIENT VISIT NEW 4 6776 $88 $101 $112 $138 $155 $169 $90 $134 G0202 Screeningmammographydigital 2 7444 $123 $206 $285 $380 $425 $479 $228 $342 G0202 Screeningmammographydigital 5 2754 $117 $165 $195 $230 $247 $252 $156 $234 88305 TISSUE EXAM BY PATHOLOGIST 8 20834 $51 $74 $112 $235 $168 $261 $478 $90 $134 93306 TTE WDOPPLER COMPLETE 2 931 $194 $377 $739 $960 $1267 $1480 $1849 $591 $887 93306 TTE WDOPPLER COMPLETE 5 2299 $151 $296 $373 $538 $573 $834 $298 $448 43239 UPPER GI ENDOSCOPY BIOPSY 6 1264 $424 $514 $550 $800 $1838 $2833 $440 $660 76700 US EXAM ABDOM COMPLETE 2 321 $96 $165 $271 $509 $584 $857 $217 $325 76700 US EXAM ABDOM COMPLETE 5 444 $111 $129 $147 $156 $220 $279 $118 $176 Key 1 Facility - Inpatient 2 Facility - Imaging 3 Physician - Imaging 4 Physician 5 Global - Imaging 6 Facility - Outpatient 8 Lab 41 Physician - Primary Care 42 Physician - Specialist Cardiovascular stress test $ 38279 TTE wDoppler complete $ 96037 Colonoscopy and biopsy $ 287709 Diagnostic colonoscopy $ 291434 Upper gi endoscopy biopsy $ 300526 Knee Arthroscopy $ 523584 Arthroscopy Ligament Repair $ 514501 Comp Metabolic Panel $ 5552 Surgical Path Tissue Exam $ 23570 MRI Abdomen $ 123786 MRI Brain $ 123786 MRI Joint Lower Extremity $ 123786 CT Thorax wo contrast $ 88213 X-ray Chest $ 11548 Screening mammography $ 14098 Mammo Computer Aided $ 11179 US Abdomen Complete $ 39695 Officeoutpatient visit new pt 30 min $ 24753 Vaginal delivery $ 729025 Lap Sleeve Gastrectomy $ 2042124
Page 6
Background Discussion
6
Stakeholder Landscape
Source Re-Igniting the Growth Engine Part 2 Winning Increased Share of Lucrative Patient Volumes Advisory Board
68 68 55 55
42 49
40 44 40 47 50
80 80 80
68 60 60 50
60 50
53 55
0
5
10
Health care trend after plan changes (total plan costs)
Health care trend before plan changes
Consumer Price Index for all urban consumers (CPI-U)Source Willis Towers Watson 23rd Annual Best Practices in Health Care Employer Survey
Hos
pita
ls Are experiencing a compression of margins due to lower revenue and higher expense trends
Seek improvement in market share and improved margins Em
ploy
ers Face unstainable year over year healthcare costs To
mitigate costs they are forced to implement annual benefit plan changes
Seek lower more predictable medical expenses and healthy productive employees
Direct Contacting Arrangement Types
7
Bundled Payments prospective payment which covers patientrsquos care from start to finish
Reference Based Pricing (RBP) plan pays up to fixed amount for procedure any excess is billed to member
bull PCP-centric bull Level of provider risk can vary from partial to full bull May be offered with other options or full replacement if adequate network
bull Promotes shopping for services via price transparency bull Most common for elective procedures ndash joint surgeries spine gastric bypass
bull Appropriate for high volume procedures bull Medical expense more predictable for these services may not be fixed price bull May result in lower provider revenue than FFS providers seek steerage volume
Center of Excellence (COE) designated provider identified for specific procedures that may require travel
bull Appropriate for high volume procedures bull Specialization amp operational efficiencies reduce utilization variations improves patient
experience amp improves outcomes (eg lower LOS return to work time) bull Members out-of-pocket often low to $0 including travelhotel not always lowest ldquopricerdquo
Accountable Care Organization (ACO) provider reimbursements are directly tied to quality and financial outcomes
Mos
t Com
mon
Ar
rang
emen
ts
On-site health education seminars
Wellness services
On-site clinic
Bundled payments
Employer liaison coordinator
On-site coaching Andor counseling
Care pathways
Direct contracting narrow networks
Source Re-Igniting the Growth Engine Part 2 Winning Increased Share of Lucrative Patient Volumes Advisory Board
Boeing 1UW Med 2Memorial Care 3Mercy MO 4Roper St Francis 5ProvSwedish
DART amp Baylor Scott and White Health
Intel amp 1 Presbyterian ACO 2 Arizona Care Network
Quallcom amp Scripps Health
Stanford Healthcare Alliance
General Motors amp Henry Ford Health
Disney amp 1Orlando Health 2Florida Hospital
Walmart amp 1 Banner 2 Emory 3 Memorial Hermann 4 Mercy AK 5Mercy OK 6 Mercy MO 7Oschner Health 8 Presbyterian 9 St Lukersquos 10 Unity Point 11 Cleveland Clinic 12 Geisinger Health 13Johns Hopkins 14Mayo Clinic AZ 15Mayo Clinic FL 16Mayo MN 17Mercy MO
1 2
3
4 5
6
8
7
9
10
1
3
4 2
1
2
1
Whole Foods amp Adventis Health
11 12 13
14
15
16
17
Emergence of Direct Contracting
8
DC with providers to secure improved pricing
COE through a carve-out provider
COE within the health plans
Source Willis Towers Watson 23rd Annual Best Practices in Health Care Employer Survey Full report and high-performance insights httpswwwwillistowerswatsoncom-mediaWTWPDFInsights201812willis-towers-watson-23rd-annual-best-practices-in-health-care-employer-survey-full-reportpdf 2018
Trends in Direct Contracting amp COE
According to Willis Towers Watsonrsquos survey employers are using COEs mostly through their health plans however direct contracting considerations are expected to grow considerably
6
7
48
2
2
7
14
13
20
0 20 40 60 80
Action taken or tactic used in 2018
Planning for 2019
Considering for 2020
bull Almost 50 use COEs in 18rsquo expected to rise to 2 out of 3 by 2020
bull Employers engaging employees in multiple ways to use COE bull Ongoing communications bull Reducing member cost share
to use bull Increasing member cost
share when not using bull Mandatory use
9
16
12
18
9
3
6
2
50
39
19
22
26
11
10
15
19
31
30
31
22
11
Transplants
Bariatric Surgery
Knees hips or spine
Cardiovascularcardiac
Cancer
Fertility
Other Procedures
Yes with incentives Yes but no incentives No but considering
10
A 2015 survey by the National Business Group on Health shows the status of large employersrsquo contracts with COEs (note reflects all COEs not specifically direct contracts)
Source Large Employersrsquo 2016 Health Plan Design Survey copy 2015 National Business Group on Health
Other centers of excellence programs include maternity NICU sleep apnea pancreas cornea and kidney
National Business Group on Healthrsquos Large Employers 2019 Health Care Strategy and Plan Design Survey showed DC arrangements between employers and bull Health systemsproviders will
increase from 3 in 2018 to 11 in 20191
bull COEs will increase from 12 in 2018 to 18 in 20191
bull Cancer cardiovascular and fertility COEs are experiencing the greatest growth
Source National Business Group on Health ldquoLarge US Employers Eye Changes to Health Care Delivery System as Cost to Provide Health Benefits Nears $15000 per Employeerdquo August 2018
10
Trends in Direct Contracting amp COE
Outcomes amp Benefits bull Employers with COE arrangements are seeing reduction in procedures
bull Walmart (15rsquo-18rsquo) 50+ of spine surgeries amp 20 of kneehip procedures recommended by local providers were determined lsquonot necessaryrsquo by COE (see table)
bull Employers like Walmart amp Boeing continue to sign new providers which suggest (employersrsquo) continued interest in pursuing DC arrangements2 However Boeing and Providence Swedish did end relationship due to inability to capture enoughright data to estimate cost of care3
bull John Hopkinsrsquo Bayview campus COE emerging metrics4
bull 121 referrals in the first three months
bull 352 referrals and 183 surgeries over 18 months
bull 23 of all joint replacement volumes at facility now attributed to travel program
bull 96 of patients said they would recommend this program to family friends coworkers
bull Bingham Memorial in Idaho direct contracting emerging metrics4
bull 17 companies participating covering over 5000 lives
bull +3000 new patients as of October 2018
bull +$3M Revenue from new patients
11
1 How Employers Are Fixing Health Care Harvard Business Review March 2019 2 httpswwwhealthleadersmediacomstrategywalmart-escalates-strategy-solve-employee-healthcare Health Leaders Media Nov 18rsquo 3 Do Providers Have the Data chops to Success with Direct Contract Modern Healthcare August 2018 4 Re-Igniting the Growth Engine Part 2 Winning Increased Share of Lucrative Patient Volumes Advisory Board 5 httpswwwautonewscomarticle20180806OEM180809831gm-signs-major-health-care-services-deal-for-salaried-employees
Walmart COE Programs1
Program Key Benefits
Spin
e Su
rger
y 2300 EEs 50 COE approved of those applied
bull 95 lower readmission bull 14 less time in hospital bull 1 COE vs 5 non-COE patients discharged to SNF bull Returned to work sooner reducing 20 of OOO
time bull More-effective less dangerous amp less expensive bull The COE surgery ldquopricerdquo is 8 higher but value in
earlier discharge lower readmission rates far less utilization of SNF faster return to work
Join
t
1836 EEs 18 COE approved of those applied
bull 32 less time in hospital bull 70 less likely to be readmitted than non-COE
patients bull Fewer postsurgical complications bull 0 COE vs 5 non-COE patients discharged to SNF bull COE patients returned to work a 15 weeks sooner bull Cost of surgery is 15 less at COE hospitals
Baria
tric
300+ EEs
bull Preliminary data suggests the weight loss from surgery reduces absenteeism or presentism (working while sick)
bull Dramatically cuts pharmacy amp medical costs Complications of obesity drop sharply as does the need for medication
bull GMrsquos direct contract benefit plans with Henry Ford allows it to offer similarly designed plans to that of Blue Cross with savings in monthly EE contributions ranging from $300-$19805
Walmartrsquos Travel (Surgery) Program
Mem
ber F
eedb
ack
12
Looking beyond traditional cost management techniques Walmart designed a program to address wild variations in cost and become directly in improving quality of care for its employees FIRST SELECTING PROVIDERS 1 Identify providers with high volume and high quality 2 Target regions in country to support Walmartrsquos employees 3Focus on Integrated Health Systems Hospitals within these systems were best aligned to Walmarts mission could take on risks associated with bundling 4 Eliminate systems unwilling to do bundled payments model were
PROVIDERS VALUE IN PARICIPATING
Build Bundles bull Define bundles and negotiate price (typically 10-15 below FFS ) bull Definitions of service limit disputes of what is covered vs not (covers
entryexit of facility SNF not part of bundle) bull Contract flexibility covers unforeseen testcosts and reinforces
Walmarthealth system partnership bull Warrantees if further treatment - can return in 30 days no
additional cost to Walmart bull Strict criteria and providers with track record of clinically sound
decisions are included to mitigate any incentivizing of volume Business bull 100 travelaccom brings
new volume of patients from outside of market
bull More stable payments for services (vs Medicare or commercial FFS)
bull Increased visibility and attract new business
Clinical bull lsquoHalorsquo effect ndash Building a highly
efficient multidiscipline program brings improvements throughout health system
bull Onsite collaboration among health systems allows sharing of outcomesbest practices
Source How Employers Are Fixing Health Care Harvard Business Review March 2019
5000 participants in the program
95 satisfiedvery satisfied
Denied by care because not deemed necessary by COE Treatment denied due to lifestyle weightsmoking
The Member Experience
13
Engagement begins when employee on clear
path to surgery
Patient contacts with COE TPA
TPA team triages and ensures basic criteria
met
Employee put in touch with nurse team
Car pick-up Flight Hotel all arranged by
TPA
Navigators and nurse coordinators help
throughout the stay
Patient visits to hospital to understand
exceptions of procedure and meet treatment
team
Surgery occurs typically next day
Stay length according to procedure typically a
few days
Discharged from facility Travel home COE team updates local
PCP and discuss follow up care
COE provider checks in with local physician
frequently Revert back to standard coverage
Source How Employers Are Fixing Health Care Harvard Business Review March 2019
Case Study 1
Case study 1 ndash Pop Health Approach bull ProblemCircumstance Large multi-employer group needs to
evaluate benefit design disease prevalence health spend and utilization to manage their population
bull ConsiderationsValue Prop Unique industry and geography drive chronic conditions and utilization patterns
bull Solution Provide opportunity assessment comparing this population to other benchmarks to understand where to target intervention and management as well as assess efforts already taken
15
Market Comparison Preference Sensitive Procedures
16
Legend vs
Mt States vs
National gt120 gt110
110-120 105-110 lt80 lt90
Source Multi-payer commercial benchmark Results are weighted by AgeGender Broader market area includes multi-payer data from the mountain regions
Preference Sensitive Procedures Benchmark Comparison
Dartmouth Atlas Preference Sensitive Procedures
IP allowed dollars ALOS Employer vs
Mt States Employer
vs National FY 2017 FY 2018 FY 2017 FY 2018
Hysterectomy for Uterine Fibroids Rate $569354 $436932 45 54 124 140 CABG Rate $1800260 $2400608 53 60 218 130 Cholycystectomy Rate $832675 $755565 68 39 92 120 C-Section Rate 116 110 HighTech Radiology Rate 103 101 PCIPTCA Rate $934486 $1133708 37 55 82 80 Back Surgery Rate $3237613 $4003212 39 57 52 70 Knee Replacement Rate $3086693 $2177334 41 48 50 64 Total Hip Replacement Rate $1023675 $747491 45 64 37 34
Strengths (+)
Employer compares favorably for orthopedic procedures (back hip knee)
Opportunity (-)
Employer has higher than expected rates for CABG and hysterectomy (Note Low PTCA rate combined with high CABG rate may suggest provider practice patterns favoring CABG)
0 50 100 150 200 250
Total Hip Replacement
Knee Replacement
Back Surgery
PCIPTCA
Cholycystectomy
HighTech Radiology
C-Section
CABG
Culinary VsNational
Culinary Vs MtStates
Employer vs Mt States
Employer vs National
Market Comparison Condition Prevalence
17 Source Multi-payer commercial benchmark Results are weighted by AgeGender Broader market area includes multi-payer data from the mountain regions
Condition Prevalence Benchmark Comparison
Condition Employer vs
Mt States Employer vs
National Prevalence Diabetes Rate 229 219 Prevalence Hyperlipidemia Rate 259 207 Prevalence Kidney Disease Rate 143 174 Prevalence Migraine Rate 166 164 Prevalence Low Back Pain Rate 136 139 Prevalence Hypertension Rate 156 134 Prevalence Asthma Rate 146 128 Prevalence CAD Rate 175 115 Prevalence Pregnancy Rate 110 109 Prevalence Adult Preventive Screening Rate 114 91 Prevalence Depression Rate 63 60
Strengths (+)
Rate of depression is low (Note May be due to incomplete behavioral health claims)
Opportunity (-)
Employer has a higher prevalence of most chronic conditions including asthma CAD diabetes hypertension hyperlipidemia Kidney Disease LBP and migraines
0
100
200
300Hyperlipidemia
Diabetes
CAD
Migraine
Hypertension
AsthmaKidney Disease
Low Back Pain
Pregnancy
Depression
Employer vsMt States
Employer vsNational Legend
vs Mt States
vs National
gt120 gt110 110-120 105-110
lt80 lt90
Market Comparison Utilization Rates
18
A higher preventive office visit rate is better Source Multi-payer commercial benchmark Results are weighted by AgeGender Broader market area includes multi-payer data from the mountain regions
Strengths (+)
Lower than average utilization of ED and high dollar patient rate
Opportunity (-)
Higher LOS lengthy admits avoidable admits and readmissions which all drive significantly more spend
Utilization Benchmark Comparison
Condition Employer vs
Mt States Employer vs
National Avoidable Admit Rate 142 144 Lengthy Admit Rate 175 136 Outpatient Problem Focused Office Rate 146 131 Readmission Rate (readmitadmit) 135 126 Average LOS 125 116 One Day Admit Rate 76 103 Office Visit Rate 106 96 Acute Admit Rate 80 95 Avoidable ED Rate 68 86 ED Rate 54 69 Preventive Office Rate 95 68 High Dollar Patient Rate 49 51 Frequent ED User (gt3 times) Rate 24 36
Legend vs
Mt States vs
National gt120 gt110
110-120 105-110 lt80 lt90
0 50 100 150 200
Frequent ED User (gt3 times)
High Dollar Patient
Preventive Office
ED
Avoidable ED
Acute Admit
Office Visit
One Day Admit
Average LOS
Readmissionhellip
Outpt Problem Focusedhellip
Lengthy Admit
Avoidable Admit
Employer vsNational
Employer vsMt States
ED and Avoidable ED
19
Potentially Avoidable ED - Trend View Overall ED
Period Change FY 2017 FY 2018 Count Rate
Measure Mbrs Rate Mbrs Rate Overall ED 16394 12626 13820 10745 -16 -15 FREQUENT ED UTILIZER (mbr1k) 1581 1218 1468 1141 -7 -6 AVOIDABLE ED 6371 4907 5288 4111 -17 -16 Potentially Avoidable ED
Period Change FY 2017 FY 2018 Count Rate
Avoid ED Condition Mbrs Rate Mbrs Rate ABDOMINAL_PAIN 1092 841 895 696 -18 -17 ENT_INFECTION 854 658 742 577 -13 -12 FEVER 715 551 700 544 -2 -1 URINARY 650 501 468 364 -28 -27 HEADACHE 558 430 434 337 -22 -21 BACK_PAIN 414 319 423 329 2 3 NAUSEA 394 303 271 211 -31 -31 ASTHMA 294 226 209 162 -29 -28 CELLULITIS 210 162 198 154 -6 -5 GASTROENTERITIS 254 196 171 133 -33 -32 OTITIS_MEDIA 201 155 160 124 -20 -20 COPD 132 102 108 084 -18 -17 DIABETES 123 095 91 071 -26 -25 BACT_PNEUMONIA 111 085 86 067 -23 -22 DENTAL 93 072 83 065 -11 -10 DEHYDRATION 98 075 81 063 -17 -17 HYPERTENSION 16 012 24 019 50 51 CHF 4 003 3 002 -25 -24 ANGINA 8 006 3 002 -63 -62 IMMUNIZATION_RELATED 2 002 0 000 -100 -100 Grand Total 6371 4907 5288 4111 -17 -16
AHRQ avoidable ED visits are based on the logic for ambulatory care sensitive ED visits from AHRQ and diagnosis code driven
696
577
544 364
337
329
211 162
154 133 ABDOMINAL_PAIN
ENT_INFECTION
FEVER
URINARY
HEADACHE
BACK_PAIN
NAUSEA
- 200 400 600 800
1000 1200
2017 Members 2018 Members
Top Ten 2018 Conditions by Rate
Top Ten Conditions by Member Count
ED Avoidable ED and the impact of new on-site clinic
20
0
1000
2000
3000
4000
5000
6000
0200400600800
10001200140016001800
Clinic Visits ED Visits
Avoidable ED VisitsED Visits (non-avoidable)Clinic EampM Visits
0
500000
1000000
1500000
2000000
2500000
3000000
3500000
$s
Clinic EampM Profess DollarsAvoidable ED Dollars
bull Clinic visits have a clear impact on ED and avoidable ED use and spend
bull Combined ED visits are down on average 157 in FY 18 from FY 17
bull Combined ED spend is down 128 in FY 18 from FY 17
Clinic Live 62017
Pitfalls and Challenges bull Face many of the challenges similar to startup health
plan bull Critical to determine how you will deliver value and
communicate the value to potential customers and brokersconsultants
bull Care management bull Network
21
Considerations in Offering Development bull Care Management Model
bull Traditional care model bull Case management bull Utilization management bull Disease management
bull Longitudinal care model with value based care philosophy bull Primary care driven bull Local care management
bull Predictive analytics and risk stratification model bull Claims history and ongoing data bull EMR data
22
Case Study 2
Case study 2 ndash Large Employer bull Business Problem Large employer wants to contract
directly with 2 major hospital systems developing professional fee schedules
bull ConsiderationsValue Prop Fee schedule should be competitive but also nuanced to minimize gap relative to current reimbursement at physician level
bull Solution Data-driven approach using current market-wide reimbursement distinguished by service level
24
Evaluate Provider Spend Top 25 Service Lines by Allowable Spend
Evaluate Provider Spend Top 20 Professional CPTs by Total Spend
Understand relative market pricing position
27
21
-1
-28
14 10
28
-22
-11 -13
24
3
20 21
8
-20
13
3 9
-39
56
-26
4
-42
60
MRI Colonoscopy Cardiac Cath Lab - OrganPanel
Memorial Hospital Beta Hospital Delta Hospital Charlie Hospital Echo Hospital Alpha Medical Center
ndash25 5 -15 10 0 39
State Charges as a Percent of Peer Average Weighted Averages for MRI Colonoscopy Cardiology and Lab
Total Percent Above Below Market Average2
Memorial Hospital Beta Hospital Delta Hospital Charlie Hospital Echo Hospital Alpha Medical Center
Develop fee schedule relative to market
28
Service Line Procedure CPT CodeDRG
Memorial Hospital
Beta Hosptial
Charlie Hospital
Delta Hospital
Echo Hospital
Alpha Medical Center
Arthroscopy Ligament Repair 29888 $ 5062 $ 9557 $ 5983 $ 10096 $ 7519 $ 2502 Knee Arthroscopy 29881 $ 5069 $ 4185 $ 3837 $ 3022 $ 3729 $ 2266 Upper GI Endoscopy 43239 $ 3075 $ 2539 $ 2012 $ 1132 $ 1565 $ 2240 Lap Sleeve Gastrectomy DRG 621 $ 20421 $ 20815 $ 12105 $ 13230 $ 14600 $ 17800 Colonoscopy and biopsy 45380 $ 3075 $ 3071 $ 2013 $ 1244 $ 1972 $ 859 Diagnostic Colonoscopy 45378 $ 3075 $ 2805 $ 2013 $ 1244 $ 1972 $ 859 MRI Brain w amp wo dye 70553 $ 1238 $ 1468 $ 1117 $ 967 $ 2805 $ 1052 MRI Joint of Lower Extremity wo dye 73721 $ 1238 $ 1398 $ 1042 $ 967 $ 925 $ 557 MRI Abdomen w amp wo dye 74183 $ 1238 $ 1468 $ 1106 $ 967 $ 2805 $ 836 X-ray Chest 71020 $ 115 $ 266 $ 305 $ 279 $ 375 $ 72 CT Thorax wo dye 71250 $ 882 $ 810 $ 505 $ 491 $ 579 $ 319 Ultrasound Abdomen Complete 76700 $ 397 $ 538 $ 545 $ 195 $ 190 $ 168 Mammogram Screening G0202 $ 141 $ 328 $ 431 $ 294 $ 425 $ 168 Computer Detection Add-on 77052 $ 112 $ 99 $ 41 $ 15 $ 45 $ 23 Comp Metabolic Panel 80053 $ 56 $ 15 $ 24 $ 56 $ 51 $ 25 Tissue Exam by Pathologist 88305 $ 236 $ 307 $ 80 $ 152 $ 78 $ 232 Cardiovascular Stress Test 93017 $ 383 $ 432 $ 1299 $ 907 $ 717 $ 797 TTE w Doppler 93306 $ 960 $ 1566 $ 1388 $ 1173 $ 1125 $ 1157
Obstetrics Vaginal Delivery DRG 755 7290$ 5730$ 4654$ 4607$ 5855$ 4688$
GI
Lab
Radiology
Medical Cardiology
Orthopedics
KEY OBSERVA TIONS bull Potential exposure on GI bull Opportunity to align price and acuity in MRI bull Opportunity to raise rates on chest x-ray and mammogram
Percentile Bands Emory Allowables Heatmap TEC ASC Heatmap Allowable Comp Analysis Portal Pricing Sheet1 image1png A few words on Bundled Payments bull Bundled payments are growing as a type of direct contracting bull In some cases third parties match-make between employers
and providers bull Contracts may vary in definitions prepost admission
coverage duration readmission cause (ie all-cause vs medically related) outlier provisions LOS caps andor per diems
bull Providers need to be strategic in pricing to enable profitable growth of market share
29
Considerations in Offering Development bull Network Development
bull Build off existing structure eg health system employee plan network bull How does this fit into your broader value based care strategy bull Employed and independent physicians bull How do you want to approach the buildout of high performance
network bull Quality focus bull Cost efficiency
bull Integrated behavioral health bull Wrap network for other markets
30
Considerations in Offering Development bull Target Market
bull Consideration of employer profile in market bull Fully-insured vs ASO bull Total cost of care vs bundled services
bull Distribution bull Direct marketing bull Brokerconsultant community
bull Plan designs bull Standard designs vs flexible ndash Dependent on target market
bull Claims administration bull Data sharing amp analytics
31
Considerations in Offering Development bull Other components of comprehensive offering
bull Pharmacy bull Preventive health bull Onsite clinics bull Wellness programs bull Technology platform
32
Sample Bundle Analysis
33
Cover page Dotson Hazelrigs Nation Mainly of charge of fixed Cardiovascular stress test TTE wDoppler complete Colonoscopy and biopsy (Combined) Diagnostic colonoscopy (Combined) Upper gi endoscopy biopsy (Combined) Knee Arthroscopy (Combined) Arthroscopy Ligament Repair Comp Metabolic Panel Surgical Path Tissue Exam MRI Abdomen MRI Brain MRI Joint Lower Extremity CT Thorax wo contrast X-ray Chest Screening mammography Mammo Computer Aided US Abdomen Complete Officeoutpatient visit new pt 30 min Vaginal delivery Lap Sleeve Gastrectomy
Piedmont Piedmont Piedmont Piedmont Northside Northside Northside Northside Gwinnett Gwinnett Gwinnett Gwinnett WellStar WellStar WellStar WellStar AMC - Tenet AMC - Tenet AMC - Tenet AMC - Tenet CPT Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing 29881 $11312 $10872 NA NA $7476 $9338 NA $23655 $11856 $3668 NA $17871 $12253 NA NA $15645 $5490 NA NA $23039 29888 NA NA NA NA NA NA NA $23784 NA $8261 NA $18000 NA NA NA $15774 NA NA NA $23168 43239 NA $4408 NA NA NA NA $5997 $8852 NA $3304 NA $7424 $1267 NA NA $9230 NA $2458 NA $8274 43644 $26468 NA NA NA $3382 $12050 NA $1861 NA NA NA $1316 $7841 NA NA $3444 $18892 $27950 NA $979 43775 NA NA NA NA NA NA NA $352 NA NA NA $302 NA NA NA $413 NA NA NA $83 45378 $2705 $2530 NA NA $4381 $3676 $4496 $1022 $2938 $2138 NA $695 $5504 NA NA $2036 NA NA NA $372 45380 $3075 $2600 NA NA $4723 $3527 $3012 $1757 $4215 $2285 NA NA $5298 NA NA $3268 NA NA NA $627 59400 $6160 NA NA NA NA $5100 NA $1851 NA NA NA $1304 $9035 NA NA $3427 $9116 $5150 NA $966 70553 $2985 NA $1153 NA $2182 NA $1192 $492 NA NA $803 $489 $1512 NA $985 $1187 NA NA NA $197 71020 $61 $69 $43 NA $113 $319 $307 NA $183 $59 $32 NA $213 $66 $40 NA $83 $53 NA NA 71250 $1837 $621 $989 NA $1490 $931 $755 NA NA $745 $401 NA $1067 $982 $616 NA NA $304 NA NA 73721 NA $1098 $1153 NA $2042 $1065 $1192 NA NA $998 $803 NA NA $1275 $985 NA NA $644 NA $178 74183 $2971 $1144 NA NA NA $1092 $1192 $6884 NA $1098 $803 NA $2960 $1197 $985 $5454 NA NA NA $7607 76700 $364 $247 $207 NA $427 $708 $614 $13267 $428 $214 $152 NA $747 $263 $189 $9139 NA $235 NA NA 77052 NA NA NA NA NA NA NA $4744 NA NA NA NA NA NA NA $3070 NA NA NA $5611 93306 $1220 $1117 NA NA $1877 $1657 $2100 $4605 $1433 $413 $945 NA $1336 $1434 $1951 $2931 NA $2399 NA $5472 G0202 $262 $187 NA NA $431 NA NA $4605 $292 NA NA NA $530 $281 NA $2931 $327 NA NA $5472
Provider Group 29881_6 29888_6 43239_6 43644_1 43775_1 45378_6 45380_6 59400_1 70553_2 71020_2 71250_2 73721_2 74183_2 76700_2 77052_2 77052_5 80053_8 88305_8 93306_2 99203_4 G0202_2 G0202_5 93017_2 Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Atlanta Gastroenterology Associates $2399 $536 348 $1628 $536 204 $2400 $536 348 Atlanta Medical Center $24889 $2266 999 $25897 $2502 935 $11449 $2240 411 $81927 $15300 435 $75815 $17800 326 $7317 $859 752 $7317 $859 752 $12821 $4688 173 $6581 $1052 526 $645 $72 796 $3265 $319 925 $3450 $557 519 $7398 $836 785 $1576 $133 1084 $73 $23 217 $635 $25 2440 $891 $232 285 $2967 $1157 156 $344 $168 105 $1265 $797 59 Atlanta Womens Health Physicians Group $29 $14 107 $40 $13 208 $396 $188 111 $278 $118 135 $450 $231 95 Gwinnett Hospital $11941 $3022 295 $21654 $10096 114 $3551 $1132 214 $34384 $10800 218 $56472 $13230 327 $3003 $1244 141 $3533 $1244 184 $8984 $4607 95 $3901 $967 303 $417 $279 49 $2247 $491 358 $4000 $967 314 $3755 $967 288 $1593 $195 717 $50 $15 233 $186 $56 233 $505 $152 233 $1750 $1173 49 $418 $294 42 $1396 $907 54 Northside Hospital $15482 $4185 270 $21651 $9557 127 $4885 $2539 92 $35176 $17000 107 $35233 $20815 69 $3883 $2805 38 $5256 $3071 71 $10911 $5730 90 $4856 $1468 231 $443 $266 67 $2379 $810 194 $3776 $1398 170 $5105 $1468 248 $942 $538 75 $167 $99 69 $379 $15 2427 $433 $307 41 $2252 $1566 44 $459 $328 40 $576 $432 33 Piedmont Hospital $14772 $3837 285 $35493 $5983 493 $5069 $2012 152 $38320 $17750 116 $37125 $12105 207 $3485 $2013 73 $4993 $2013 148 $10143 $4654 118 $5939 $1117 432 $542 $305 78 $2983 $505 491 $3410 $1042 227 $6067 $1106 449 $1364 $545 150 $75 $41 85 $231 $24 863 $657 $80 721 $2041 $1388 47 $490 $431 14 $1780 $1299 37 Piedmont Physicians Group $42 $22 87 $318 $179 78 $239 $159 50 Resurgens $8558 $2036 320 $9293 $2258 312 $4638 $2067 124 $4039 $2164 87 $4392 $2164 103 $2252 $1371 64 $459 $330 39 Wellstar Hospital $9330 $3729 150 $17479 $7519 132 $5261 $1565 236 $35794 $18200 97 $46780 $14600 220 $3707 $1972 88 $4928 $1972 150 $13549 $5855 131 $5054 $2805 80 $528 $375 41 $3222 $579 457 $3694 $925 299 $5495 $2805 96 $1355 $190 615 $66 $45 46 $73 $51 43 $133 $78 71 $1785 $1125 59 $599 $425 41 $1010 $717 41 Avg Mark UpProcedure Atlanta Medical Center 634 Gwinnett Hospital 223 Northside Hospital 233 Piedmont Hospital 259 Wellstar Hospital 155 Emory 105
Atlanta Gastroenterology Associates Atlanta Medical Center Atlanta Womens Health Gwinnett Hospital Northside Hospital Piedmont Hospital Piedmont Physicians Group Resurgens Wellstar Hospital CPT Code CPT Proc Cat Comp Avg Allow Allow Allow Allow Allow Allow Allow Allow Allow 29881 KNEE ARTHROSCOPYSURGERY 6 $3179 $2266 $3022 $4185 $3837 $2036 $3729 29888 KNEE ARTHROSCOPYSURGERY 6 $6319 $2502 $10096 $9557 $5983 $2258 $7519 43239 UPPER GI ENDOSCOPY BIOPSY 6 $1727 $536 $2240 $1132 $2539 $2012 $2067 $1565 43644 LAP GASTRIC BYPASSROUX-EN-Y 1 $15810 $15300 $10800 $17000 $17750 $18200 43775 LAP SLEEVE GASTRECTOMY 1 $17800 $13230 $20815 $12105 $14600 45378 DIAGNOSTIC COLONOSCOPY 6 $1656 $536 $859 $1244 $2805 $2013 $2164 $1972 45380 COLONOSCOPY AND BIOPSY 6 $1694 $536 $859 $1244 $3071 $2013 $2164 $1972 59400 OBSTETRICAL CARE 1 $5107 $4688 $4607 $5730 $4654 $5855 70553 MRI BRAIN WO amp WDYE 2 $1482 $1052 $967 $1468 $1117 $2805 71020 CHEST X-RAY 2 $259 $72 $279 $266 $305 $375 71250 CT THORAX WO DYE 2 $541 $319 $491 $810 $505 $579 73721 MRI JNT OF LWR EXTRE WO DYE 2 $978 $557 $967 $1398 $1042 $925 74183 MRI ABDOMEN WO amp WDYE 2 $1436 $836 $967 $1468 $1106 $2805 76700 US EXAM ABDOM COMPLETE 2 $320 $133 $195 $538 $545 $190 77052 COMP SCREEN MAMMOGRAM ADD-ON 2 $45 $23 $15 $99 $41 $45 77052 COMP SCREEN MAMMOGRAM ADD-ON 5 $14 $14 80053 COMPREHEN METABOLIC PANEL 8 $29 $25 $13 $56 $15 $24 $22 $51 88305 TISSUE EXAM BY PATHOLOGIST 8 $174 $232 $188 $152 $307 $80 $179 $78 93306 TTE WDOPPLER COMPLETE 2 $1297 $1157 $1173 $1566 $1388 $1371 $1125 93017 STRESS TEST 5 $830 $797 $907 $432 $1299 $717 99203 OFFICEOUTPATIENT VISIT NEW 4 $139 $118 $159 G0202 Screeningmammographydigital 2 $329 $168 $294 $328 $431 $330 $425 G0202 Screeningmammographydigital 5 $231 $231
Service Line Procedure CPT Code Emory Atlanta Gastroenterology Associates Resurgens Atlanta Womens Health Piedmont Physicians Group Orthopedics (ASC) Knee Arthroscopy 29881 $3467 $2036 Arthroscopy Ligament Repair 29888 $3386 $2258 GI (ASC) Upper GI Endoscopy 43239 $2758 $536 Diagnostic Colonoscopy 45378 $2348 $536 Colonoscopy and biopsy 45380 $2181 $536 Radiology Mammogram Screening G0202 $164 $231 Computer Detection Add-on 77052 $93 $14 Lab Comp Metabolic Panel 80053 $53 $13 $22 Tissue Exam by Pathologist 88305 $277 $188 $179 EampM (TEC) Office Visit new pt 99203 $269 $118 $159
Service Line Procedure CPT CodeDRG Memorial Hospital Beta Hosptial Charlie Hospital Delta Hospital Echo Hospital Alpha Medical Center Atlanta Gastroenterology Associates Resurgens Atlanta Womens Health Piedmont Physicians Group Market Avg Emory abovebelow Orthopedics Arthroscopy Ligament Repair 29888 $ 5062 $ 9557 $ 5983 $ 10096 $ 7519 $ 2502 $ 2258 $ 6319 -20 Knee Arthroscopy 29881 6 $ 5069 $ 4185 $ 3837 $ 3022 $ 3729 $ 2266 $ 2036 $ 3179 59 GI Upper GI Endoscopy 43239 6 $ 3075 $ 2539 $ 2012 $ 1132 $ 1565 $ 2240 $ 536 $ 1671 84 Lap Sleeve Gastrectomy DRG 621 $ 20421 $ 20815 $ 12105 $ 13230 $ 14600 $ 17800 $ 15710 30 Colonoscopy and biopsy 45380 $ 3075 $ 3071 $ 2013 $ 1244 $ 1972 $ 859 $ 536 $ 1616 90 Diagnostic Colonoscopy 45378 6 $ 3075 $ 2805 $ 2013 $ 1244 $ 1972 $ 859 $ 536 $ 1572 96 Radiology MRI Brain w amp wo dye 70553 2 $ 1238 $ 1468 $ 1117 $ 967 $ 2805 $ 1052 $ 1482 -16 MRI Joint of Lower Extremity wo dye 73721 2 $ 1238 $ 1398 $ 1042 $ 967 $ 925 $ 557 $ 978 27 MRI Abdomen w amp wo dye 74183 2 $ 1238 $ 1468 $ 1106 $ 967 $ 2805 $ 836 $ 1436 -14 X-ray Chest 71020 $ 115 $ 266 $ 305 $ 279 $ 375 $ 72 $ 259 -56 CT Thorax wo dye 71250 $ 882 $ 810 $ 505 $ 491 $ 579 $ 319 $ 541 63 Ultrasound Abdomen Complete 76700 $ 397 $ 538 $ 545 $ 195 $ 190 $ 168 $ 327 21 Mammogram Screening G0202 2 $ 141 $ 328 $ 431 $ 294 $ 425 $ 168 $ 231 $ 313 -55 Computer Detection Add-on 77052 2 $ 112 $ 99 $ 41 $ 15 $ 45 $ 23 $ 14 $ 39 183 Lab Comp Metabolic Panel 80053 8 $ 56 $ 15 $ 24 $ 56 $ 51 $ 25 $ 13 $ 22 $ 29 88 Tissue Exam by Pathologist 88305 8 $ 236 $ 307 $ 80 $ 152 $ 78 $ 232 $ 188 $ 179 $ 174 36 Medical Cardiology Cardiovascular Stress Test 93017 $ 383 $ 432 $ 1299 $ 907 $ 717 $ 797 $ 830 -54 TTE w Doppler 93306 2 $ 960 $ 1566 $ 1388 $ 1173 $ 1125 $ 1157 $ 1282 -25 Obstetrics Vaginal Delivery DRG 755 $ 7290 $ 5730 $ 4654 $ 4607 $ 5855 $ 4688 $ 5107 43 EampM Office Visit new pt 99203 4 $ 248 $ 118 $ 159 $ 139 78 Colonoscopy and biopsy (HOSPITAL ONLY) 45380 Surg 2530 $ 307591 Diagnostic colonoscopy (HOSPITAL ONLY) 45378 Surg 2255 $ 307591 Upper gi endoscopy biopsy (HOSPITAL ONLY) 43239 Surg 1787 $ 307591 Knee Arthroscopy (HOSPITAL ONLY) 29881 Surg 10900 $ 506893 Arthroscopy Ligament Repair (HOSPITAL ONLY) 29888 Surg 10900 $ 506200 Key 1 Facility - Inpatient 2 Facility - Imaging 3 Physician - Imaging 4 Physician 5 Global - Imaging 6 Facility - Outpatient 8 Lab 41 Physician - Primary Care 42 Physician - Specialist
Blue Cross United - EJCH EUH EUHM WW United - SJH Non Options United - SJH Options Aetna - ASC TEC (HMO) Cigna - ASC TEC (HMO) Aetna - EJCH ESJH ECHM WW Cigna - EJCH (HMO) Cigna - ESJH EUHM (HMO) List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract Description CPT Code Charge Average Final Price (all plans) Emory Mark Up Reimbursement Method ( of charge or fixed) - 1713 Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Cardiovascular stress test 93017 Cardio $543 $ 425 28 of Charge 70 $ 380 of Charge 65 $ 353 of Charge 60 $ 326 of Charge 70 $ 380 of Charge 70 $ 380 of charge 100 $ 543 of Charge 70 $ 380 of charge 100 $ 543 of charge 100 $ 543 TTE wDoppler complete 93306 Cardio $1226 $ 960 28 of Charge 70 $ 858 of Charge 65 $ 797 of Charge 60 $ 736 of Charge 70 $ 858 of Charge 70 $ 858 of charge 100 $ 1226 of Charge 70 $ 858 of charge 100 $ 1226 of charge 100 $ 1226 Colonoscopy and biopsy (HOSPITAL ONLY) 45380 Surg $2530 $ 3076 -18 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 of Charge 70 $ 1771 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Diagnostic colonoscopy (HOSPITAL ONLY) 45378 Surg $2255 $ 3076 -27 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 of Charge 70 $ 1579 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Upper gi endoscopy biopsy (HOSPITAL ONLY) 43239 Surg $1787 $ 3076 -42 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Knee Arthroscopy (HOSPITAL ONLY) 29881 Surg $10900 $ 5069 115 Fixed Rate SC 4 $ 3865 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 449300 $ 4493 Fixed Rate $ 654700 $ 6547 of Charge 70 $ 7630 Fixed Rate $ 401000 $ 4010 of Charge 70 $ 7630 Fixed Rate $ 398300 $ 3983 Fixed Rate $ 398100 $ 3981 Arthroscopy Ligament Repair (HOSPITAL ONLY) 29888 Surg $10900 $ 5062 115 Fixed Rate SC 3 $ 3121 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 556900 $ 5569 Fixed Rate $ 770100 $ 7701 of Charge 70 $ 7630 Fixed Rate $ 323900 $ 3239 of Charge 70 $ 7630 Fixed Rate $ 321700 $ 3217 Fixed Rate $ 321400 $ 3214 Comp Metabolic Panel 80053 Lab $132 $ 56 138 RBRVS Fee (100) $ 1437 of Charge 65 $ 86 of Charge 65 $ 86 of Charge 65 $ 86 of Charge 70 $ 92 RBRVS Fee (100) $ 1437 $ 14 of Charge 70 $ 92 RBRVS Fee (100) $ 1437 $ 14 RBRVS Fee (100) $ 1437 $ 14 Surgical Path Tissue Exam 88305 Lab $326 $ 236 38 of Charge 150 $ 51 of Charge 65 $ 212 of Charge 65 $ 212 of Charge 65 $ 212 of Charge 70 $ 228 of charge 100 $ 326 of Charge 70 $ 228 of charge 100 $ 326 of charge 100 $ 326 MRI Abdomen 74183 Radiology $6960 $ 1238 462 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 MRI Brain 70553 Radiology $6804 $ 1238 450 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 MRI Joint Lower Extremity 73721 Radiology $3067 $ 1238 148 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 CT Thorax wo contrast 71250 Radiology $2199 $ 882 149 Fixed Rate $ 771 Fixed Rate $ 47100 $ 471 Fixed Rate $ 81700 $ 817 Fixed Rate $ 116000 $ 1160 of Charge 70 $ 1539 Fixed Rate $ 80100 $ 801 Fixed Rate $ 79200 $ 792 Fixed Rate $ 79300 $ 793 Fixed Rate $ 79500 $ 795 X-ray Chest 71020 Radiology $280 $ 115 142 of Charge 150 $ 25 of Charge 65 $ 182 of Charge 60 $ 168 of Charge 70 $ 196 of Charge 70 $ 196 RBRVS Fee (150) $ 2534 $ 25 of Charge 70 $ 196 RBRVS Fee (150) $ 2534 $ 25 RBRVS Fee (150) $ 2534 $ 25 Screening mammography G0202 Radiology $279 $ 141 98 Fixed Rate $ 128 Fixed Rate $ 13100 $ 131 Fixed Rate $ 14300 $ 143 Fixed Rate $ 16100 $ 161 of Charge 70 $ 195 Fixed Rate $ 13300 $ 133 Fixed Rate $ 13500 $ 135 Fixed Rate $ 13000 $ 130 Fixed Rate $ 11200 $ 112 Mammo Computer Aided 77052 Radiology $75 $ 112 -33 Fixed Rate $ 9 Fixed Rate $ 13100 $ 131 Fixed Rate $ 14300 $ 143 Fixed Rate $ 16100 $ 161 of Charge 70 $ 53 Fixed Rate $ 13300 $ 133 Fixed Rate $ 13500 $ 135 Fixed Rate $ 13000 $ 130 Fixed Rate $ 11200 $ 112 US Abdomen Complete 76700 Radiology $917 $ 397 131 of Charge 150 $ 125 of Charge 65 $ 596 of Charge 60 $ 550 of Charge 70 $ 642 of Charge 70 $ 642 RBRVS Fee (150) $ 12519 $ 125 of Charge 70 $ 642 RBRVS Fee (150) $ 12519 $ 125 RBRVS Fee (150) $ 12519 $ 125 Officeoutpatient visit new pt 30 min (TEC) 99203 EampM $316 $ 248 28 of Charge 70 $ 221 of Charge 65 $ 205 of Charge 60 $ 190 of Charge 70 $ 221 of Charge 70 $ 221 of charge 100 $ 316 of Charge 70 $ 221 of charge 100 $ 316 of charge 100 $ 316 Vaginal delivery 59409 Surg $14484 $ 7290 99 Fixed Rate DRG - 775 $ 5437 2 Day Case Rate + LOC 561700 $ 5617 BaseCMS Weight 584741 $ 5847 BaseCMS Weight 726146 $ 7261 No IP Terms $ - 0 No IP BaseCMS Weight 659343 $ 6593 BaseContract Weight 479451 100 $ 14484 BaseCMS Weight 579110 $ 5791 Lap Sleeve Gastrectomy 43775 Surg $29961 $ 20421 47 Fixed Rate DRG - 621 $ 14872 BaseCMS Weight 1810697 $ 18107 BaseCMS Weight 1835178 $ 18352 BaseCMS Weight 2278911 $ 22789 No IP Terms $ - 0 No IP BaseCMS Weight 2069315 $ 20693 BaseCMS Weight 1730442 100 $ 29961 BaseCMS Weight 1817507 $ 18175 105 Colonoscopy and biopsy (ASC ONLY) Surg $ 219200 $ 2181 Diagnostic colonoscopy (ASC ONLY) Surg $ 267100 $ 2348 Upper gi endoscopy biopsy (ASC ONLY) Surg $ 207500 $ 2758 Knee Arthroscopy (ASC ONLY) Surg $ 417900 $ 3467 Arthroscopy Ligament Repair (ASC ONLY) Surg $ 504800 $ 3386
Cpt Code CPT Description Procedure Category Claims Min 25thNtile 50thNtile Emorys Rates 75thNtile 90thNtile Max 20 Below 50th Ntile 20 Above 50th Ntile 93017 CARDIOVASCULAR STRESS TEST 5 82 $80 $125 $321 $382 $568 $791 $930 $257 $386 71020 CHEST X-RAY 2 2638 $11 $45 $152 $115 $289 $373 $585 $122 $182 71020 CHEST X-RAY 5 8106 $25 $34 $38 $54 $57 $69 $30 $46 45380 COLONOSCOPY AND BIOPSY 6 1256 $541 $560 $572 $2877 $1000 $2024 $3289 $458 $686 77052 COMP SCREEN MAMMOGRAM ADD-ON 2 194 $13 $15 $25 $38 $47 $134 $20 $30 77052 COMP SCREEN MAMMOGRAM ADD-ON 5 2411 $13 $16 $20 $23 $26 $28 $16 $24 80053 COMPREHEN METABOLIC PANEL 8 13019 $9 $19 $23 $55 $24 $25 $69 $19 $28 71250 CT THORAX WO DYE 2 302 $165 $372 $545 $878 $1658 $2067 $436 $654 71250 CT THORAX WO DYE 5 209 $53 $127 $203 $289 $419 $534 $162 $244 45378 DIAGNOSTIC COLONOSCOPY 6 1479 $484 $515 $536 $2914 $831 $1971 $2828 $428 $643 29881 KNEE ARTHROSCOPYSURGERY 6 152 $1650 $1826 $2036 $5235 $3054 $4216 $6461 $1629 $2443 29888 KNEE ARTHROSCOPYSURGERY 6 82 $1682 $3615 $5081 $5145 $7553 $12924 $18532 $4065 $6097 43644 LAP GASTRIC BYPASSROUX-EN-Y 1 21 $11821 $13873 $17050 $18391 $25029 $31079 $13640 $20460 43775 LAP SLEEVE GASTRECTOMY 1 38 $4215 $8250 $13253 $20421 $19197 $21509 $24260 $10602 $15903 74183 MRI ABDOMEN WO amp WDYE 2 120 $919 $987 $1015 $1237 $1252 $2534 $3177 $812 $1218 74183 MRI ABDOMEN WO amp WDYE 5 112 $475 $490 $521 $1154 $1337 $1696 $417 $625 70553 MRI BRAIN WO amp WDYE 2 324 $633 $987 $1142 $1237 $1706 $2805 $3331 $914 $1370 70553 MRI BRAIN WO amp WDYE 5 467 $280 $539 $1023 $1277 $1363 $1726 $818 $1228 73721 MRI JNT OF LWR EXTRE WO DYE 2 304 $804 $859 $967 $1237 $1063 $1598 $2485 $774 $1160 73721 MRI JNT OF LWR EXTRE WO DYE 5 1130 $500 $520 $530 $628 $679 $859 $424 $636 59400 OBSTETRICAL CARE 1 494 $3699 $4402 $4969 $6655 $7307 $8613 $3975 $5963 99203 OFFICEOUTPATIENT VISIT NEW 4 6776 $88 $101 $112 $138 $155 $169 $90 $134 G0202 Screeningmammographydigital 2 7444 $123 $206 $285 $380 $425 $479 $228 $342 G0202 Screeningmammographydigital 5 2754 $117 $165 $195 $230 $247 $252 $156 $234 88305 TISSUE EXAM BY PATHOLOGIST 8 20834 $51 $74 $112 $235 $168 $261 $478 $90 $134 93306 TTE WDOPPLER COMPLETE 2 931 $194 $377 $739 $960 $1267 $1480 $1849 $591 $887 93306 TTE WDOPPLER COMPLETE 5 2299 $151 $296 $373 $538 $573 $834 $298 $448 43239 UPPER GI ENDOSCOPY BIOPSY 6 1264 $424 $514 $550 $800 $1838 $2833 $440 $660 76700 US EXAM ABDOM COMPLETE 2 321 $96 $165 $271 $509 $584 $857 $217 $325 76700 US EXAM ABDOM COMPLETE 5 444 $111 $129 $147 $156 $220 $279 $118 $176 Key 1 Facility - Inpatient 2 Facility - Imaging 3 Physician - Imaging 4 Physician 5 Global - Imaging 6 Facility - Outpatient 8 Lab 41 Physician - Primary Care 42 Physician - Specialist Cardiovascular stress test $ 38279 TTE wDoppler complete $ 96037 Colonoscopy and biopsy $ 287709 Diagnostic colonoscopy $ 291434 Upper gi endoscopy biopsy $ 300526 Knee Arthroscopy $ 523584 Arthroscopy Ligament Repair $ 514501 Comp Metabolic Panel $ 5552 Surgical Path Tissue Exam $ 23570 MRI Abdomen $ 123786 MRI Brain $ 123786 MRI Joint Lower Extremity $ 123786 CT Thorax wo contrast $ 88213 X-ray Chest $ 11548 Screening mammography $ 14098 Mammo Computer Aided $ 11179 US Abdomen Complete $ 39695 Officeoutpatient visit new pt 30 min $ 24753 Vaginal delivery $ 729025 Lap Sleeve Gastrectomy $ 2042124
Page 7
6
Stakeholder Landscape
Source Re-Igniting the Growth Engine Part 2 Winning Increased Share of Lucrative Patient Volumes Advisory Board
68 68 55 55
42 49
40 44 40 47 50
80 80 80
68 60 60 50
60 50
53 55
0
5
10
Health care trend after plan changes (total plan costs)
Health care trend before plan changes
Consumer Price Index for all urban consumers (CPI-U)Source Willis Towers Watson 23rd Annual Best Practices in Health Care Employer Survey
Hos
pita
ls Are experiencing a compression of margins due to lower revenue and higher expense trends
Seek improvement in market share and improved margins Em
ploy
ers Face unstainable year over year healthcare costs To
mitigate costs they are forced to implement annual benefit plan changes
Seek lower more predictable medical expenses and healthy productive employees
Direct Contacting Arrangement Types
7
Bundled Payments prospective payment which covers patientrsquos care from start to finish
Reference Based Pricing (RBP) plan pays up to fixed amount for procedure any excess is billed to member
bull PCP-centric bull Level of provider risk can vary from partial to full bull May be offered with other options or full replacement if adequate network
bull Promotes shopping for services via price transparency bull Most common for elective procedures ndash joint surgeries spine gastric bypass
bull Appropriate for high volume procedures bull Medical expense more predictable for these services may not be fixed price bull May result in lower provider revenue than FFS providers seek steerage volume
Center of Excellence (COE) designated provider identified for specific procedures that may require travel
bull Appropriate for high volume procedures bull Specialization amp operational efficiencies reduce utilization variations improves patient
experience amp improves outcomes (eg lower LOS return to work time) bull Members out-of-pocket often low to $0 including travelhotel not always lowest ldquopricerdquo
Accountable Care Organization (ACO) provider reimbursements are directly tied to quality and financial outcomes
Mos
t Com
mon
Ar
rang
emen
ts
On-site health education seminars
Wellness services
On-site clinic
Bundled payments
Employer liaison coordinator
On-site coaching Andor counseling
Care pathways
Direct contracting narrow networks
Source Re-Igniting the Growth Engine Part 2 Winning Increased Share of Lucrative Patient Volumes Advisory Board
Boeing 1UW Med 2Memorial Care 3Mercy MO 4Roper St Francis 5ProvSwedish
DART amp Baylor Scott and White Health
Intel amp 1 Presbyterian ACO 2 Arizona Care Network
Quallcom amp Scripps Health
Stanford Healthcare Alliance
General Motors amp Henry Ford Health
Disney amp 1Orlando Health 2Florida Hospital
Walmart amp 1 Banner 2 Emory 3 Memorial Hermann 4 Mercy AK 5Mercy OK 6 Mercy MO 7Oschner Health 8 Presbyterian 9 St Lukersquos 10 Unity Point 11 Cleveland Clinic 12 Geisinger Health 13Johns Hopkins 14Mayo Clinic AZ 15Mayo Clinic FL 16Mayo MN 17Mercy MO
1 2
3
4 5
6
8
7
9
10
1
3
4 2
1
2
1
Whole Foods amp Adventis Health
11 12 13
14
15
16
17
Emergence of Direct Contracting
8
DC with providers to secure improved pricing
COE through a carve-out provider
COE within the health plans
Source Willis Towers Watson 23rd Annual Best Practices in Health Care Employer Survey Full report and high-performance insights httpswwwwillistowerswatsoncom-mediaWTWPDFInsights201812willis-towers-watson-23rd-annual-best-practices-in-health-care-employer-survey-full-reportpdf 2018
Trends in Direct Contracting amp COE
According to Willis Towers Watsonrsquos survey employers are using COEs mostly through their health plans however direct contracting considerations are expected to grow considerably
6
7
48
2
2
7
14
13
20
0 20 40 60 80
Action taken or tactic used in 2018
Planning for 2019
Considering for 2020
bull Almost 50 use COEs in 18rsquo expected to rise to 2 out of 3 by 2020
bull Employers engaging employees in multiple ways to use COE bull Ongoing communications bull Reducing member cost share
to use bull Increasing member cost
share when not using bull Mandatory use
9
16
12
18
9
3
6
2
50
39
19
22
26
11
10
15
19
31
30
31
22
11
Transplants
Bariatric Surgery
Knees hips or spine
Cardiovascularcardiac
Cancer
Fertility
Other Procedures
Yes with incentives Yes but no incentives No but considering
10
A 2015 survey by the National Business Group on Health shows the status of large employersrsquo contracts with COEs (note reflects all COEs not specifically direct contracts)
Source Large Employersrsquo 2016 Health Plan Design Survey copy 2015 National Business Group on Health
Other centers of excellence programs include maternity NICU sleep apnea pancreas cornea and kidney
National Business Group on Healthrsquos Large Employers 2019 Health Care Strategy and Plan Design Survey showed DC arrangements between employers and bull Health systemsproviders will
increase from 3 in 2018 to 11 in 20191
bull COEs will increase from 12 in 2018 to 18 in 20191
bull Cancer cardiovascular and fertility COEs are experiencing the greatest growth
Source National Business Group on Health ldquoLarge US Employers Eye Changes to Health Care Delivery System as Cost to Provide Health Benefits Nears $15000 per Employeerdquo August 2018
10
Trends in Direct Contracting amp COE
Outcomes amp Benefits bull Employers with COE arrangements are seeing reduction in procedures
bull Walmart (15rsquo-18rsquo) 50+ of spine surgeries amp 20 of kneehip procedures recommended by local providers were determined lsquonot necessaryrsquo by COE (see table)
bull Employers like Walmart amp Boeing continue to sign new providers which suggest (employersrsquo) continued interest in pursuing DC arrangements2 However Boeing and Providence Swedish did end relationship due to inability to capture enoughright data to estimate cost of care3
bull John Hopkinsrsquo Bayview campus COE emerging metrics4
bull 121 referrals in the first three months
bull 352 referrals and 183 surgeries over 18 months
bull 23 of all joint replacement volumes at facility now attributed to travel program
bull 96 of patients said they would recommend this program to family friends coworkers
bull Bingham Memorial in Idaho direct contracting emerging metrics4
bull 17 companies participating covering over 5000 lives
bull +3000 new patients as of October 2018
bull +$3M Revenue from new patients
11
1 How Employers Are Fixing Health Care Harvard Business Review March 2019 2 httpswwwhealthleadersmediacomstrategywalmart-escalates-strategy-solve-employee-healthcare Health Leaders Media Nov 18rsquo 3 Do Providers Have the Data chops to Success with Direct Contract Modern Healthcare August 2018 4 Re-Igniting the Growth Engine Part 2 Winning Increased Share of Lucrative Patient Volumes Advisory Board 5 httpswwwautonewscomarticle20180806OEM180809831gm-signs-major-health-care-services-deal-for-salaried-employees
Walmart COE Programs1
Program Key Benefits
Spin
e Su
rger
y 2300 EEs 50 COE approved of those applied
bull 95 lower readmission bull 14 less time in hospital bull 1 COE vs 5 non-COE patients discharged to SNF bull Returned to work sooner reducing 20 of OOO
time bull More-effective less dangerous amp less expensive bull The COE surgery ldquopricerdquo is 8 higher but value in
earlier discharge lower readmission rates far less utilization of SNF faster return to work
Join
t
1836 EEs 18 COE approved of those applied
bull 32 less time in hospital bull 70 less likely to be readmitted than non-COE
patients bull Fewer postsurgical complications bull 0 COE vs 5 non-COE patients discharged to SNF bull COE patients returned to work a 15 weeks sooner bull Cost of surgery is 15 less at COE hospitals
Baria
tric
300+ EEs
bull Preliminary data suggests the weight loss from surgery reduces absenteeism or presentism (working while sick)
bull Dramatically cuts pharmacy amp medical costs Complications of obesity drop sharply as does the need for medication
bull GMrsquos direct contract benefit plans with Henry Ford allows it to offer similarly designed plans to that of Blue Cross with savings in monthly EE contributions ranging from $300-$19805
Walmartrsquos Travel (Surgery) Program
Mem
ber F
eedb
ack
12
Looking beyond traditional cost management techniques Walmart designed a program to address wild variations in cost and become directly in improving quality of care for its employees FIRST SELECTING PROVIDERS 1 Identify providers with high volume and high quality 2 Target regions in country to support Walmartrsquos employees 3Focus on Integrated Health Systems Hospitals within these systems were best aligned to Walmarts mission could take on risks associated with bundling 4 Eliminate systems unwilling to do bundled payments model were
PROVIDERS VALUE IN PARICIPATING
Build Bundles bull Define bundles and negotiate price (typically 10-15 below FFS ) bull Definitions of service limit disputes of what is covered vs not (covers
entryexit of facility SNF not part of bundle) bull Contract flexibility covers unforeseen testcosts and reinforces
Walmarthealth system partnership bull Warrantees if further treatment - can return in 30 days no
additional cost to Walmart bull Strict criteria and providers with track record of clinically sound
decisions are included to mitigate any incentivizing of volume Business bull 100 travelaccom brings
new volume of patients from outside of market
bull More stable payments for services (vs Medicare or commercial FFS)
bull Increased visibility and attract new business
Clinical bull lsquoHalorsquo effect ndash Building a highly
efficient multidiscipline program brings improvements throughout health system
bull Onsite collaboration among health systems allows sharing of outcomesbest practices
Source How Employers Are Fixing Health Care Harvard Business Review March 2019
5000 participants in the program
95 satisfiedvery satisfied
Denied by care because not deemed necessary by COE Treatment denied due to lifestyle weightsmoking
The Member Experience
13
Engagement begins when employee on clear
path to surgery
Patient contacts with COE TPA
TPA team triages and ensures basic criteria
met
Employee put in touch with nurse team
Car pick-up Flight Hotel all arranged by
TPA
Navigators and nurse coordinators help
throughout the stay
Patient visits to hospital to understand
exceptions of procedure and meet treatment
team
Surgery occurs typically next day
Stay length according to procedure typically a
few days
Discharged from facility Travel home COE team updates local
PCP and discuss follow up care
COE provider checks in with local physician
frequently Revert back to standard coverage
Source How Employers Are Fixing Health Care Harvard Business Review March 2019
Case Study 1
Case study 1 ndash Pop Health Approach bull ProblemCircumstance Large multi-employer group needs to
evaluate benefit design disease prevalence health spend and utilization to manage their population
bull ConsiderationsValue Prop Unique industry and geography drive chronic conditions and utilization patterns
bull Solution Provide opportunity assessment comparing this population to other benchmarks to understand where to target intervention and management as well as assess efforts already taken
15
Market Comparison Preference Sensitive Procedures
16
Legend vs
Mt States vs
National gt120 gt110
110-120 105-110 lt80 lt90
Source Multi-payer commercial benchmark Results are weighted by AgeGender Broader market area includes multi-payer data from the mountain regions
Preference Sensitive Procedures Benchmark Comparison
Dartmouth Atlas Preference Sensitive Procedures
IP allowed dollars ALOS Employer vs
Mt States Employer
vs National FY 2017 FY 2018 FY 2017 FY 2018
Hysterectomy for Uterine Fibroids Rate $569354 $436932 45 54 124 140 CABG Rate $1800260 $2400608 53 60 218 130 Cholycystectomy Rate $832675 $755565 68 39 92 120 C-Section Rate 116 110 HighTech Radiology Rate 103 101 PCIPTCA Rate $934486 $1133708 37 55 82 80 Back Surgery Rate $3237613 $4003212 39 57 52 70 Knee Replacement Rate $3086693 $2177334 41 48 50 64 Total Hip Replacement Rate $1023675 $747491 45 64 37 34
Strengths (+)
Employer compares favorably for orthopedic procedures (back hip knee)
Opportunity (-)
Employer has higher than expected rates for CABG and hysterectomy (Note Low PTCA rate combined with high CABG rate may suggest provider practice patterns favoring CABG)
0 50 100 150 200 250
Total Hip Replacement
Knee Replacement
Back Surgery
PCIPTCA
Cholycystectomy
HighTech Radiology
C-Section
CABG
Culinary VsNational
Culinary Vs MtStates
Employer vs Mt States
Employer vs National
Market Comparison Condition Prevalence
17 Source Multi-payer commercial benchmark Results are weighted by AgeGender Broader market area includes multi-payer data from the mountain regions
Condition Prevalence Benchmark Comparison
Condition Employer vs
Mt States Employer vs
National Prevalence Diabetes Rate 229 219 Prevalence Hyperlipidemia Rate 259 207 Prevalence Kidney Disease Rate 143 174 Prevalence Migraine Rate 166 164 Prevalence Low Back Pain Rate 136 139 Prevalence Hypertension Rate 156 134 Prevalence Asthma Rate 146 128 Prevalence CAD Rate 175 115 Prevalence Pregnancy Rate 110 109 Prevalence Adult Preventive Screening Rate 114 91 Prevalence Depression Rate 63 60
Strengths (+)
Rate of depression is low (Note May be due to incomplete behavioral health claims)
Opportunity (-)
Employer has a higher prevalence of most chronic conditions including asthma CAD diabetes hypertension hyperlipidemia Kidney Disease LBP and migraines
0
100
200
300Hyperlipidemia
Diabetes
CAD
Migraine
Hypertension
AsthmaKidney Disease
Low Back Pain
Pregnancy
Depression
Employer vsMt States
Employer vsNational Legend
vs Mt States
vs National
gt120 gt110 110-120 105-110
lt80 lt90
Market Comparison Utilization Rates
18
A higher preventive office visit rate is better Source Multi-payer commercial benchmark Results are weighted by AgeGender Broader market area includes multi-payer data from the mountain regions
Strengths (+)
Lower than average utilization of ED and high dollar patient rate
Opportunity (-)
Higher LOS lengthy admits avoidable admits and readmissions which all drive significantly more spend
Utilization Benchmark Comparison
Condition Employer vs
Mt States Employer vs
National Avoidable Admit Rate 142 144 Lengthy Admit Rate 175 136 Outpatient Problem Focused Office Rate 146 131 Readmission Rate (readmitadmit) 135 126 Average LOS 125 116 One Day Admit Rate 76 103 Office Visit Rate 106 96 Acute Admit Rate 80 95 Avoidable ED Rate 68 86 ED Rate 54 69 Preventive Office Rate 95 68 High Dollar Patient Rate 49 51 Frequent ED User (gt3 times) Rate 24 36
Legend vs
Mt States vs
National gt120 gt110
110-120 105-110 lt80 lt90
0 50 100 150 200
Frequent ED User (gt3 times)
High Dollar Patient
Preventive Office
ED
Avoidable ED
Acute Admit
Office Visit
One Day Admit
Average LOS
Readmissionhellip
Outpt Problem Focusedhellip
Lengthy Admit
Avoidable Admit
Employer vsNational
Employer vsMt States
ED and Avoidable ED
19
Potentially Avoidable ED - Trend View Overall ED
Period Change FY 2017 FY 2018 Count Rate
Measure Mbrs Rate Mbrs Rate Overall ED 16394 12626 13820 10745 -16 -15 FREQUENT ED UTILIZER (mbr1k) 1581 1218 1468 1141 -7 -6 AVOIDABLE ED 6371 4907 5288 4111 -17 -16 Potentially Avoidable ED
Period Change FY 2017 FY 2018 Count Rate
Avoid ED Condition Mbrs Rate Mbrs Rate ABDOMINAL_PAIN 1092 841 895 696 -18 -17 ENT_INFECTION 854 658 742 577 -13 -12 FEVER 715 551 700 544 -2 -1 URINARY 650 501 468 364 -28 -27 HEADACHE 558 430 434 337 -22 -21 BACK_PAIN 414 319 423 329 2 3 NAUSEA 394 303 271 211 -31 -31 ASTHMA 294 226 209 162 -29 -28 CELLULITIS 210 162 198 154 -6 -5 GASTROENTERITIS 254 196 171 133 -33 -32 OTITIS_MEDIA 201 155 160 124 -20 -20 COPD 132 102 108 084 -18 -17 DIABETES 123 095 91 071 -26 -25 BACT_PNEUMONIA 111 085 86 067 -23 -22 DENTAL 93 072 83 065 -11 -10 DEHYDRATION 98 075 81 063 -17 -17 HYPERTENSION 16 012 24 019 50 51 CHF 4 003 3 002 -25 -24 ANGINA 8 006 3 002 -63 -62 IMMUNIZATION_RELATED 2 002 0 000 -100 -100 Grand Total 6371 4907 5288 4111 -17 -16
AHRQ avoidable ED visits are based on the logic for ambulatory care sensitive ED visits from AHRQ and diagnosis code driven
696
577
544 364
337
329
211 162
154 133 ABDOMINAL_PAIN
ENT_INFECTION
FEVER
URINARY
HEADACHE
BACK_PAIN
NAUSEA
- 200 400 600 800
1000 1200
2017 Members 2018 Members
Top Ten 2018 Conditions by Rate
Top Ten Conditions by Member Count
ED Avoidable ED and the impact of new on-site clinic
20
0
1000
2000
3000
4000
5000
6000
0200400600800
10001200140016001800
Clinic Visits ED Visits
Avoidable ED VisitsED Visits (non-avoidable)Clinic EampM Visits
0
500000
1000000
1500000
2000000
2500000
3000000
3500000
$s
Clinic EampM Profess DollarsAvoidable ED Dollars
bull Clinic visits have a clear impact on ED and avoidable ED use and spend
bull Combined ED visits are down on average 157 in FY 18 from FY 17
bull Combined ED spend is down 128 in FY 18 from FY 17
Clinic Live 62017
Pitfalls and Challenges bull Face many of the challenges similar to startup health
plan bull Critical to determine how you will deliver value and
communicate the value to potential customers and brokersconsultants
bull Care management bull Network
21
Considerations in Offering Development bull Care Management Model
bull Traditional care model bull Case management bull Utilization management bull Disease management
bull Longitudinal care model with value based care philosophy bull Primary care driven bull Local care management
bull Predictive analytics and risk stratification model bull Claims history and ongoing data bull EMR data
22
Case Study 2
Case study 2 ndash Large Employer bull Business Problem Large employer wants to contract
directly with 2 major hospital systems developing professional fee schedules
bull ConsiderationsValue Prop Fee schedule should be competitive but also nuanced to minimize gap relative to current reimbursement at physician level
bull Solution Data-driven approach using current market-wide reimbursement distinguished by service level
24
Evaluate Provider Spend Top 25 Service Lines by Allowable Spend
Evaluate Provider Spend Top 20 Professional CPTs by Total Spend
Understand relative market pricing position
27
21
-1
-28
14 10
28
-22
-11 -13
24
3
20 21
8
-20
13
3 9
-39
56
-26
4
-42
60
MRI Colonoscopy Cardiac Cath Lab - OrganPanel
Memorial Hospital Beta Hospital Delta Hospital Charlie Hospital Echo Hospital Alpha Medical Center
ndash25 5 -15 10 0 39
State Charges as a Percent of Peer Average Weighted Averages for MRI Colonoscopy Cardiology and Lab
Total Percent Above Below Market Average2
Memorial Hospital Beta Hospital Delta Hospital Charlie Hospital Echo Hospital Alpha Medical Center
Develop fee schedule relative to market
28
Service Line Procedure CPT CodeDRG
Memorial Hospital
Beta Hosptial
Charlie Hospital
Delta Hospital
Echo Hospital
Alpha Medical Center
Arthroscopy Ligament Repair 29888 $ 5062 $ 9557 $ 5983 $ 10096 $ 7519 $ 2502 Knee Arthroscopy 29881 $ 5069 $ 4185 $ 3837 $ 3022 $ 3729 $ 2266 Upper GI Endoscopy 43239 $ 3075 $ 2539 $ 2012 $ 1132 $ 1565 $ 2240 Lap Sleeve Gastrectomy DRG 621 $ 20421 $ 20815 $ 12105 $ 13230 $ 14600 $ 17800 Colonoscopy and biopsy 45380 $ 3075 $ 3071 $ 2013 $ 1244 $ 1972 $ 859 Diagnostic Colonoscopy 45378 $ 3075 $ 2805 $ 2013 $ 1244 $ 1972 $ 859 MRI Brain w amp wo dye 70553 $ 1238 $ 1468 $ 1117 $ 967 $ 2805 $ 1052 MRI Joint of Lower Extremity wo dye 73721 $ 1238 $ 1398 $ 1042 $ 967 $ 925 $ 557 MRI Abdomen w amp wo dye 74183 $ 1238 $ 1468 $ 1106 $ 967 $ 2805 $ 836 X-ray Chest 71020 $ 115 $ 266 $ 305 $ 279 $ 375 $ 72 CT Thorax wo dye 71250 $ 882 $ 810 $ 505 $ 491 $ 579 $ 319 Ultrasound Abdomen Complete 76700 $ 397 $ 538 $ 545 $ 195 $ 190 $ 168 Mammogram Screening G0202 $ 141 $ 328 $ 431 $ 294 $ 425 $ 168 Computer Detection Add-on 77052 $ 112 $ 99 $ 41 $ 15 $ 45 $ 23 Comp Metabolic Panel 80053 $ 56 $ 15 $ 24 $ 56 $ 51 $ 25 Tissue Exam by Pathologist 88305 $ 236 $ 307 $ 80 $ 152 $ 78 $ 232 Cardiovascular Stress Test 93017 $ 383 $ 432 $ 1299 $ 907 $ 717 $ 797 TTE w Doppler 93306 $ 960 $ 1566 $ 1388 $ 1173 $ 1125 $ 1157
Obstetrics Vaginal Delivery DRG 755 7290$ 5730$ 4654$ 4607$ 5855$ 4688$
GI
Lab
Radiology
Medical Cardiology
Orthopedics
KEY OBSERVA TIONS bull Potential exposure on GI bull Opportunity to align price and acuity in MRI bull Opportunity to raise rates on chest x-ray and mammogram
Percentile Bands Emory Allowables Heatmap TEC ASC Heatmap Allowable Comp Analysis Portal Pricing Sheet1 image1png A few words on Bundled Payments bull Bundled payments are growing as a type of direct contracting bull In some cases third parties match-make between employers
and providers bull Contracts may vary in definitions prepost admission
coverage duration readmission cause (ie all-cause vs medically related) outlier provisions LOS caps andor per diems
bull Providers need to be strategic in pricing to enable profitable growth of market share
29
Considerations in Offering Development bull Network Development
bull Build off existing structure eg health system employee plan network bull How does this fit into your broader value based care strategy bull Employed and independent physicians bull How do you want to approach the buildout of high performance
network bull Quality focus bull Cost efficiency
bull Integrated behavioral health bull Wrap network for other markets
30
Considerations in Offering Development bull Target Market
bull Consideration of employer profile in market bull Fully-insured vs ASO bull Total cost of care vs bundled services
bull Distribution bull Direct marketing bull Brokerconsultant community
bull Plan designs bull Standard designs vs flexible ndash Dependent on target market
bull Claims administration bull Data sharing amp analytics
31
Considerations in Offering Development bull Other components of comprehensive offering
bull Pharmacy bull Preventive health bull Onsite clinics bull Wellness programs bull Technology platform
32
Sample Bundle Analysis
33
Cover page Dotson Hazelrigs Nation Mainly of charge of fixed Cardiovascular stress test TTE wDoppler complete Colonoscopy and biopsy (Combined) Diagnostic colonoscopy (Combined) Upper gi endoscopy biopsy (Combined) Knee Arthroscopy (Combined) Arthroscopy Ligament Repair Comp Metabolic Panel Surgical Path Tissue Exam MRI Abdomen MRI Brain MRI Joint Lower Extremity CT Thorax wo contrast X-ray Chest Screening mammography Mammo Computer Aided US Abdomen Complete Officeoutpatient visit new pt 30 min Vaginal delivery Lap Sleeve Gastrectomy
Piedmont Piedmont Piedmont Piedmont Northside Northside Northside Northside Gwinnett Gwinnett Gwinnett Gwinnett WellStar WellStar WellStar WellStar AMC - Tenet AMC - Tenet AMC - Tenet AMC - Tenet CPT Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing 29881 $11312 $10872 NA NA $7476 $9338 NA $23655 $11856 $3668 NA $17871 $12253 NA NA $15645 $5490 NA NA $23039 29888 NA NA NA NA NA NA NA $23784 NA $8261 NA $18000 NA NA NA $15774 NA NA NA $23168 43239 NA $4408 NA NA NA NA $5997 $8852 NA $3304 NA $7424 $1267 NA NA $9230 NA $2458 NA $8274 43644 $26468 NA NA NA $3382 $12050 NA $1861 NA NA NA $1316 $7841 NA NA $3444 $18892 $27950 NA $979 43775 NA NA NA NA NA NA NA $352 NA NA NA $302 NA NA NA $413 NA NA NA $83 45378 $2705 $2530 NA NA $4381 $3676 $4496 $1022 $2938 $2138 NA $695 $5504 NA NA $2036 NA NA NA $372 45380 $3075 $2600 NA NA $4723 $3527 $3012 $1757 $4215 $2285 NA NA $5298 NA NA $3268 NA NA NA $627 59400 $6160 NA NA NA NA $5100 NA $1851 NA NA NA $1304 $9035 NA NA $3427 $9116 $5150 NA $966 70553 $2985 NA $1153 NA $2182 NA $1192 $492 NA NA $803 $489 $1512 NA $985 $1187 NA NA NA $197 71020 $61 $69 $43 NA $113 $319 $307 NA $183 $59 $32 NA $213 $66 $40 NA $83 $53 NA NA 71250 $1837 $621 $989 NA $1490 $931 $755 NA NA $745 $401 NA $1067 $982 $616 NA NA $304 NA NA 73721 NA $1098 $1153 NA $2042 $1065 $1192 NA NA $998 $803 NA NA $1275 $985 NA NA $644 NA $178 74183 $2971 $1144 NA NA NA $1092 $1192 $6884 NA $1098 $803 NA $2960 $1197 $985 $5454 NA NA NA $7607 76700 $364 $247 $207 NA $427 $708 $614 $13267 $428 $214 $152 NA $747 $263 $189 $9139 NA $235 NA NA 77052 NA NA NA NA NA NA NA $4744 NA NA NA NA NA NA NA $3070 NA NA NA $5611 93306 $1220 $1117 NA NA $1877 $1657 $2100 $4605 $1433 $413 $945 NA $1336 $1434 $1951 $2931 NA $2399 NA $5472 G0202 $262 $187 NA NA $431 NA NA $4605 $292 NA NA NA $530 $281 NA $2931 $327 NA NA $5472
Provider Group 29881_6 29888_6 43239_6 43644_1 43775_1 45378_6 45380_6 59400_1 70553_2 71020_2 71250_2 73721_2 74183_2 76700_2 77052_2 77052_5 80053_8 88305_8 93306_2 99203_4 G0202_2 G0202_5 93017_2 Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Atlanta Gastroenterology Associates $2399 $536 348 $1628 $536 204 $2400 $536 348 Atlanta Medical Center $24889 $2266 999 $25897 $2502 935 $11449 $2240 411 $81927 $15300 435 $75815 $17800 326 $7317 $859 752 $7317 $859 752 $12821 $4688 173 $6581 $1052 526 $645 $72 796 $3265 $319 925 $3450 $557 519 $7398 $836 785 $1576 $133 1084 $73 $23 217 $635 $25 2440 $891 $232 285 $2967 $1157 156 $344 $168 105 $1265 $797 59 Atlanta Womens Health Physicians Group $29 $14 107 $40 $13 208 $396 $188 111 $278 $118 135 $450 $231 95 Gwinnett Hospital $11941 $3022 295 $21654 $10096 114 $3551 $1132 214 $34384 $10800 218 $56472 $13230 327 $3003 $1244 141 $3533 $1244 184 $8984 $4607 95 $3901 $967 303 $417 $279 49 $2247 $491 358 $4000 $967 314 $3755 $967 288 $1593 $195 717 $50 $15 233 $186 $56 233 $505 $152 233 $1750 $1173 49 $418 $294 42 $1396 $907 54 Northside Hospital $15482 $4185 270 $21651 $9557 127 $4885 $2539 92 $35176 $17000 107 $35233 $20815 69 $3883 $2805 38 $5256 $3071 71 $10911 $5730 90 $4856 $1468 231 $443 $266 67 $2379 $810 194 $3776 $1398 170 $5105 $1468 248 $942 $538 75 $167 $99 69 $379 $15 2427 $433 $307 41 $2252 $1566 44 $459 $328 40 $576 $432 33 Piedmont Hospital $14772 $3837 285 $35493 $5983 493 $5069 $2012 152 $38320 $17750 116 $37125 $12105 207 $3485 $2013 73 $4993 $2013 148 $10143 $4654 118 $5939 $1117 432 $542 $305 78 $2983 $505 491 $3410 $1042 227 $6067 $1106 449 $1364 $545 150 $75 $41 85 $231 $24 863 $657 $80 721 $2041 $1388 47 $490 $431 14 $1780 $1299 37 Piedmont Physicians Group $42 $22 87 $318 $179 78 $239 $159 50 Resurgens $8558 $2036 320 $9293 $2258 312 $4638 $2067 124 $4039 $2164 87 $4392 $2164 103 $2252 $1371 64 $459 $330 39 Wellstar Hospital $9330 $3729 150 $17479 $7519 132 $5261 $1565 236 $35794 $18200 97 $46780 $14600 220 $3707 $1972 88 $4928 $1972 150 $13549 $5855 131 $5054 $2805 80 $528 $375 41 $3222 $579 457 $3694 $925 299 $5495 $2805 96 $1355 $190 615 $66 $45 46 $73 $51 43 $133 $78 71 $1785 $1125 59 $599 $425 41 $1010 $717 41 Avg Mark UpProcedure Atlanta Medical Center 634 Gwinnett Hospital 223 Northside Hospital 233 Piedmont Hospital 259 Wellstar Hospital 155 Emory 105
Atlanta Gastroenterology Associates Atlanta Medical Center Atlanta Womens Health Gwinnett Hospital Northside Hospital Piedmont Hospital Piedmont Physicians Group Resurgens Wellstar Hospital CPT Code CPT Proc Cat Comp Avg Allow Allow Allow Allow Allow Allow Allow Allow Allow 29881 KNEE ARTHROSCOPYSURGERY 6 $3179 $2266 $3022 $4185 $3837 $2036 $3729 29888 KNEE ARTHROSCOPYSURGERY 6 $6319 $2502 $10096 $9557 $5983 $2258 $7519 43239 UPPER GI ENDOSCOPY BIOPSY 6 $1727 $536 $2240 $1132 $2539 $2012 $2067 $1565 43644 LAP GASTRIC BYPASSROUX-EN-Y 1 $15810 $15300 $10800 $17000 $17750 $18200 43775 LAP SLEEVE GASTRECTOMY 1 $17800 $13230 $20815 $12105 $14600 45378 DIAGNOSTIC COLONOSCOPY 6 $1656 $536 $859 $1244 $2805 $2013 $2164 $1972 45380 COLONOSCOPY AND BIOPSY 6 $1694 $536 $859 $1244 $3071 $2013 $2164 $1972 59400 OBSTETRICAL CARE 1 $5107 $4688 $4607 $5730 $4654 $5855 70553 MRI BRAIN WO amp WDYE 2 $1482 $1052 $967 $1468 $1117 $2805 71020 CHEST X-RAY 2 $259 $72 $279 $266 $305 $375 71250 CT THORAX WO DYE 2 $541 $319 $491 $810 $505 $579 73721 MRI JNT OF LWR EXTRE WO DYE 2 $978 $557 $967 $1398 $1042 $925 74183 MRI ABDOMEN WO amp WDYE 2 $1436 $836 $967 $1468 $1106 $2805 76700 US EXAM ABDOM COMPLETE 2 $320 $133 $195 $538 $545 $190 77052 COMP SCREEN MAMMOGRAM ADD-ON 2 $45 $23 $15 $99 $41 $45 77052 COMP SCREEN MAMMOGRAM ADD-ON 5 $14 $14 80053 COMPREHEN METABOLIC PANEL 8 $29 $25 $13 $56 $15 $24 $22 $51 88305 TISSUE EXAM BY PATHOLOGIST 8 $174 $232 $188 $152 $307 $80 $179 $78 93306 TTE WDOPPLER COMPLETE 2 $1297 $1157 $1173 $1566 $1388 $1371 $1125 93017 STRESS TEST 5 $830 $797 $907 $432 $1299 $717 99203 OFFICEOUTPATIENT VISIT NEW 4 $139 $118 $159 G0202 Screeningmammographydigital 2 $329 $168 $294 $328 $431 $330 $425 G0202 Screeningmammographydigital 5 $231 $231
Service Line Procedure CPT Code Emory Atlanta Gastroenterology Associates Resurgens Atlanta Womens Health Piedmont Physicians Group Orthopedics (ASC) Knee Arthroscopy 29881 $3467 $2036 Arthroscopy Ligament Repair 29888 $3386 $2258 GI (ASC) Upper GI Endoscopy 43239 $2758 $536 Diagnostic Colonoscopy 45378 $2348 $536 Colonoscopy and biopsy 45380 $2181 $536 Radiology Mammogram Screening G0202 $164 $231 Computer Detection Add-on 77052 $93 $14 Lab Comp Metabolic Panel 80053 $53 $13 $22 Tissue Exam by Pathologist 88305 $277 $188 $179 EampM (TEC) Office Visit new pt 99203 $269 $118 $159
Service Line Procedure CPT CodeDRG Memorial Hospital Beta Hosptial Charlie Hospital Delta Hospital Echo Hospital Alpha Medical Center Atlanta Gastroenterology Associates Resurgens Atlanta Womens Health Piedmont Physicians Group Market Avg Emory abovebelow Orthopedics Arthroscopy Ligament Repair 29888 $ 5062 $ 9557 $ 5983 $ 10096 $ 7519 $ 2502 $ 2258 $ 6319 -20 Knee Arthroscopy 29881 6 $ 5069 $ 4185 $ 3837 $ 3022 $ 3729 $ 2266 $ 2036 $ 3179 59 GI Upper GI Endoscopy 43239 6 $ 3075 $ 2539 $ 2012 $ 1132 $ 1565 $ 2240 $ 536 $ 1671 84 Lap Sleeve Gastrectomy DRG 621 $ 20421 $ 20815 $ 12105 $ 13230 $ 14600 $ 17800 $ 15710 30 Colonoscopy and biopsy 45380 $ 3075 $ 3071 $ 2013 $ 1244 $ 1972 $ 859 $ 536 $ 1616 90 Diagnostic Colonoscopy 45378 6 $ 3075 $ 2805 $ 2013 $ 1244 $ 1972 $ 859 $ 536 $ 1572 96 Radiology MRI Brain w amp wo dye 70553 2 $ 1238 $ 1468 $ 1117 $ 967 $ 2805 $ 1052 $ 1482 -16 MRI Joint of Lower Extremity wo dye 73721 2 $ 1238 $ 1398 $ 1042 $ 967 $ 925 $ 557 $ 978 27 MRI Abdomen w amp wo dye 74183 2 $ 1238 $ 1468 $ 1106 $ 967 $ 2805 $ 836 $ 1436 -14 X-ray Chest 71020 $ 115 $ 266 $ 305 $ 279 $ 375 $ 72 $ 259 -56 CT Thorax wo dye 71250 $ 882 $ 810 $ 505 $ 491 $ 579 $ 319 $ 541 63 Ultrasound Abdomen Complete 76700 $ 397 $ 538 $ 545 $ 195 $ 190 $ 168 $ 327 21 Mammogram Screening G0202 2 $ 141 $ 328 $ 431 $ 294 $ 425 $ 168 $ 231 $ 313 -55 Computer Detection Add-on 77052 2 $ 112 $ 99 $ 41 $ 15 $ 45 $ 23 $ 14 $ 39 183 Lab Comp Metabolic Panel 80053 8 $ 56 $ 15 $ 24 $ 56 $ 51 $ 25 $ 13 $ 22 $ 29 88 Tissue Exam by Pathologist 88305 8 $ 236 $ 307 $ 80 $ 152 $ 78 $ 232 $ 188 $ 179 $ 174 36 Medical Cardiology Cardiovascular Stress Test 93017 $ 383 $ 432 $ 1299 $ 907 $ 717 $ 797 $ 830 -54 TTE w Doppler 93306 2 $ 960 $ 1566 $ 1388 $ 1173 $ 1125 $ 1157 $ 1282 -25 Obstetrics Vaginal Delivery DRG 755 $ 7290 $ 5730 $ 4654 $ 4607 $ 5855 $ 4688 $ 5107 43 EampM Office Visit new pt 99203 4 $ 248 $ 118 $ 159 $ 139 78 Colonoscopy and biopsy (HOSPITAL ONLY) 45380 Surg 2530 $ 307591 Diagnostic colonoscopy (HOSPITAL ONLY) 45378 Surg 2255 $ 307591 Upper gi endoscopy biopsy (HOSPITAL ONLY) 43239 Surg 1787 $ 307591 Knee Arthroscopy (HOSPITAL ONLY) 29881 Surg 10900 $ 506893 Arthroscopy Ligament Repair (HOSPITAL ONLY) 29888 Surg 10900 $ 506200 Key 1 Facility - Inpatient 2 Facility - Imaging 3 Physician - Imaging 4 Physician 5 Global - Imaging 6 Facility - Outpatient 8 Lab 41 Physician - Primary Care 42 Physician - Specialist
Blue Cross United - EJCH EUH EUHM WW United - SJH Non Options United - SJH Options Aetna - ASC TEC (HMO) Cigna - ASC TEC (HMO) Aetna - EJCH ESJH ECHM WW Cigna - EJCH (HMO) Cigna - ESJH EUHM (HMO) List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract Description CPT Code Charge Average Final Price (all plans) Emory Mark Up Reimbursement Method ( of charge or fixed) - 1713 Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Cardiovascular stress test 93017 Cardio $543 $ 425 28 of Charge 70 $ 380 of Charge 65 $ 353 of Charge 60 $ 326 of Charge 70 $ 380 of Charge 70 $ 380 of charge 100 $ 543 of Charge 70 $ 380 of charge 100 $ 543 of charge 100 $ 543 TTE wDoppler complete 93306 Cardio $1226 $ 960 28 of Charge 70 $ 858 of Charge 65 $ 797 of Charge 60 $ 736 of Charge 70 $ 858 of Charge 70 $ 858 of charge 100 $ 1226 of Charge 70 $ 858 of charge 100 $ 1226 of charge 100 $ 1226 Colonoscopy and biopsy (HOSPITAL ONLY) 45380 Surg $2530 $ 3076 -18 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 of Charge 70 $ 1771 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Diagnostic colonoscopy (HOSPITAL ONLY) 45378 Surg $2255 $ 3076 -27 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 of Charge 70 $ 1579 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Upper gi endoscopy biopsy (HOSPITAL ONLY) 43239 Surg $1787 $ 3076 -42 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Knee Arthroscopy (HOSPITAL ONLY) 29881 Surg $10900 $ 5069 115 Fixed Rate SC 4 $ 3865 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 449300 $ 4493 Fixed Rate $ 654700 $ 6547 of Charge 70 $ 7630 Fixed Rate $ 401000 $ 4010 of Charge 70 $ 7630 Fixed Rate $ 398300 $ 3983 Fixed Rate $ 398100 $ 3981 Arthroscopy Ligament Repair (HOSPITAL ONLY) 29888 Surg $10900 $ 5062 115 Fixed Rate SC 3 $ 3121 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 556900 $ 5569 Fixed Rate $ 770100 $ 7701 of Charge 70 $ 7630 Fixed Rate $ 323900 $ 3239 of Charge 70 $ 7630 Fixed Rate $ 321700 $ 3217 Fixed Rate $ 321400 $ 3214 Comp Metabolic Panel 80053 Lab $132 $ 56 138 RBRVS Fee (100) $ 1437 of Charge 65 $ 86 of Charge 65 $ 86 of Charge 65 $ 86 of Charge 70 $ 92 RBRVS Fee (100) $ 1437 $ 14 of Charge 70 $ 92 RBRVS Fee (100) $ 1437 $ 14 RBRVS Fee (100) $ 1437 $ 14 Surgical Path Tissue Exam 88305 Lab $326 $ 236 38 of Charge 150 $ 51 of Charge 65 $ 212 of Charge 65 $ 212 of Charge 65 $ 212 of Charge 70 $ 228 of charge 100 $ 326 of Charge 70 $ 228 of charge 100 $ 326 of charge 100 $ 326 MRI Abdomen 74183 Radiology $6960 $ 1238 462 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 MRI Brain 70553 Radiology $6804 $ 1238 450 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 MRI Joint Lower Extremity 73721 Radiology $3067 $ 1238 148 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 CT Thorax wo contrast 71250 Radiology $2199 $ 882 149 Fixed Rate $ 771 Fixed Rate $ 47100 $ 471 Fixed Rate $ 81700 $ 817 Fixed Rate $ 116000 $ 1160 of Charge 70 $ 1539 Fixed Rate $ 80100 $ 801 Fixed Rate $ 79200 $ 792 Fixed Rate $ 79300 $ 793 Fixed Rate $ 79500 $ 795 X-ray Chest 71020 Radiology $280 $ 115 142 of Charge 150 $ 25 of Charge 65 $ 182 of Charge 60 $ 168 of Charge 70 $ 196 of Charge 70 $ 196 RBRVS Fee (150) $ 2534 $ 25 of Charge 70 $ 196 RBRVS Fee (150) $ 2534 $ 25 RBRVS Fee (150) $ 2534 $ 25 Screening mammography G0202 Radiology $279 $ 141 98 Fixed Rate $ 128 Fixed Rate $ 13100 $ 131 Fixed Rate $ 14300 $ 143 Fixed Rate $ 16100 $ 161 of Charge 70 $ 195 Fixed Rate $ 13300 $ 133 Fixed Rate $ 13500 $ 135 Fixed Rate $ 13000 $ 130 Fixed Rate $ 11200 $ 112 Mammo Computer Aided 77052 Radiology $75 $ 112 -33 Fixed Rate $ 9 Fixed Rate $ 13100 $ 131 Fixed Rate $ 14300 $ 143 Fixed Rate $ 16100 $ 161 of Charge 70 $ 53 Fixed Rate $ 13300 $ 133 Fixed Rate $ 13500 $ 135 Fixed Rate $ 13000 $ 130 Fixed Rate $ 11200 $ 112 US Abdomen Complete 76700 Radiology $917 $ 397 131 of Charge 150 $ 125 of Charge 65 $ 596 of Charge 60 $ 550 of Charge 70 $ 642 of Charge 70 $ 642 RBRVS Fee (150) $ 12519 $ 125 of Charge 70 $ 642 RBRVS Fee (150) $ 12519 $ 125 RBRVS Fee (150) $ 12519 $ 125 Officeoutpatient visit new pt 30 min (TEC) 99203 EampM $316 $ 248 28 of Charge 70 $ 221 of Charge 65 $ 205 of Charge 60 $ 190 of Charge 70 $ 221 of Charge 70 $ 221 of charge 100 $ 316 of Charge 70 $ 221 of charge 100 $ 316 of charge 100 $ 316 Vaginal delivery 59409 Surg $14484 $ 7290 99 Fixed Rate DRG - 775 $ 5437 2 Day Case Rate + LOC 561700 $ 5617 BaseCMS Weight 584741 $ 5847 BaseCMS Weight 726146 $ 7261 No IP Terms $ - 0 No IP BaseCMS Weight 659343 $ 6593 BaseContract Weight 479451 100 $ 14484 BaseCMS Weight 579110 $ 5791 Lap Sleeve Gastrectomy 43775 Surg $29961 $ 20421 47 Fixed Rate DRG - 621 $ 14872 BaseCMS Weight 1810697 $ 18107 BaseCMS Weight 1835178 $ 18352 BaseCMS Weight 2278911 $ 22789 No IP Terms $ - 0 No IP BaseCMS Weight 2069315 $ 20693 BaseCMS Weight 1730442 100 $ 29961 BaseCMS Weight 1817507 $ 18175 105 Colonoscopy and biopsy (ASC ONLY) Surg $ 219200 $ 2181 Diagnostic colonoscopy (ASC ONLY) Surg $ 267100 $ 2348 Upper gi endoscopy biopsy (ASC ONLY) Surg $ 207500 $ 2758 Knee Arthroscopy (ASC ONLY) Surg $ 417900 $ 3467 Arthroscopy Ligament Repair (ASC ONLY) Surg $ 504800 $ 3386
Cpt Code CPT Description Procedure Category Claims Min 25thNtile 50thNtile Emorys Rates 75thNtile 90thNtile Max 20 Below 50th Ntile 20 Above 50th Ntile 93017 CARDIOVASCULAR STRESS TEST 5 82 $80 $125 $321 $382 $568 $791 $930 $257 $386 71020 CHEST X-RAY 2 2638 $11 $45 $152 $115 $289 $373 $585 $122 $182 71020 CHEST X-RAY 5 8106 $25 $34 $38 $54 $57 $69 $30 $46 45380 COLONOSCOPY AND BIOPSY 6 1256 $541 $560 $572 $2877 $1000 $2024 $3289 $458 $686 77052 COMP SCREEN MAMMOGRAM ADD-ON 2 194 $13 $15 $25 $38 $47 $134 $20 $30 77052 COMP SCREEN MAMMOGRAM ADD-ON 5 2411 $13 $16 $20 $23 $26 $28 $16 $24 80053 COMPREHEN METABOLIC PANEL 8 13019 $9 $19 $23 $55 $24 $25 $69 $19 $28 71250 CT THORAX WO DYE 2 302 $165 $372 $545 $878 $1658 $2067 $436 $654 71250 CT THORAX WO DYE 5 209 $53 $127 $203 $289 $419 $534 $162 $244 45378 DIAGNOSTIC COLONOSCOPY 6 1479 $484 $515 $536 $2914 $831 $1971 $2828 $428 $643 29881 KNEE ARTHROSCOPYSURGERY 6 152 $1650 $1826 $2036 $5235 $3054 $4216 $6461 $1629 $2443 29888 KNEE ARTHROSCOPYSURGERY 6 82 $1682 $3615 $5081 $5145 $7553 $12924 $18532 $4065 $6097 43644 LAP GASTRIC BYPASSROUX-EN-Y 1 21 $11821 $13873 $17050 $18391 $25029 $31079 $13640 $20460 43775 LAP SLEEVE GASTRECTOMY 1 38 $4215 $8250 $13253 $20421 $19197 $21509 $24260 $10602 $15903 74183 MRI ABDOMEN WO amp WDYE 2 120 $919 $987 $1015 $1237 $1252 $2534 $3177 $812 $1218 74183 MRI ABDOMEN WO amp WDYE 5 112 $475 $490 $521 $1154 $1337 $1696 $417 $625 70553 MRI BRAIN WO amp WDYE 2 324 $633 $987 $1142 $1237 $1706 $2805 $3331 $914 $1370 70553 MRI BRAIN WO amp WDYE 5 467 $280 $539 $1023 $1277 $1363 $1726 $818 $1228 73721 MRI JNT OF LWR EXTRE WO DYE 2 304 $804 $859 $967 $1237 $1063 $1598 $2485 $774 $1160 73721 MRI JNT OF LWR EXTRE WO DYE 5 1130 $500 $520 $530 $628 $679 $859 $424 $636 59400 OBSTETRICAL CARE 1 494 $3699 $4402 $4969 $6655 $7307 $8613 $3975 $5963 99203 OFFICEOUTPATIENT VISIT NEW 4 6776 $88 $101 $112 $138 $155 $169 $90 $134 G0202 Screeningmammographydigital 2 7444 $123 $206 $285 $380 $425 $479 $228 $342 G0202 Screeningmammographydigital 5 2754 $117 $165 $195 $230 $247 $252 $156 $234 88305 TISSUE EXAM BY PATHOLOGIST 8 20834 $51 $74 $112 $235 $168 $261 $478 $90 $134 93306 TTE WDOPPLER COMPLETE 2 931 $194 $377 $739 $960 $1267 $1480 $1849 $591 $887 93306 TTE WDOPPLER COMPLETE 5 2299 $151 $296 $373 $538 $573 $834 $298 $448 43239 UPPER GI ENDOSCOPY BIOPSY 6 1264 $424 $514 $550 $800 $1838 $2833 $440 $660 76700 US EXAM ABDOM COMPLETE 2 321 $96 $165 $271 $509 $584 $857 $217 $325 76700 US EXAM ABDOM COMPLETE 5 444 $111 $129 $147 $156 $220 $279 $118 $176 Key 1 Facility - Inpatient 2 Facility - Imaging 3 Physician - Imaging 4 Physician 5 Global - Imaging 6 Facility - Outpatient 8 Lab 41 Physician - Primary Care 42 Physician - Specialist Cardiovascular stress test $ 38279 TTE wDoppler complete $ 96037 Colonoscopy and biopsy $ 287709 Diagnostic colonoscopy $ 291434 Upper gi endoscopy biopsy $ 300526 Knee Arthroscopy $ 523584 Arthroscopy Ligament Repair $ 514501 Comp Metabolic Panel $ 5552 Surgical Path Tissue Exam $ 23570 MRI Abdomen $ 123786 MRI Brain $ 123786 MRI Joint Lower Extremity $ 123786 CT Thorax wo contrast $ 88213 X-ray Chest $ 11548 Screening mammography $ 14098 Mammo Computer Aided $ 11179 US Abdomen Complete $ 39695 Officeoutpatient visit new pt 30 min $ 24753 Vaginal delivery $ 729025 Lap Sleeve Gastrectomy $ 2042124
Page 8
Direct Contacting Arrangement Types
7
Bundled Payments prospective payment which covers patientrsquos care from start to finish
Reference Based Pricing (RBP) plan pays up to fixed amount for procedure any excess is billed to member
bull PCP-centric bull Level of provider risk can vary from partial to full bull May be offered with other options or full replacement if adequate network
bull Promotes shopping for services via price transparency bull Most common for elective procedures ndash joint surgeries spine gastric bypass
bull Appropriate for high volume procedures bull Medical expense more predictable for these services may not be fixed price bull May result in lower provider revenue than FFS providers seek steerage volume
Center of Excellence (COE) designated provider identified for specific procedures that may require travel
bull Appropriate for high volume procedures bull Specialization amp operational efficiencies reduce utilization variations improves patient
experience amp improves outcomes (eg lower LOS return to work time) bull Members out-of-pocket often low to $0 including travelhotel not always lowest ldquopricerdquo
Accountable Care Organization (ACO) provider reimbursements are directly tied to quality and financial outcomes
Mos
t Com
mon
Ar
rang
emen
ts
On-site health education seminars
Wellness services
On-site clinic
Bundled payments
Employer liaison coordinator
On-site coaching Andor counseling
Care pathways
Direct contracting narrow networks
Source Re-Igniting the Growth Engine Part 2 Winning Increased Share of Lucrative Patient Volumes Advisory Board
Boeing 1UW Med 2Memorial Care 3Mercy MO 4Roper St Francis 5ProvSwedish
DART amp Baylor Scott and White Health
Intel amp 1 Presbyterian ACO 2 Arizona Care Network
Quallcom amp Scripps Health
Stanford Healthcare Alliance
General Motors amp Henry Ford Health
Disney amp 1Orlando Health 2Florida Hospital
Walmart amp 1 Banner 2 Emory 3 Memorial Hermann 4 Mercy AK 5Mercy OK 6 Mercy MO 7Oschner Health 8 Presbyterian 9 St Lukersquos 10 Unity Point 11 Cleveland Clinic 12 Geisinger Health 13Johns Hopkins 14Mayo Clinic AZ 15Mayo Clinic FL 16Mayo MN 17Mercy MO
1 2
3
4 5
6
8
7
9
10
1
3
4 2
1
2
1
Whole Foods amp Adventis Health
11 12 13
14
15
16
17
Emergence of Direct Contracting
8
DC with providers to secure improved pricing
COE through a carve-out provider
COE within the health plans
Source Willis Towers Watson 23rd Annual Best Practices in Health Care Employer Survey Full report and high-performance insights httpswwwwillistowerswatsoncom-mediaWTWPDFInsights201812willis-towers-watson-23rd-annual-best-practices-in-health-care-employer-survey-full-reportpdf 2018
Trends in Direct Contracting amp COE
According to Willis Towers Watsonrsquos survey employers are using COEs mostly through their health plans however direct contracting considerations are expected to grow considerably
6
7
48
2
2
7
14
13
20
0 20 40 60 80
Action taken or tactic used in 2018
Planning for 2019
Considering for 2020
bull Almost 50 use COEs in 18rsquo expected to rise to 2 out of 3 by 2020
bull Employers engaging employees in multiple ways to use COE bull Ongoing communications bull Reducing member cost share
to use bull Increasing member cost
share when not using bull Mandatory use
9
16
12
18
9
3
6
2
50
39
19
22
26
11
10
15
19
31
30
31
22
11
Transplants
Bariatric Surgery
Knees hips or spine
Cardiovascularcardiac
Cancer
Fertility
Other Procedures
Yes with incentives Yes but no incentives No but considering
10
A 2015 survey by the National Business Group on Health shows the status of large employersrsquo contracts with COEs (note reflects all COEs not specifically direct contracts)
Source Large Employersrsquo 2016 Health Plan Design Survey copy 2015 National Business Group on Health
Other centers of excellence programs include maternity NICU sleep apnea pancreas cornea and kidney
National Business Group on Healthrsquos Large Employers 2019 Health Care Strategy and Plan Design Survey showed DC arrangements between employers and bull Health systemsproviders will
increase from 3 in 2018 to 11 in 20191
bull COEs will increase from 12 in 2018 to 18 in 20191
bull Cancer cardiovascular and fertility COEs are experiencing the greatest growth
Source National Business Group on Health ldquoLarge US Employers Eye Changes to Health Care Delivery System as Cost to Provide Health Benefits Nears $15000 per Employeerdquo August 2018
10
Trends in Direct Contracting amp COE
Outcomes amp Benefits bull Employers with COE arrangements are seeing reduction in procedures
bull Walmart (15rsquo-18rsquo) 50+ of spine surgeries amp 20 of kneehip procedures recommended by local providers were determined lsquonot necessaryrsquo by COE (see table)
bull Employers like Walmart amp Boeing continue to sign new providers which suggest (employersrsquo) continued interest in pursuing DC arrangements2 However Boeing and Providence Swedish did end relationship due to inability to capture enoughright data to estimate cost of care3
bull John Hopkinsrsquo Bayview campus COE emerging metrics4
bull 121 referrals in the first three months
bull 352 referrals and 183 surgeries over 18 months
bull 23 of all joint replacement volumes at facility now attributed to travel program
bull 96 of patients said they would recommend this program to family friends coworkers
bull Bingham Memorial in Idaho direct contracting emerging metrics4
bull 17 companies participating covering over 5000 lives
bull +3000 new patients as of October 2018
bull +$3M Revenue from new patients
11
1 How Employers Are Fixing Health Care Harvard Business Review March 2019 2 httpswwwhealthleadersmediacomstrategywalmart-escalates-strategy-solve-employee-healthcare Health Leaders Media Nov 18rsquo 3 Do Providers Have the Data chops to Success with Direct Contract Modern Healthcare August 2018 4 Re-Igniting the Growth Engine Part 2 Winning Increased Share of Lucrative Patient Volumes Advisory Board 5 httpswwwautonewscomarticle20180806OEM180809831gm-signs-major-health-care-services-deal-for-salaried-employees
Walmart COE Programs1
Program Key Benefits
Spin
e Su
rger
y 2300 EEs 50 COE approved of those applied
bull 95 lower readmission bull 14 less time in hospital bull 1 COE vs 5 non-COE patients discharged to SNF bull Returned to work sooner reducing 20 of OOO
time bull More-effective less dangerous amp less expensive bull The COE surgery ldquopricerdquo is 8 higher but value in
earlier discharge lower readmission rates far less utilization of SNF faster return to work
Join
t
1836 EEs 18 COE approved of those applied
bull 32 less time in hospital bull 70 less likely to be readmitted than non-COE
patients bull Fewer postsurgical complications bull 0 COE vs 5 non-COE patients discharged to SNF bull COE patients returned to work a 15 weeks sooner bull Cost of surgery is 15 less at COE hospitals
Baria
tric
300+ EEs
bull Preliminary data suggests the weight loss from surgery reduces absenteeism or presentism (working while sick)
bull Dramatically cuts pharmacy amp medical costs Complications of obesity drop sharply as does the need for medication
bull GMrsquos direct contract benefit plans with Henry Ford allows it to offer similarly designed plans to that of Blue Cross with savings in monthly EE contributions ranging from $300-$19805
Walmartrsquos Travel (Surgery) Program
Mem
ber F
eedb
ack
12
Looking beyond traditional cost management techniques Walmart designed a program to address wild variations in cost and become directly in improving quality of care for its employees FIRST SELECTING PROVIDERS 1 Identify providers with high volume and high quality 2 Target regions in country to support Walmartrsquos employees 3Focus on Integrated Health Systems Hospitals within these systems were best aligned to Walmarts mission could take on risks associated with bundling 4 Eliminate systems unwilling to do bundled payments model were
PROVIDERS VALUE IN PARICIPATING
Build Bundles bull Define bundles and negotiate price (typically 10-15 below FFS ) bull Definitions of service limit disputes of what is covered vs not (covers
entryexit of facility SNF not part of bundle) bull Contract flexibility covers unforeseen testcosts and reinforces
Walmarthealth system partnership bull Warrantees if further treatment - can return in 30 days no
additional cost to Walmart bull Strict criteria and providers with track record of clinically sound
decisions are included to mitigate any incentivizing of volume Business bull 100 travelaccom brings
new volume of patients from outside of market
bull More stable payments for services (vs Medicare or commercial FFS)
bull Increased visibility and attract new business
Clinical bull lsquoHalorsquo effect ndash Building a highly
efficient multidiscipline program brings improvements throughout health system
bull Onsite collaboration among health systems allows sharing of outcomesbest practices
Source How Employers Are Fixing Health Care Harvard Business Review March 2019
5000 participants in the program
95 satisfiedvery satisfied
Denied by care because not deemed necessary by COE Treatment denied due to lifestyle weightsmoking
The Member Experience
13
Engagement begins when employee on clear
path to surgery
Patient contacts with COE TPA
TPA team triages and ensures basic criteria
met
Employee put in touch with nurse team
Car pick-up Flight Hotel all arranged by
TPA
Navigators and nurse coordinators help
throughout the stay
Patient visits to hospital to understand
exceptions of procedure and meet treatment
team
Surgery occurs typically next day
Stay length according to procedure typically a
few days
Discharged from facility Travel home COE team updates local
PCP and discuss follow up care
COE provider checks in with local physician
frequently Revert back to standard coverage
Source How Employers Are Fixing Health Care Harvard Business Review March 2019
Case Study 1
Case study 1 ndash Pop Health Approach bull ProblemCircumstance Large multi-employer group needs to
evaluate benefit design disease prevalence health spend and utilization to manage their population
bull ConsiderationsValue Prop Unique industry and geography drive chronic conditions and utilization patterns
bull Solution Provide opportunity assessment comparing this population to other benchmarks to understand where to target intervention and management as well as assess efforts already taken
15
Market Comparison Preference Sensitive Procedures
16
Legend vs
Mt States vs
National gt120 gt110
110-120 105-110 lt80 lt90
Source Multi-payer commercial benchmark Results are weighted by AgeGender Broader market area includes multi-payer data from the mountain regions
Preference Sensitive Procedures Benchmark Comparison
Dartmouth Atlas Preference Sensitive Procedures
IP allowed dollars ALOS Employer vs
Mt States Employer
vs National FY 2017 FY 2018 FY 2017 FY 2018
Hysterectomy for Uterine Fibroids Rate $569354 $436932 45 54 124 140 CABG Rate $1800260 $2400608 53 60 218 130 Cholycystectomy Rate $832675 $755565 68 39 92 120 C-Section Rate 116 110 HighTech Radiology Rate 103 101 PCIPTCA Rate $934486 $1133708 37 55 82 80 Back Surgery Rate $3237613 $4003212 39 57 52 70 Knee Replacement Rate $3086693 $2177334 41 48 50 64 Total Hip Replacement Rate $1023675 $747491 45 64 37 34
Strengths (+)
Employer compares favorably for orthopedic procedures (back hip knee)
Opportunity (-)
Employer has higher than expected rates for CABG and hysterectomy (Note Low PTCA rate combined with high CABG rate may suggest provider practice patterns favoring CABG)
0 50 100 150 200 250
Total Hip Replacement
Knee Replacement
Back Surgery
PCIPTCA
Cholycystectomy
HighTech Radiology
C-Section
CABG
Culinary VsNational
Culinary Vs MtStates
Employer vs Mt States
Employer vs National
Market Comparison Condition Prevalence
17 Source Multi-payer commercial benchmark Results are weighted by AgeGender Broader market area includes multi-payer data from the mountain regions
Condition Prevalence Benchmark Comparison
Condition Employer vs
Mt States Employer vs
National Prevalence Diabetes Rate 229 219 Prevalence Hyperlipidemia Rate 259 207 Prevalence Kidney Disease Rate 143 174 Prevalence Migraine Rate 166 164 Prevalence Low Back Pain Rate 136 139 Prevalence Hypertension Rate 156 134 Prevalence Asthma Rate 146 128 Prevalence CAD Rate 175 115 Prevalence Pregnancy Rate 110 109 Prevalence Adult Preventive Screening Rate 114 91 Prevalence Depression Rate 63 60
Strengths (+)
Rate of depression is low (Note May be due to incomplete behavioral health claims)
Opportunity (-)
Employer has a higher prevalence of most chronic conditions including asthma CAD diabetes hypertension hyperlipidemia Kidney Disease LBP and migraines
0
100
200
300Hyperlipidemia
Diabetes
CAD
Migraine
Hypertension
AsthmaKidney Disease
Low Back Pain
Pregnancy
Depression
Employer vsMt States
Employer vsNational Legend
vs Mt States
vs National
gt120 gt110 110-120 105-110
lt80 lt90
Market Comparison Utilization Rates
18
A higher preventive office visit rate is better Source Multi-payer commercial benchmark Results are weighted by AgeGender Broader market area includes multi-payer data from the mountain regions
Strengths (+)
Lower than average utilization of ED and high dollar patient rate
Opportunity (-)
Higher LOS lengthy admits avoidable admits and readmissions which all drive significantly more spend
Utilization Benchmark Comparison
Condition Employer vs
Mt States Employer vs
National Avoidable Admit Rate 142 144 Lengthy Admit Rate 175 136 Outpatient Problem Focused Office Rate 146 131 Readmission Rate (readmitadmit) 135 126 Average LOS 125 116 One Day Admit Rate 76 103 Office Visit Rate 106 96 Acute Admit Rate 80 95 Avoidable ED Rate 68 86 ED Rate 54 69 Preventive Office Rate 95 68 High Dollar Patient Rate 49 51 Frequent ED User (gt3 times) Rate 24 36
Legend vs
Mt States vs
National gt120 gt110
110-120 105-110 lt80 lt90
0 50 100 150 200
Frequent ED User (gt3 times)
High Dollar Patient
Preventive Office
ED
Avoidable ED
Acute Admit
Office Visit
One Day Admit
Average LOS
Readmissionhellip
Outpt Problem Focusedhellip
Lengthy Admit
Avoidable Admit
Employer vsNational
Employer vsMt States
ED and Avoidable ED
19
Potentially Avoidable ED - Trend View Overall ED
Period Change FY 2017 FY 2018 Count Rate
Measure Mbrs Rate Mbrs Rate Overall ED 16394 12626 13820 10745 -16 -15 FREQUENT ED UTILIZER (mbr1k) 1581 1218 1468 1141 -7 -6 AVOIDABLE ED 6371 4907 5288 4111 -17 -16 Potentially Avoidable ED
Period Change FY 2017 FY 2018 Count Rate
Avoid ED Condition Mbrs Rate Mbrs Rate ABDOMINAL_PAIN 1092 841 895 696 -18 -17 ENT_INFECTION 854 658 742 577 -13 -12 FEVER 715 551 700 544 -2 -1 URINARY 650 501 468 364 -28 -27 HEADACHE 558 430 434 337 -22 -21 BACK_PAIN 414 319 423 329 2 3 NAUSEA 394 303 271 211 -31 -31 ASTHMA 294 226 209 162 -29 -28 CELLULITIS 210 162 198 154 -6 -5 GASTROENTERITIS 254 196 171 133 -33 -32 OTITIS_MEDIA 201 155 160 124 -20 -20 COPD 132 102 108 084 -18 -17 DIABETES 123 095 91 071 -26 -25 BACT_PNEUMONIA 111 085 86 067 -23 -22 DENTAL 93 072 83 065 -11 -10 DEHYDRATION 98 075 81 063 -17 -17 HYPERTENSION 16 012 24 019 50 51 CHF 4 003 3 002 -25 -24 ANGINA 8 006 3 002 -63 -62 IMMUNIZATION_RELATED 2 002 0 000 -100 -100 Grand Total 6371 4907 5288 4111 -17 -16
AHRQ avoidable ED visits are based on the logic for ambulatory care sensitive ED visits from AHRQ and diagnosis code driven
696
577
544 364
337
329
211 162
154 133 ABDOMINAL_PAIN
ENT_INFECTION
FEVER
URINARY
HEADACHE
BACK_PAIN
NAUSEA
- 200 400 600 800
1000 1200
2017 Members 2018 Members
Top Ten 2018 Conditions by Rate
Top Ten Conditions by Member Count
ED Avoidable ED and the impact of new on-site clinic
20
0
1000
2000
3000
4000
5000
6000
0200400600800
10001200140016001800
Clinic Visits ED Visits
Avoidable ED VisitsED Visits (non-avoidable)Clinic EampM Visits
0
500000
1000000
1500000
2000000
2500000
3000000
3500000
$s
Clinic EampM Profess DollarsAvoidable ED Dollars
bull Clinic visits have a clear impact on ED and avoidable ED use and spend
bull Combined ED visits are down on average 157 in FY 18 from FY 17
bull Combined ED spend is down 128 in FY 18 from FY 17
Clinic Live 62017
Pitfalls and Challenges bull Face many of the challenges similar to startup health
plan bull Critical to determine how you will deliver value and
communicate the value to potential customers and brokersconsultants
bull Care management bull Network
21
Considerations in Offering Development bull Care Management Model
bull Traditional care model bull Case management bull Utilization management bull Disease management
bull Longitudinal care model with value based care philosophy bull Primary care driven bull Local care management
bull Predictive analytics and risk stratification model bull Claims history and ongoing data bull EMR data
22
Case Study 2
Case study 2 ndash Large Employer bull Business Problem Large employer wants to contract
directly with 2 major hospital systems developing professional fee schedules
bull ConsiderationsValue Prop Fee schedule should be competitive but also nuanced to minimize gap relative to current reimbursement at physician level
bull Solution Data-driven approach using current market-wide reimbursement distinguished by service level
24
Evaluate Provider Spend Top 25 Service Lines by Allowable Spend
Evaluate Provider Spend Top 20 Professional CPTs by Total Spend
Understand relative market pricing position
27
21
-1
-28
14 10
28
-22
-11 -13
24
3
20 21
8
-20
13
3 9
-39
56
-26
4
-42
60
MRI Colonoscopy Cardiac Cath Lab - OrganPanel
Memorial Hospital Beta Hospital Delta Hospital Charlie Hospital Echo Hospital Alpha Medical Center
ndash25 5 -15 10 0 39
State Charges as a Percent of Peer Average Weighted Averages for MRI Colonoscopy Cardiology and Lab
Total Percent Above Below Market Average2
Memorial Hospital Beta Hospital Delta Hospital Charlie Hospital Echo Hospital Alpha Medical Center
Develop fee schedule relative to market
28
Service Line Procedure CPT CodeDRG
Memorial Hospital
Beta Hosptial
Charlie Hospital
Delta Hospital
Echo Hospital
Alpha Medical Center
Arthroscopy Ligament Repair 29888 $ 5062 $ 9557 $ 5983 $ 10096 $ 7519 $ 2502 Knee Arthroscopy 29881 $ 5069 $ 4185 $ 3837 $ 3022 $ 3729 $ 2266 Upper GI Endoscopy 43239 $ 3075 $ 2539 $ 2012 $ 1132 $ 1565 $ 2240 Lap Sleeve Gastrectomy DRG 621 $ 20421 $ 20815 $ 12105 $ 13230 $ 14600 $ 17800 Colonoscopy and biopsy 45380 $ 3075 $ 3071 $ 2013 $ 1244 $ 1972 $ 859 Diagnostic Colonoscopy 45378 $ 3075 $ 2805 $ 2013 $ 1244 $ 1972 $ 859 MRI Brain w amp wo dye 70553 $ 1238 $ 1468 $ 1117 $ 967 $ 2805 $ 1052 MRI Joint of Lower Extremity wo dye 73721 $ 1238 $ 1398 $ 1042 $ 967 $ 925 $ 557 MRI Abdomen w amp wo dye 74183 $ 1238 $ 1468 $ 1106 $ 967 $ 2805 $ 836 X-ray Chest 71020 $ 115 $ 266 $ 305 $ 279 $ 375 $ 72 CT Thorax wo dye 71250 $ 882 $ 810 $ 505 $ 491 $ 579 $ 319 Ultrasound Abdomen Complete 76700 $ 397 $ 538 $ 545 $ 195 $ 190 $ 168 Mammogram Screening G0202 $ 141 $ 328 $ 431 $ 294 $ 425 $ 168 Computer Detection Add-on 77052 $ 112 $ 99 $ 41 $ 15 $ 45 $ 23 Comp Metabolic Panel 80053 $ 56 $ 15 $ 24 $ 56 $ 51 $ 25 Tissue Exam by Pathologist 88305 $ 236 $ 307 $ 80 $ 152 $ 78 $ 232 Cardiovascular Stress Test 93017 $ 383 $ 432 $ 1299 $ 907 $ 717 $ 797 TTE w Doppler 93306 $ 960 $ 1566 $ 1388 $ 1173 $ 1125 $ 1157
Obstetrics Vaginal Delivery DRG 755 7290$ 5730$ 4654$ 4607$ 5855$ 4688$
GI
Lab
Radiology
Medical Cardiology
Orthopedics
KEY OBSERVA TIONS bull Potential exposure on GI bull Opportunity to align price and acuity in MRI bull Opportunity to raise rates on chest x-ray and mammogram
Percentile Bands Emory Allowables Heatmap TEC ASC Heatmap Allowable Comp Analysis Portal Pricing Sheet1 image1png A few words on Bundled Payments bull Bundled payments are growing as a type of direct contracting bull In some cases third parties match-make between employers
and providers bull Contracts may vary in definitions prepost admission
coverage duration readmission cause (ie all-cause vs medically related) outlier provisions LOS caps andor per diems
bull Providers need to be strategic in pricing to enable profitable growth of market share
29
Considerations in Offering Development bull Network Development
bull Build off existing structure eg health system employee plan network bull How does this fit into your broader value based care strategy bull Employed and independent physicians bull How do you want to approach the buildout of high performance
network bull Quality focus bull Cost efficiency
bull Integrated behavioral health bull Wrap network for other markets
30
Considerations in Offering Development bull Target Market
bull Consideration of employer profile in market bull Fully-insured vs ASO bull Total cost of care vs bundled services
bull Distribution bull Direct marketing bull Brokerconsultant community
bull Plan designs bull Standard designs vs flexible ndash Dependent on target market
bull Claims administration bull Data sharing amp analytics
31
Considerations in Offering Development bull Other components of comprehensive offering
bull Pharmacy bull Preventive health bull Onsite clinics bull Wellness programs bull Technology platform
32
Sample Bundle Analysis
33
Cover page Dotson Hazelrigs Nation Mainly of charge of fixed Cardiovascular stress test TTE wDoppler complete Colonoscopy and biopsy (Combined) Diagnostic colonoscopy (Combined) Upper gi endoscopy biopsy (Combined) Knee Arthroscopy (Combined) Arthroscopy Ligament Repair Comp Metabolic Panel Surgical Path Tissue Exam MRI Abdomen MRI Brain MRI Joint Lower Extremity CT Thorax wo contrast X-ray Chest Screening mammography Mammo Computer Aided US Abdomen Complete Officeoutpatient visit new pt 30 min Vaginal delivery Lap Sleeve Gastrectomy
Piedmont Piedmont Piedmont Piedmont Northside Northside Northside Northside Gwinnett Gwinnett Gwinnett Gwinnett WellStar WellStar WellStar WellStar AMC - Tenet AMC - Tenet AMC - Tenet AMC - Tenet CPT Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing 29881 $11312 $10872 NA NA $7476 $9338 NA $23655 $11856 $3668 NA $17871 $12253 NA NA $15645 $5490 NA NA $23039 29888 NA NA NA NA NA NA NA $23784 NA $8261 NA $18000 NA NA NA $15774 NA NA NA $23168 43239 NA $4408 NA NA NA NA $5997 $8852 NA $3304 NA $7424 $1267 NA NA $9230 NA $2458 NA $8274 43644 $26468 NA NA NA $3382 $12050 NA $1861 NA NA NA $1316 $7841 NA NA $3444 $18892 $27950 NA $979 43775 NA NA NA NA NA NA NA $352 NA NA NA $302 NA NA NA $413 NA NA NA $83 45378 $2705 $2530 NA NA $4381 $3676 $4496 $1022 $2938 $2138 NA $695 $5504 NA NA $2036 NA NA NA $372 45380 $3075 $2600 NA NA $4723 $3527 $3012 $1757 $4215 $2285 NA NA $5298 NA NA $3268 NA NA NA $627 59400 $6160 NA NA NA NA $5100 NA $1851 NA NA NA $1304 $9035 NA NA $3427 $9116 $5150 NA $966 70553 $2985 NA $1153 NA $2182 NA $1192 $492 NA NA $803 $489 $1512 NA $985 $1187 NA NA NA $197 71020 $61 $69 $43 NA $113 $319 $307 NA $183 $59 $32 NA $213 $66 $40 NA $83 $53 NA NA 71250 $1837 $621 $989 NA $1490 $931 $755 NA NA $745 $401 NA $1067 $982 $616 NA NA $304 NA NA 73721 NA $1098 $1153 NA $2042 $1065 $1192 NA NA $998 $803 NA NA $1275 $985 NA NA $644 NA $178 74183 $2971 $1144 NA NA NA $1092 $1192 $6884 NA $1098 $803 NA $2960 $1197 $985 $5454 NA NA NA $7607 76700 $364 $247 $207 NA $427 $708 $614 $13267 $428 $214 $152 NA $747 $263 $189 $9139 NA $235 NA NA 77052 NA NA NA NA NA NA NA $4744 NA NA NA NA NA NA NA $3070 NA NA NA $5611 93306 $1220 $1117 NA NA $1877 $1657 $2100 $4605 $1433 $413 $945 NA $1336 $1434 $1951 $2931 NA $2399 NA $5472 G0202 $262 $187 NA NA $431 NA NA $4605 $292 NA NA NA $530 $281 NA $2931 $327 NA NA $5472
Provider Group 29881_6 29888_6 43239_6 43644_1 43775_1 45378_6 45380_6 59400_1 70553_2 71020_2 71250_2 73721_2 74183_2 76700_2 77052_2 77052_5 80053_8 88305_8 93306_2 99203_4 G0202_2 G0202_5 93017_2 Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Atlanta Gastroenterology Associates $2399 $536 348 $1628 $536 204 $2400 $536 348 Atlanta Medical Center $24889 $2266 999 $25897 $2502 935 $11449 $2240 411 $81927 $15300 435 $75815 $17800 326 $7317 $859 752 $7317 $859 752 $12821 $4688 173 $6581 $1052 526 $645 $72 796 $3265 $319 925 $3450 $557 519 $7398 $836 785 $1576 $133 1084 $73 $23 217 $635 $25 2440 $891 $232 285 $2967 $1157 156 $344 $168 105 $1265 $797 59 Atlanta Womens Health Physicians Group $29 $14 107 $40 $13 208 $396 $188 111 $278 $118 135 $450 $231 95 Gwinnett Hospital $11941 $3022 295 $21654 $10096 114 $3551 $1132 214 $34384 $10800 218 $56472 $13230 327 $3003 $1244 141 $3533 $1244 184 $8984 $4607 95 $3901 $967 303 $417 $279 49 $2247 $491 358 $4000 $967 314 $3755 $967 288 $1593 $195 717 $50 $15 233 $186 $56 233 $505 $152 233 $1750 $1173 49 $418 $294 42 $1396 $907 54 Northside Hospital $15482 $4185 270 $21651 $9557 127 $4885 $2539 92 $35176 $17000 107 $35233 $20815 69 $3883 $2805 38 $5256 $3071 71 $10911 $5730 90 $4856 $1468 231 $443 $266 67 $2379 $810 194 $3776 $1398 170 $5105 $1468 248 $942 $538 75 $167 $99 69 $379 $15 2427 $433 $307 41 $2252 $1566 44 $459 $328 40 $576 $432 33 Piedmont Hospital $14772 $3837 285 $35493 $5983 493 $5069 $2012 152 $38320 $17750 116 $37125 $12105 207 $3485 $2013 73 $4993 $2013 148 $10143 $4654 118 $5939 $1117 432 $542 $305 78 $2983 $505 491 $3410 $1042 227 $6067 $1106 449 $1364 $545 150 $75 $41 85 $231 $24 863 $657 $80 721 $2041 $1388 47 $490 $431 14 $1780 $1299 37 Piedmont Physicians Group $42 $22 87 $318 $179 78 $239 $159 50 Resurgens $8558 $2036 320 $9293 $2258 312 $4638 $2067 124 $4039 $2164 87 $4392 $2164 103 $2252 $1371 64 $459 $330 39 Wellstar Hospital $9330 $3729 150 $17479 $7519 132 $5261 $1565 236 $35794 $18200 97 $46780 $14600 220 $3707 $1972 88 $4928 $1972 150 $13549 $5855 131 $5054 $2805 80 $528 $375 41 $3222 $579 457 $3694 $925 299 $5495 $2805 96 $1355 $190 615 $66 $45 46 $73 $51 43 $133 $78 71 $1785 $1125 59 $599 $425 41 $1010 $717 41 Avg Mark UpProcedure Atlanta Medical Center 634 Gwinnett Hospital 223 Northside Hospital 233 Piedmont Hospital 259 Wellstar Hospital 155 Emory 105
Atlanta Gastroenterology Associates Atlanta Medical Center Atlanta Womens Health Gwinnett Hospital Northside Hospital Piedmont Hospital Piedmont Physicians Group Resurgens Wellstar Hospital CPT Code CPT Proc Cat Comp Avg Allow Allow Allow Allow Allow Allow Allow Allow Allow 29881 KNEE ARTHROSCOPYSURGERY 6 $3179 $2266 $3022 $4185 $3837 $2036 $3729 29888 KNEE ARTHROSCOPYSURGERY 6 $6319 $2502 $10096 $9557 $5983 $2258 $7519 43239 UPPER GI ENDOSCOPY BIOPSY 6 $1727 $536 $2240 $1132 $2539 $2012 $2067 $1565 43644 LAP GASTRIC BYPASSROUX-EN-Y 1 $15810 $15300 $10800 $17000 $17750 $18200 43775 LAP SLEEVE GASTRECTOMY 1 $17800 $13230 $20815 $12105 $14600 45378 DIAGNOSTIC COLONOSCOPY 6 $1656 $536 $859 $1244 $2805 $2013 $2164 $1972 45380 COLONOSCOPY AND BIOPSY 6 $1694 $536 $859 $1244 $3071 $2013 $2164 $1972 59400 OBSTETRICAL CARE 1 $5107 $4688 $4607 $5730 $4654 $5855 70553 MRI BRAIN WO amp WDYE 2 $1482 $1052 $967 $1468 $1117 $2805 71020 CHEST X-RAY 2 $259 $72 $279 $266 $305 $375 71250 CT THORAX WO DYE 2 $541 $319 $491 $810 $505 $579 73721 MRI JNT OF LWR EXTRE WO DYE 2 $978 $557 $967 $1398 $1042 $925 74183 MRI ABDOMEN WO amp WDYE 2 $1436 $836 $967 $1468 $1106 $2805 76700 US EXAM ABDOM COMPLETE 2 $320 $133 $195 $538 $545 $190 77052 COMP SCREEN MAMMOGRAM ADD-ON 2 $45 $23 $15 $99 $41 $45 77052 COMP SCREEN MAMMOGRAM ADD-ON 5 $14 $14 80053 COMPREHEN METABOLIC PANEL 8 $29 $25 $13 $56 $15 $24 $22 $51 88305 TISSUE EXAM BY PATHOLOGIST 8 $174 $232 $188 $152 $307 $80 $179 $78 93306 TTE WDOPPLER COMPLETE 2 $1297 $1157 $1173 $1566 $1388 $1371 $1125 93017 STRESS TEST 5 $830 $797 $907 $432 $1299 $717 99203 OFFICEOUTPATIENT VISIT NEW 4 $139 $118 $159 G0202 Screeningmammographydigital 2 $329 $168 $294 $328 $431 $330 $425 G0202 Screeningmammographydigital 5 $231 $231
Service Line Procedure CPT Code Emory Atlanta Gastroenterology Associates Resurgens Atlanta Womens Health Piedmont Physicians Group Orthopedics (ASC) Knee Arthroscopy 29881 $3467 $2036 Arthroscopy Ligament Repair 29888 $3386 $2258 GI (ASC) Upper GI Endoscopy 43239 $2758 $536 Diagnostic Colonoscopy 45378 $2348 $536 Colonoscopy and biopsy 45380 $2181 $536 Radiology Mammogram Screening G0202 $164 $231 Computer Detection Add-on 77052 $93 $14 Lab Comp Metabolic Panel 80053 $53 $13 $22 Tissue Exam by Pathologist 88305 $277 $188 $179 EampM (TEC) Office Visit new pt 99203 $269 $118 $159
Service Line Procedure CPT CodeDRG Memorial Hospital Beta Hosptial Charlie Hospital Delta Hospital Echo Hospital Alpha Medical Center Atlanta Gastroenterology Associates Resurgens Atlanta Womens Health Piedmont Physicians Group Market Avg Emory abovebelow Orthopedics Arthroscopy Ligament Repair 29888 $ 5062 $ 9557 $ 5983 $ 10096 $ 7519 $ 2502 $ 2258 $ 6319 -20 Knee Arthroscopy 29881 6 $ 5069 $ 4185 $ 3837 $ 3022 $ 3729 $ 2266 $ 2036 $ 3179 59 GI Upper GI Endoscopy 43239 6 $ 3075 $ 2539 $ 2012 $ 1132 $ 1565 $ 2240 $ 536 $ 1671 84 Lap Sleeve Gastrectomy DRG 621 $ 20421 $ 20815 $ 12105 $ 13230 $ 14600 $ 17800 $ 15710 30 Colonoscopy and biopsy 45380 $ 3075 $ 3071 $ 2013 $ 1244 $ 1972 $ 859 $ 536 $ 1616 90 Diagnostic Colonoscopy 45378 6 $ 3075 $ 2805 $ 2013 $ 1244 $ 1972 $ 859 $ 536 $ 1572 96 Radiology MRI Brain w amp wo dye 70553 2 $ 1238 $ 1468 $ 1117 $ 967 $ 2805 $ 1052 $ 1482 -16 MRI Joint of Lower Extremity wo dye 73721 2 $ 1238 $ 1398 $ 1042 $ 967 $ 925 $ 557 $ 978 27 MRI Abdomen w amp wo dye 74183 2 $ 1238 $ 1468 $ 1106 $ 967 $ 2805 $ 836 $ 1436 -14 X-ray Chest 71020 $ 115 $ 266 $ 305 $ 279 $ 375 $ 72 $ 259 -56 CT Thorax wo dye 71250 $ 882 $ 810 $ 505 $ 491 $ 579 $ 319 $ 541 63 Ultrasound Abdomen Complete 76700 $ 397 $ 538 $ 545 $ 195 $ 190 $ 168 $ 327 21 Mammogram Screening G0202 2 $ 141 $ 328 $ 431 $ 294 $ 425 $ 168 $ 231 $ 313 -55 Computer Detection Add-on 77052 2 $ 112 $ 99 $ 41 $ 15 $ 45 $ 23 $ 14 $ 39 183 Lab Comp Metabolic Panel 80053 8 $ 56 $ 15 $ 24 $ 56 $ 51 $ 25 $ 13 $ 22 $ 29 88 Tissue Exam by Pathologist 88305 8 $ 236 $ 307 $ 80 $ 152 $ 78 $ 232 $ 188 $ 179 $ 174 36 Medical Cardiology Cardiovascular Stress Test 93017 $ 383 $ 432 $ 1299 $ 907 $ 717 $ 797 $ 830 -54 TTE w Doppler 93306 2 $ 960 $ 1566 $ 1388 $ 1173 $ 1125 $ 1157 $ 1282 -25 Obstetrics Vaginal Delivery DRG 755 $ 7290 $ 5730 $ 4654 $ 4607 $ 5855 $ 4688 $ 5107 43 EampM Office Visit new pt 99203 4 $ 248 $ 118 $ 159 $ 139 78 Colonoscopy and biopsy (HOSPITAL ONLY) 45380 Surg 2530 $ 307591 Diagnostic colonoscopy (HOSPITAL ONLY) 45378 Surg 2255 $ 307591 Upper gi endoscopy biopsy (HOSPITAL ONLY) 43239 Surg 1787 $ 307591 Knee Arthroscopy (HOSPITAL ONLY) 29881 Surg 10900 $ 506893 Arthroscopy Ligament Repair (HOSPITAL ONLY) 29888 Surg 10900 $ 506200 Key 1 Facility - Inpatient 2 Facility - Imaging 3 Physician - Imaging 4 Physician 5 Global - Imaging 6 Facility - Outpatient 8 Lab 41 Physician - Primary Care 42 Physician - Specialist
Blue Cross United - EJCH EUH EUHM WW United - SJH Non Options United - SJH Options Aetna - ASC TEC (HMO) Cigna - ASC TEC (HMO) Aetna - EJCH ESJH ECHM WW Cigna - EJCH (HMO) Cigna - ESJH EUHM (HMO) List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract Description CPT Code Charge Average Final Price (all plans) Emory Mark Up Reimbursement Method ( of charge or fixed) - 1713 Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Cardiovascular stress test 93017 Cardio $543 $ 425 28 of Charge 70 $ 380 of Charge 65 $ 353 of Charge 60 $ 326 of Charge 70 $ 380 of Charge 70 $ 380 of charge 100 $ 543 of Charge 70 $ 380 of charge 100 $ 543 of charge 100 $ 543 TTE wDoppler complete 93306 Cardio $1226 $ 960 28 of Charge 70 $ 858 of Charge 65 $ 797 of Charge 60 $ 736 of Charge 70 $ 858 of Charge 70 $ 858 of charge 100 $ 1226 of Charge 70 $ 858 of charge 100 $ 1226 of charge 100 $ 1226 Colonoscopy and biopsy (HOSPITAL ONLY) 45380 Surg $2530 $ 3076 -18 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 of Charge 70 $ 1771 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Diagnostic colonoscopy (HOSPITAL ONLY) 45378 Surg $2255 $ 3076 -27 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 of Charge 70 $ 1579 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Upper gi endoscopy biopsy (HOSPITAL ONLY) 43239 Surg $1787 $ 3076 -42 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Knee Arthroscopy (HOSPITAL ONLY) 29881 Surg $10900 $ 5069 115 Fixed Rate SC 4 $ 3865 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 449300 $ 4493 Fixed Rate $ 654700 $ 6547 of Charge 70 $ 7630 Fixed Rate $ 401000 $ 4010 of Charge 70 $ 7630 Fixed Rate $ 398300 $ 3983 Fixed Rate $ 398100 $ 3981 Arthroscopy Ligament Repair (HOSPITAL ONLY) 29888 Surg $10900 $ 5062 115 Fixed Rate SC 3 $ 3121 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 556900 $ 5569 Fixed Rate $ 770100 $ 7701 of Charge 70 $ 7630 Fixed Rate $ 323900 $ 3239 of Charge 70 $ 7630 Fixed Rate $ 321700 $ 3217 Fixed Rate $ 321400 $ 3214 Comp Metabolic Panel 80053 Lab $132 $ 56 138 RBRVS Fee (100) $ 1437 of Charge 65 $ 86 of Charge 65 $ 86 of Charge 65 $ 86 of Charge 70 $ 92 RBRVS Fee (100) $ 1437 $ 14 of Charge 70 $ 92 RBRVS Fee (100) $ 1437 $ 14 RBRVS Fee (100) $ 1437 $ 14 Surgical Path Tissue Exam 88305 Lab $326 $ 236 38 of Charge 150 $ 51 of Charge 65 $ 212 of Charge 65 $ 212 of Charge 65 $ 212 of Charge 70 $ 228 of charge 100 $ 326 of Charge 70 $ 228 of charge 100 $ 326 of charge 100 $ 326 MRI Abdomen 74183 Radiology $6960 $ 1238 462 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 MRI Brain 70553 Radiology $6804 $ 1238 450 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 MRI Joint Lower Extremity 73721 Radiology $3067 $ 1238 148 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 CT Thorax wo contrast 71250 Radiology $2199 $ 882 149 Fixed Rate $ 771 Fixed Rate $ 47100 $ 471 Fixed Rate $ 81700 $ 817 Fixed Rate $ 116000 $ 1160 of Charge 70 $ 1539 Fixed Rate $ 80100 $ 801 Fixed Rate $ 79200 $ 792 Fixed Rate $ 79300 $ 793 Fixed Rate $ 79500 $ 795 X-ray Chest 71020 Radiology $280 $ 115 142 of Charge 150 $ 25 of Charge 65 $ 182 of Charge 60 $ 168 of Charge 70 $ 196 of Charge 70 $ 196 RBRVS Fee (150) $ 2534 $ 25 of Charge 70 $ 196 RBRVS Fee (150) $ 2534 $ 25 RBRVS Fee (150) $ 2534 $ 25 Screening mammography G0202 Radiology $279 $ 141 98 Fixed Rate $ 128 Fixed Rate $ 13100 $ 131 Fixed Rate $ 14300 $ 143 Fixed Rate $ 16100 $ 161 of Charge 70 $ 195 Fixed Rate $ 13300 $ 133 Fixed Rate $ 13500 $ 135 Fixed Rate $ 13000 $ 130 Fixed Rate $ 11200 $ 112 Mammo Computer Aided 77052 Radiology $75 $ 112 -33 Fixed Rate $ 9 Fixed Rate $ 13100 $ 131 Fixed Rate $ 14300 $ 143 Fixed Rate $ 16100 $ 161 of Charge 70 $ 53 Fixed Rate $ 13300 $ 133 Fixed Rate $ 13500 $ 135 Fixed Rate $ 13000 $ 130 Fixed Rate $ 11200 $ 112 US Abdomen Complete 76700 Radiology $917 $ 397 131 of Charge 150 $ 125 of Charge 65 $ 596 of Charge 60 $ 550 of Charge 70 $ 642 of Charge 70 $ 642 RBRVS Fee (150) $ 12519 $ 125 of Charge 70 $ 642 RBRVS Fee (150) $ 12519 $ 125 RBRVS Fee (150) $ 12519 $ 125 Officeoutpatient visit new pt 30 min (TEC) 99203 EampM $316 $ 248 28 of Charge 70 $ 221 of Charge 65 $ 205 of Charge 60 $ 190 of Charge 70 $ 221 of Charge 70 $ 221 of charge 100 $ 316 of Charge 70 $ 221 of charge 100 $ 316 of charge 100 $ 316 Vaginal delivery 59409 Surg $14484 $ 7290 99 Fixed Rate DRG - 775 $ 5437 2 Day Case Rate + LOC 561700 $ 5617 BaseCMS Weight 584741 $ 5847 BaseCMS Weight 726146 $ 7261 No IP Terms $ - 0 No IP BaseCMS Weight 659343 $ 6593 BaseContract Weight 479451 100 $ 14484 BaseCMS Weight 579110 $ 5791 Lap Sleeve Gastrectomy 43775 Surg $29961 $ 20421 47 Fixed Rate DRG - 621 $ 14872 BaseCMS Weight 1810697 $ 18107 BaseCMS Weight 1835178 $ 18352 BaseCMS Weight 2278911 $ 22789 No IP Terms $ - 0 No IP BaseCMS Weight 2069315 $ 20693 BaseCMS Weight 1730442 100 $ 29961 BaseCMS Weight 1817507 $ 18175 105 Colonoscopy and biopsy (ASC ONLY) Surg $ 219200 $ 2181 Diagnostic colonoscopy (ASC ONLY) Surg $ 267100 $ 2348 Upper gi endoscopy biopsy (ASC ONLY) Surg $ 207500 $ 2758 Knee Arthroscopy (ASC ONLY) Surg $ 417900 $ 3467 Arthroscopy Ligament Repair (ASC ONLY) Surg $ 504800 $ 3386
Cpt Code CPT Description Procedure Category Claims Min 25thNtile 50thNtile Emorys Rates 75thNtile 90thNtile Max 20 Below 50th Ntile 20 Above 50th Ntile 93017 CARDIOVASCULAR STRESS TEST 5 82 $80 $125 $321 $382 $568 $791 $930 $257 $386 71020 CHEST X-RAY 2 2638 $11 $45 $152 $115 $289 $373 $585 $122 $182 71020 CHEST X-RAY 5 8106 $25 $34 $38 $54 $57 $69 $30 $46 45380 COLONOSCOPY AND BIOPSY 6 1256 $541 $560 $572 $2877 $1000 $2024 $3289 $458 $686 77052 COMP SCREEN MAMMOGRAM ADD-ON 2 194 $13 $15 $25 $38 $47 $134 $20 $30 77052 COMP SCREEN MAMMOGRAM ADD-ON 5 2411 $13 $16 $20 $23 $26 $28 $16 $24 80053 COMPREHEN METABOLIC PANEL 8 13019 $9 $19 $23 $55 $24 $25 $69 $19 $28 71250 CT THORAX WO DYE 2 302 $165 $372 $545 $878 $1658 $2067 $436 $654 71250 CT THORAX WO DYE 5 209 $53 $127 $203 $289 $419 $534 $162 $244 45378 DIAGNOSTIC COLONOSCOPY 6 1479 $484 $515 $536 $2914 $831 $1971 $2828 $428 $643 29881 KNEE ARTHROSCOPYSURGERY 6 152 $1650 $1826 $2036 $5235 $3054 $4216 $6461 $1629 $2443 29888 KNEE ARTHROSCOPYSURGERY 6 82 $1682 $3615 $5081 $5145 $7553 $12924 $18532 $4065 $6097 43644 LAP GASTRIC BYPASSROUX-EN-Y 1 21 $11821 $13873 $17050 $18391 $25029 $31079 $13640 $20460 43775 LAP SLEEVE GASTRECTOMY 1 38 $4215 $8250 $13253 $20421 $19197 $21509 $24260 $10602 $15903 74183 MRI ABDOMEN WO amp WDYE 2 120 $919 $987 $1015 $1237 $1252 $2534 $3177 $812 $1218 74183 MRI ABDOMEN WO amp WDYE 5 112 $475 $490 $521 $1154 $1337 $1696 $417 $625 70553 MRI BRAIN WO amp WDYE 2 324 $633 $987 $1142 $1237 $1706 $2805 $3331 $914 $1370 70553 MRI BRAIN WO amp WDYE 5 467 $280 $539 $1023 $1277 $1363 $1726 $818 $1228 73721 MRI JNT OF LWR EXTRE WO DYE 2 304 $804 $859 $967 $1237 $1063 $1598 $2485 $774 $1160 73721 MRI JNT OF LWR EXTRE WO DYE 5 1130 $500 $520 $530 $628 $679 $859 $424 $636 59400 OBSTETRICAL CARE 1 494 $3699 $4402 $4969 $6655 $7307 $8613 $3975 $5963 99203 OFFICEOUTPATIENT VISIT NEW 4 6776 $88 $101 $112 $138 $155 $169 $90 $134 G0202 Screeningmammographydigital 2 7444 $123 $206 $285 $380 $425 $479 $228 $342 G0202 Screeningmammographydigital 5 2754 $117 $165 $195 $230 $247 $252 $156 $234 88305 TISSUE EXAM BY PATHOLOGIST 8 20834 $51 $74 $112 $235 $168 $261 $478 $90 $134 93306 TTE WDOPPLER COMPLETE 2 931 $194 $377 $739 $960 $1267 $1480 $1849 $591 $887 93306 TTE WDOPPLER COMPLETE 5 2299 $151 $296 $373 $538 $573 $834 $298 $448 43239 UPPER GI ENDOSCOPY BIOPSY 6 1264 $424 $514 $550 $800 $1838 $2833 $440 $660 76700 US EXAM ABDOM COMPLETE 2 321 $96 $165 $271 $509 $584 $857 $217 $325 76700 US EXAM ABDOM COMPLETE 5 444 $111 $129 $147 $156 $220 $279 $118 $176 Key 1 Facility - Inpatient 2 Facility - Imaging 3 Physician - Imaging 4 Physician 5 Global - Imaging 6 Facility - Outpatient 8 Lab 41 Physician - Primary Care 42 Physician - Specialist Cardiovascular stress test $ 38279 TTE wDoppler complete $ 96037 Colonoscopy and biopsy $ 287709 Diagnostic colonoscopy $ 291434 Upper gi endoscopy biopsy $ 300526 Knee Arthroscopy $ 523584 Arthroscopy Ligament Repair $ 514501 Comp Metabolic Panel $ 5552 Surgical Path Tissue Exam $ 23570 MRI Abdomen $ 123786 MRI Brain $ 123786 MRI Joint Lower Extremity $ 123786 CT Thorax wo contrast $ 88213 X-ray Chest $ 11548 Screening mammography $ 14098 Mammo Computer Aided $ 11179 US Abdomen Complete $ 39695 Officeoutpatient visit new pt 30 min $ 24753 Vaginal delivery $ 729025 Lap Sleeve Gastrectomy $ 2042124
Page 9
Boeing 1UW Med 2Memorial Care 3Mercy MO 4Roper St Francis 5ProvSwedish
DART amp Baylor Scott and White Health
Intel amp 1 Presbyterian ACO 2 Arizona Care Network
Quallcom amp Scripps Health
Stanford Healthcare Alliance
General Motors amp Henry Ford Health
Disney amp 1Orlando Health 2Florida Hospital
Walmart amp 1 Banner 2 Emory 3 Memorial Hermann 4 Mercy AK 5Mercy OK 6 Mercy MO 7Oschner Health 8 Presbyterian 9 St Lukersquos 10 Unity Point 11 Cleveland Clinic 12 Geisinger Health 13Johns Hopkins 14Mayo Clinic AZ 15Mayo Clinic FL 16Mayo MN 17Mercy MO
1 2
3
4 5
6
8
7
9
10
1
3
4 2
1
2
1
Whole Foods amp Adventis Health
11 12 13
14
15
16
17
Emergence of Direct Contracting
8
DC with providers to secure improved pricing
COE through a carve-out provider
COE within the health plans
Source Willis Towers Watson 23rd Annual Best Practices in Health Care Employer Survey Full report and high-performance insights httpswwwwillistowerswatsoncom-mediaWTWPDFInsights201812willis-towers-watson-23rd-annual-best-practices-in-health-care-employer-survey-full-reportpdf 2018
Trends in Direct Contracting amp COE
According to Willis Towers Watsonrsquos survey employers are using COEs mostly through their health plans however direct contracting considerations are expected to grow considerably
6
7
48
2
2
7
14
13
20
0 20 40 60 80
Action taken or tactic used in 2018
Planning for 2019
Considering for 2020
bull Almost 50 use COEs in 18rsquo expected to rise to 2 out of 3 by 2020
bull Employers engaging employees in multiple ways to use COE bull Ongoing communications bull Reducing member cost share
to use bull Increasing member cost
share when not using bull Mandatory use
9
16
12
18
9
3
6
2
50
39
19
22
26
11
10
15
19
31
30
31
22
11
Transplants
Bariatric Surgery
Knees hips or spine
Cardiovascularcardiac
Cancer
Fertility
Other Procedures
Yes with incentives Yes but no incentives No but considering
10
A 2015 survey by the National Business Group on Health shows the status of large employersrsquo contracts with COEs (note reflects all COEs not specifically direct contracts)
Source Large Employersrsquo 2016 Health Plan Design Survey copy 2015 National Business Group on Health
Other centers of excellence programs include maternity NICU sleep apnea pancreas cornea and kidney
National Business Group on Healthrsquos Large Employers 2019 Health Care Strategy and Plan Design Survey showed DC arrangements between employers and bull Health systemsproviders will
increase from 3 in 2018 to 11 in 20191
bull COEs will increase from 12 in 2018 to 18 in 20191
bull Cancer cardiovascular and fertility COEs are experiencing the greatest growth
Source National Business Group on Health ldquoLarge US Employers Eye Changes to Health Care Delivery System as Cost to Provide Health Benefits Nears $15000 per Employeerdquo August 2018
10
Trends in Direct Contracting amp COE
Outcomes amp Benefits bull Employers with COE arrangements are seeing reduction in procedures
bull Walmart (15rsquo-18rsquo) 50+ of spine surgeries amp 20 of kneehip procedures recommended by local providers were determined lsquonot necessaryrsquo by COE (see table)
bull Employers like Walmart amp Boeing continue to sign new providers which suggest (employersrsquo) continued interest in pursuing DC arrangements2 However Boeing and Providence Swedish did end relationship due to inability to capture enoughright data to estimate cost of care3
bull John Hopkinsrsquo Bayview campus COE emerging metrics4
bull 121 referrals in the first three months
bull 352 referrals and 183 surgeries over 18 months
bull 23 of all joint replacement volumes at facility now attributed to travel program
bull 96 of patients said they would recommend this program to family friends coworkers
bull Bingham Memorial in Idaho direct contracting emerging metrics4
bull 17 companies participating covering over 5000 lives
bull +3000 new patients as of October 2018
bull +$3M Revenue from new patients
11
1 How Employers Are Fixing Health Care Harvard Business Review March 2019 2 httpswwwhealthleadersmediacomstrategywalmart-escalates-strategy-solve-employee-healthcare Health Leaders Media Nov 18rsquo 3 Do Providers Have the Data chops to Success with Direct Contract Modern Healthcare August 2018 4 Re-Igniting the Growth Engine Part 2 Winning Increased Share of Lucrative Patient Volumes Advisory Board 5 httpswwwautonewscomarticle20180806OEM180809831gm-signs-major-health-care-services-deal-for-salaried-employees
Walmart COE Programs1
Program Key Benefits
Spin
e Su
rger
y 2300 EEs 50 COE approved of those applied
bull 95 lower readmission bull 14 less time in hospital bull 1 COE vs 5 non-COE patients discharged to SNF bull Returned to work sooner reducing 20 of OOO
time bull More-effective less dangerous amp less expensive bull The COE surgery ldquopricerdquo is 8 higher but value in
earlier discharge lower readmission rates far less utilization of SNF faster return to work
Join
t
1836 EEs 18 COE approved of those applied
bull 32 less time in hospital bull 70 less likely to be readmitted than non-COE
patients bull Fewer postsurgical complications bull 0 COE vs 5 non-COE patients discharged to SNF bull COE patients returned to work a 15 weeks sooner bull Cost of surgery is 15 less at COE hospitals
Baria
tric
300+ EEs
bull Preliminary data suggests the weight loss from surgery reduces absenteeism or presentism (working while sick)
bull Dramatically cuts pharmacy amp medical costs Complications of obesity drop sharply as does the need for medication
bull GMrsquos direct contract benefit plans with Henry Ford allows it to offer similarly designed plans to that of Blue Cross with savings in monthly EE contributions ranging from $300-$19805
Walmartrsquos Travel (Surgery) Program
Mem
ber F
eedb
ack
12
Looking beyond traditional cost management techniques Walmart designed a program to address wild variations in cost and become directly in improving quality of care for its employees FIRST SELECTING PROVIDERS 1 Identify providers with high volume and high quality 2 Target regions in country to support Walmartrsquos employees 3Focus on Integrated Health Systems Hospitals within these systems were best aligned to Walmarts mission could take on risks associated with bundling 4 Eliminate systems unwilling to do bundled payments model were
PROVIDERS VALUE IN PARICIPATING
Build Bundles bull Define bundles and negotiate price (typically 10-15 below FFS ) bull Definitions of service limit disputes of what is covered vs not (covers
entryexit of facility SNF not part of bundle) bull Contract flexibility covers unforeseen testcosts and reinforces
Walmarthealth system partnership bull Warrantees if further treatment - can return in 30 days no
additional cost to Walmart bull Strict criteria and providers with track record of clinically sound
decisions are included to mitigate any incentivizing of volume Business bull 100 travelaccom brings
new volume of patients from outside of market
bull More stable payments for services (vs Medicare or commercial FFS)
bull Increased visibility and attract new business
Clinical bull lsquoHalorsquo effect ndash Building a highly
efficient multidiscipline program brings improvements throughout health system
bull Onsite collaboration among health systems allows sharing of outcomesbest practices
Source How Employers Are Fixing Health Care Harvard Business Review March 2019
5000 participants in the program
95 satisfiedvery satisfied
Denied by care because not deemed necessary by COE Treatment denied due to lifestyle weightsmoking
The Member Experience
13
Engagement begins when employee on clear
path to surgery
Patient contacts with COE TPA
TPA team triages and ensures basic criteria
met
Employee put in touch with nurse team
Car pick-up Flight Hotel all arranged by
TPA
Navigators and nurse coordinators help
throughout the stay
Patient visits to hospital to understand
exceptions of procedure and meet treatment
team
Surgery occurs typically next day
Stay length according to procedure typically a
few days
Discharged from facility Travel home COE team updates local
PCP and discuss follow up care
COE provider checks in with local physician
frequently Revert back to standard coverage
Source How Employers Are Fixing Health Care Harvard Business Review March 2019
Case Study 1
Case study 1 ndash Pop Health Approach bull ProblemCircumstance Large multi-employer group needs to
evaluate benefit design disease prevalence health spend and utilization to manage their population
bull ConsiderationsValue Prop Unique industry and geography drive chronic conditions and utilization patterns
bull Solution Provide opportunity assessment comparing this population to other benchmarks to understand where to target intervention and management as well as assess efforts already taken
15
Market Comparison Preference Sensitive Procedures
16
Legend vs
Mt States vs
National gt120 gt110
110-120 105-110 lt80 lt90
Source Multi-payer commercial benchmark Results are weighted by AgeGender Broader market area includes multi-payer data from the mountain regions
Preference Sensitive Procedures Benchmark Comparison
Dartmouth Atlas Preference Sensitive Procedures
IP allowed dollars ALOS Employer vs
Mt States Employer
vs National FY 2017 FY 2018 FY 2017 FY 2018
Hysterectomy for Uterine Fibroids Rate $569354 $436932 45 54 124 140 CABG Rate $1800260 $2400608 53 60 218 130 Cholycystectomy Rate $832675 $755565 68 39 92 120 C-Section Rate 116 110 HighTech Radiology Rate 103 101 PCIPTCA Rate $934486 $1133708 37 55 82 80 Back Surgery Rate $3237613 $4003212 39 57 52 70 Knee Replacement Rate $3086693 $2177334 41 48 50 64 Total Hip Replacement Rate $1023675 $747491 45 64 37 34
Strengths (+)
Employer compares favorably for orthopedic procedures (back hip knee)
Opportunity (-)
Employer has higher than expected rates for CABG and hysterectomy (Note Low PTCA rate combined with high CABG rate may suggest provider practice patterns favoring CABG)
0 50 100 150 200 250
Total Hip Replacement
Knee Replacement
Back Surgery
PCIPTCA
Cholycystectomy
HighTech Radiology
C-Section
CABG
Culinary VsNational
Culinary Vs MtStates
Employer vs Mt States
Employer vs National
Market Comparison Condition Prevalence
17 Source Multi-payer commercial benchmark Results are weighted by AgeGender Broader market area includes multi-payer data from the mountain regions
Condition Prevalence Benchmark Comparison
Condition Employer vs
Mt States Employer vs
National Prevalence Diabetes Rate 229 219 Prevalence Hyperlipidemia Rate 259 207 Prevalence Kidney Disease Rate 143 174 Prevalence Migraine Rate 166 164 Prevalence Low Back Pain Rate 136 139 Prevalence Hypertension Rate 156 134 Prevalence Asthma Rate 146 128 Prevalence CAD Rate 175 115 Prevalence Pregnancy Rate 110 109 Prevalence Adult Preventive Screening Rate 114 91 Prevalence Depression Rate 63 60
Strengths (+)
Rate of depression is low (Note May be due to incomplete behavioral health claims)
Opportunity (-)
Employer has a higher prevalence of most chronic conditions including asthma CAD diabetes hypertension hyperlipidemia Kidney Disease LBP and migraines
0
100
200
300Hyperlipidemia
Diabetes
CAD
Migraine
Hypertension
AsthmaKidney Disease
Low Back Pain
Pregnancy
Depression
Employer vsMt States
Employer vsNational Legend
vs Mt States
vs National
gt120 gt110 110-120 105-110
lt80 lt90
Market Comparison Utilization Rates
18
A higher preventive office visit rate is better Source Multi-payer commercial benchmark Results are weighted by AgeGender Broader market area includes multi-payer data from the mountain regions
Strengths (+)
Lower than average utilization of ED and high dollar patient rate
Opportunity (-)
Higher LOS lengthy admits avoidable admits and readmissions which all drive significantly more spend
Utilization Benchmark Comparison
Condition Employer vs
Mt States Employer vs
National Avoidable Admit Rate 142 144 Lengthy Admit Rate 175 136 Outpatient Problem Focused Office Rate 146 131 Readmission Rate (readmitadmit) 135 126 Average LOS 125 116 One Day Admit Rate 76 103 Office Visit Rate 106 96 Acute Admit Rate 80 95 Avoidable ED Rate 68 86 ED Rate 54 69 Preventive Office Rate 95 68 High Dollar Patient Rate 49 51 Frequent ED User (gt3 times) Rate 24 36
Legend vs
Mt States vs
National gt120 gt110
110-120 105-110 lt80 lt90
0 50 100 150 200
Frequent ED User (gt3 times)
High Dollar Patient
Preventive Office
ED
Avoidable ED
Acute Admit
Office Visit
One Day Admit
Average LOS
Readmissionhellip
Outpt Problem Focusedhellip
Lengthy Admit
Avoidable Admit
Employer vsNational
Employer vsMt States
ED and Avoidable ED
19
Potentially Avoidable ED - Trend View Overall ED
Period Change FY 2017 FY 2018 Count Rate
Measure Mbrs Rate Mbrs Rate Overall ED 16394 12626 13820 10745 -16 -15 FREQUENT ED UTILIZER (mbr1k) 1581 1218 1468 1141 -7 -6 AVOIDABLE ED 6371 4907 5288 4111 -17 -16 Potentially Avoidable ED
Period Change FY 2017 FY 2018 Count Rate
Avoid ED Condition Mbrs Rate Mbrs Rate ABDOMINAL_PAIN 1092 841 895 696 -18 -17 ENT_INFECTION 854 658 742 577 -13 -12 FEVER 715 551 700 544 -2 -1 URINARY 650 501 468 364 -28 -27 HEADACHE 558 430 434 337 -22 -21 BACK_PAIN 414 319 423 329 2 3 NAUSEA 394 303 271 211 -31 -31 ASTHMA 294 226 209 162 -29 -28 CELLULITIS 210 162 198 154 -6 -5 GASTROENTERITIS 254 196 171 133 -33 -32 OTITIS_MEDIA 201 155 160 124 -20 -20 COPD 132 102 108 084 -18 -17 DIABETES 123 095 91 071 -26 -25 BACT_PNEUMONIA 111 085 86 067 -23 -22 DENTAL 93 072 83 065 -11 -10 DEHYDRATION 98 075 81 063 -17 -17 HYPERTENSION 16 012 24 019 50 51 CHF 4 003 3 002 -25 -24 ANGINA 8 006 3 002 -63 -62 IMMUNIZATION_RELATED 2 002 0 000 -100 -100 Grand Total 6371 4907 5288 4111 -17 -16
AHRQ avoidable ED visits are based on the logic for ambulatory care sensitive ED visits from AHRQ and diagnosis code driven
696
577
544 364
337
329
211 162
154 133 ABDOMINAL_PAIN
ENT_INFECTION
FEVER
URINARY
HEADACHE
BACK_PAIN
NAUSEA
- 200 400 600 800
1000 1200
2017 Members 2018 Members
Top Ten 2018 Conditions by Rate
Top Ten Conditions by Member Count
ED Avoidable ED and the impact of new on-site clinic
20
0
1000
2000
3000
4000
5000
6000
0200400600800
10001200140016001800
Clinic Visits ED Visits
Avoidable ED VisitsED Visits (non-avoidable)Clinic EampM Visits
0
500000
1000000
1500000
2000000
2500000
3000000
3500000
$s
Clinic EampM Profess DollarsAvoidable ED Dollars
bull Clinic visits have a clear impact on ED and avoidable ED use and spend
bull Combined ED visits are down on average 157 in FY 18 from FY 17
bull Combined ED spend is down 128 in FY 18 from FY 17
Clinic Live 62017
Pitfalls and Challenges bull Face many of the challenges similar to startup health
plan bull Critical to determine how you will deliver value and
communicate the value to potential customers and brokersconsultants
bull Care management bull Network
21
Considerations in Offering Development bull Care Management Model
bull Traditional care model bull Case management bull Utilization management bull Disease management
bull Longitudinal care model with value based care philosophy bull Primary care driven bull Local care management
bull Predictive analytics and risk stratification model bull Claims history and ongoing data bull EMR data
22
Case Study 2
Case study 2 ndash Large Employer bull Business Problem Large employer wants to contract
directly with 2 major hospital systems developing professional fee schedules
bull ConsiderationsValue Prop Fee schedule should be competitive but also nuanced to minimize gap relative to current reimbursement at physician level
bull Solution Data-driven approach using current market-wide reimbursement distinguished by service level
24
Evaluate Provider Spend Top 25 Service Lines by Allowable Spend
Evaluate Provider Spend Top 20 Professional CPTs by Total Spend
Understand relative market pricing position
27
21
-1
-28
14 10
28
-22
-11 -13
24
3
20 21
8
-20
13
3 9
-39
56
-26
4
-42
60
MRI Colonoscopy Cardiac Cath Lab - OrganPanel
Memorial Hospital Beta Hospital Delta Hospital Charlie Hospital Echo Hospital Alpha Medical Center
ndash25 5 -15 10 0 39
State Charges as a Percent of Peer Average Weighted Averages for MRI Colonoscopy Cardiology and Lab
Total Percent Above Below Market Average2
Memorial Hospital Beta Hospital Delta Hospital Charlie Hospital Echo Hospital Alpha Medical Center
Develop fee schedule relative to market
28
Service Line Procedure CPT CodeDRG
Memorial Hospital
Beta Hosptial
Charlie Hospital
Delta Hospital
Echo Hospital
Alpha Medical Center
Arthroscopy Ligament Repair 29888 $ 5062 $ 9557 $ 5983 $ 10096 $ 7519 $ 2502 Knee Arthroscopy 29881 $ 5069 $ 4185 $ 3837 $ 3022 $ 3729 $ 2266 Upper GI Endoscopy 43239 $ 3075 $ 2539 $ 2012 $ 1132 $ 1565 $ 2240 Lap Sleeve Gastrectomy DRG 621 $ 20421 $ 20815 $ 12105 $ 13230 $ 14600 $ 17800 Colonoscopy and biopsy 45380 $ 3075 $ 3071 $ 2013 $ 1244 $ 1972 $ 859 Diagnostic Colonoscopy 45378 $ 3075 $ 2805 $ 2013 $ 1244 $ 1972 $ 859 MRI Brain w amp wo dye 70553 $ 1238 $ 1468 $ 1117 $ 967 $ 2805 $ 1052 MRI Joint of Lower Extremity wo dye 73721 $ 1238 $ 1398 $ 1042 $ 967 $ 925 $ 557 MRI Abdomen w amp wo dye 74183 $ 1238 $ 1468 $ 1106 $ 967 $ 2805 $ 836 X-ray Chest 71020 $ 115 $ 266 $ 305 $ 279 $ 375 $ 72 CT Thorax wo dye 71250 $ 882 $ 810 $ 505 $ 491 $ 579 $ 319 Ultrasound Abdomen Complete 76700 $ 397 $ 538 $ 545 $ 195 $ 190 $ 168 Mammogram Screening G0202 $ 141 $ 328 $ 431 $ 294 $ 425 $ 168 Computer Detection Add-on 77052 $ 112 $ 99 $ 41 $ 15 $ 45 $ 23 Comp Metabolic Panel 80053 $ 56 $ 15 $ 24 $ 56 $ 51 $ 25 Tissue Exam by Pathologist 88305 $ 236 $ 307 $ 80 $ 152 $ 78 $ 232 Cardiovascular Stress Test 93017 $ 383 $ 432 $ 1299 $ 907 $ 717 $ 797 TTE w Doppler 93306 $ 960 $ 1566 $ 1388 $ 1173 $ 1125 $ 1157
Obstetrics Vaginal Delivery DRG 755 7290$ 5730$ 4654$ 4607$ 5855$ 4688$
GI
Lab
Radiology
Medical Cardiology
Orthopedics
KEY OBSERVA TIONS bull Potential exposure on GI bull Opportunity to align price and acuity in MRI bull Opportunity to raise rates on chest x-ray and mammogram
Percentile Bands Emory Allowables Heatmap TEC ASC Heatmap Allowable Comp Analysis Portal Pricing Sheet1 image1png A few words on Bundled Payments bull Bundled payments are growing as a type of direct contracting bull In some cases third parties match-make between employers
and providers bull Contracts may vary in definitions prepost admission
coverage duration readmission cause (ie all-cause vs medically related) outlier provisions LOS caps andor per diems
bull Providers need to be strategic in pricing to enable profitable growth of market share
29
Considerations in Offering Development bull Network Development
bull Build off existing structure eg health system employee plan network bull How does this fit into your broader value based care strategy bull Employed and independent physicians bull How do you want to approach the buildout of high performance
network bull Quality focus bull Cost efficiency
bull Integrated behavioral health bull Wrap network for other markets
30
Considerations in Offering Development bull Target Market
bull Consideration of employer profile in market bull Fully-insured vs ASO bull Total cost of care vs bundled services
bull Distribution bull Direct marketing bull Brokerconsultant community
bull Plan designs bull Standard designs vs flexible ndash Dependent on target market
bull Claims administration bull Data sharing amp analytics
31
Considerations in Offering Development bull Other components of comprehensive offering
bull Pharmacy bull Preventive health bull Onsite clinics bull Wellness programs bull Technology platform
32
Sample Bundle Analysis
33
Cover page Dotson Hazelrigs Nation Mainly of charge of fixed Cardiovascular stress test TTE wDoppler complete Colonoscopy and biopsy (Combined) Diagnostic colonoscopy (Combined) Upper gi endoscopy biopsy (Combined) Knee Arthroscopy (Combined) Arthroscopy Ligament Repair Comp Metabolic Panel Surgical Path Tissue Exam MRI Abdomen MRI Brain MRI Joint Lower Extremity CT Thorax wo contrast X-ray Chest Screening mammography Mammo Computer Aided US Abdomen Complete Officeoutpatient visit new pt 30 min Vaginal delivery Lap Sleeve Gastrectomy
Piedmont Piedmont Piedmont Piedmont Northside Northside Northside Northside Gwinnett Gwinnett Gwinnett Gwinnett WellStar WellStar WellStar WellStar AMC - Tenet AMC - Tenet AMC - Tenet AMC - Tenet CPT Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing 29881 $11312 $10872 NA NA $7476 $9338 NA $23655 $11856 $3668 NA $17871 $12253 NA NA $15645 $5490 NA NA $23039 29888 NA NA NA NA NA NA NA $23784 NA $8261 NA $18000 NA NA NA $15774 NA NA NA $23168 43239 NA $4408 NA NA NA NA $5997 $8852 NA $3304 NA $7424 $1267 NA NA $9230 NA $2458 NA $8274 43644 $26468 NA NA NA $3382 $12050 NA $1861 NA NA NA $1316 $7841 NA NA $3444 $18892 $27950 NA $979 43775 NA NA NA NA NA NA NA $352 NA NA NA $302 NA NA NA $413 NA NA NA $83 45378 $2705 $2530 NA NA $4381 $3676 $4496 $1022 $2938 $2138 NA $695 $5504 NA NA $2036 NA NA NA $372 45380 $3075 $2600 NA NA $4723 $3527 $3012 $1757 $4215 $2285 NA NA $5298 NA NA $3268 NA NA NA $627 59400 $6160 NA NA NA NA $5100 NA $1851 NA NA NA $1304 $9035 NA NA $3427 $9116 $5150 NA $966 70553 $2985 NA $1153 NA $2182 NA $1192 $492 NA NA $803 $489 $1512 NA $985 $1187 NA NA NA $197 71020 $61 $69 $43 NA $113 $319 $307 NA $183 $59 $32 NA $213 $66 $40 NA $83 $53 NA NA 71250 $1837 $621 $989 NA $1490 $931 $755 NA NA $745 $401 NA $1067 $982 $616 NA NA $304 NA NA 73721 NA $1098 $1153 NA $2042 $1065 $1192 NA NA $998 $803 NA NA $1275 $985 NA NA $644 NA $178 74183 $2971 $1144 NA NA NA $1092 $1192 $6884 NA $1098 $803 NA $2960 $1197 $985 $5454 NA NA NA $7607 76700 $364 $247 $207 NA $427 $708 $614 $13267 $428 $214 $152 NA $747 $263 $189 $9139 NA $235 NA NA 77052 NA NA NA NA NA NA NA $4744 NA NA NA NA NA NA NA $3070 NA NA NA $5611 93306 $1220 $1117 NA NA $1877 $1657 $2100 $4605 $1433 $413 $945 NA $1336 $1434 $1951 $2931 NA $2399 NA $5472 G0202 $262 $187 NA NA $431 NA NA $4605 $292 NA NA NA $530 $281 NA $2931 $327 NA NA $5472
Provider Group 29881_6 29888_6 43239_6 43644_1 43775_1 45378_6 45380_6 59400_1 70553_2 71020_2 71250_2 73721_2 74183_2 76700_2 77052_2 77052_5 80053_8 88305_8 93306_2 99203_4 G0202_2 G0202_5 93017_2 Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Atlanta Gastroenterology Associates $2399 $536 348 $1628 $536 204 $2400 $536 348 Atlanta Medical Center $24889 $2266 999 $25897 $2502 935 $11449 $2240 411 $81927 $15300 435 $75815 $17800 326 $7317 $859 752 $7317 $859 752 $12821 $4688 173 $6581 $1052 526 $645 $72 796 $3265 $319 925 $3450 $557 519 $7398 $836 785 $1576 $133 1084 $73 $23 217 $635 $25 2440 $891 $232 285 $2967 $1157 156 $344 $168 105 $1265 $797 59 Atlanta Womens Health Physicians Group $29 $14 107 $40 $13 208 $396 $188 111 $278 $118 135 $450 $231 95 Gwinnett Hospital $11941 $3022 295 $21654 $10096 114 $3551 $1132 214 $34384 $10800 218 $56472 $13230 327 $3003 $1244 141 $3533 $1244 184 $8984 $4607 95 $3901 $967 303 $417 $279 49 $2247 $491 358 $4000 $967 314 $3755 $967 288 $1593 $195 717 $50 $15 233 $186 $56 233 $505 $152 233 $1750 $1173 49 $418 $294 42 $1396 $907 54 Northside Hospital $15482 $4185 270 $21651 $9557 127 $4885 $2539 92 $35176 $17000 107 $35233 $20815 69 $3883 $2805 38 $5256 $3071 71 $10911 $5730 90 $4856 $1468 231 $443 $266 67 $2379 $810 194 $3776 $1398 170 $5105 $1468 248 $942 $538 75 $167 $99 69 $379 $15 2427 $433 $307 41 $2252 $1566 44 $459 $328 40 $576 $432 33 Piedmont Hospital $14772 $3837 285 $35493 $5983 493 $5069 $2012 152 $38320 $17750 116 $37125 $12105 207 $3485 $2013 73 $4993 $2013 148 $10143 $4654 118 $5939 $1117 432 $542 $305 78 $2983 $505 491 $3410 $1042 227 $6067 $1106 449 $1364 $545 150 $75 $41 85 $231 $24 863 $657 $80 721 $2041 $1388 47 $490 $431 14 $1780 $1299 37 Piedmont Physicians Group $42 $22 87 $318 $179 78 $239 $159 50 Resurgens $8558 $2036 320 $9293 $2258 312 $4638 $2067 124 $4039 $2164 87 $4392 $2164 103 $2252 $1371 64 $459 $330 39 Wellstar Hospital $9330 $3729 150 $17479 $7519 132 $5261 $1565 236 $35794 $18200 97 $46780 $14600 220 $3707 $1972 88 $4928 $1972 150 $13549 $5855 131 $5054 $2805 80 $528 $375 41 $3222 $579 457 $3694 $925 299 $5495 $2805 96 $1355 $190 615 $66 $45 46 $73 $51 43 $133 $78 71 $1785 $1125 59 $599 $425 41 $1010 $717 41 Avg Mark UpProcedure Atlanta Medical Center 634 Gwinnett Hospital 223 Northside Hospital 233 Piedmont Hospital 259 Wellstar Hospital 155 Emory 105
Atlanta Gastroenterology Associates Atlanta Medical Center Atlanta Womens Health Gwinnett Hospital Northside Hospital Piedmont Hospital Piedmont Physicians Group Resurgens Wellstar Hospital CPT Code CPT Proc Cat Comp Avg Allow Allow Allow Allow Allow Allow Allow Allow Allow 29881 KNEE ARTHROSCOPYSURGERY 6 $3179 $2266 $3022 $4185 $3837 $2036 $3729 29888 KNEE ARTHROSCOPYSURGERY 6 $6319 $2502 $10096 $9557 $5983 $2258 $7519 43239 UPPER GI ENDOSCOPY BIOPSY 6 $1727 $536 $2240 $1132 $2539 $2012 $2067 $1565 43644 LAP GASTRIC BYPASSROUX-EN-Y 1 $15810 $15300 $10800 $17000 $17750 $18200 43775 LAP SLEEVE GASTRECTOMY 1 $17800 $13230 $20815 $12105 $14600 45378 DIAGNOSTIC COLONOSCOPY 6 $1656 $536 $859 $1244 $2805 $2013 $2164 $1972 45380 COLONOSCOPY AND BIOPSY 6 $1694 $536 $859 $1244 $3071 $2013 $2164 $1972 59400 OBSTETRICAL CARE 1 $5107 $4688 $4607 $5730 $4654 $5855 70553 MRI BRAIN WO amp WDYE 2 $1482 $1052 $967 $1468 $1117 $2805 71020 CHEST X-RAY 2 $259 $72 $279 $266 $305 $375 71250 CT THORAX WO DYE 2 $541 $319 $491 $810 $505 $579 73721 MRI JNT OF LWR EXTRE WO DYE 2 $978 $557 $967 $1398 $1042 $925 74183 MRI ABDOMEN WO amp WDYE 2 $1436 $836 $967 $1468 $1106 $2805 76700 US EXAM ABDOM COMPLETE 2 $320 $133 $195 $538 $545 $190 77052 COMP SCREEN MAMMOGRAM ADD-ON 2 $45 $23 $15 $99 $41 $45 77052 COMP SCREEN MAMMOGRAM ADD-ON 5 $14 $14 80053 COMPREHEN METABOLIC PANEL 8 $29 $25 $13 $56 $15 $24 $22 $51 88305 TISSUE EXAM BY PATHOLOGIST 8 $174 $232 $188 $152 $307 $80 $179 $78 93306 TTE WDOPPLER COMPLETE 2 $1297 $1157 $1173 $1566 $1388 $1371 $1125 93017 STRESS TEST 5 $830 $797 $907 $432 $1299 $717 99203 OFFICEOUTPATIENT VISIT NEW 4 $139 $118 $159 G0202 Screeningmammographydigital 2 $329 $168 $294 $328 $431 $330 $425 G0202 Screeningmammographydigital 5 $231 $231
Service Line Procedure CPT Code Emory Atlanta Gastroenterology Associates Resurgens Atlanta Womens Health Piedmont Physicians Group Orthopedics (ASC) Knee Arthroscopy 29881 $3467 $2036 Arthroscopy Ligament Repair 29888 $3386 $2258 GI (ASC) Upper GI Endoscopy 43239 $2758 $536 Diagnostic Colonoscopy 45378 $2348 $536 Colonoscopy and biopsy 45380 $2181 $536 Radiology Mammogram Screening G0202 $164 $231 Computer Detection Add-on 77052 $93 $14 Lab Comp Metabolic Panel 80053 $53 $13 $22 Tissue Exam by Pathologist 88305 $277 $188 $179 EampM (TEC) Office Visit new pt 99203 $269 $118 $159
Service Line Procedure CPT CodeDRG Memorial Hospital Beta Hosptial Charlie Hospital Delta Hospital Echo Hospital Alpha Medical Center Atlanta Gastroenterology Associates Resurgens Atlanta Womens Health Piedmont Physicians Group Market Avg Emory abovebelow Orthopedics Arthroscopy Ligament Repair 29888 $ 5062 $ 9557 $ 5983 $ 10096 $ 7519 $ 2502 $ 2258 $ 6319 -20 Knee Arthroscopy 29881 6 $ 5069 $ 4185 $ 3837 $ 3022 $ 3729 $ 2266 $ 2036 $ 3179 59 GI Upper GI Endoscopy 43239 6 $ 3075 $ 2539 $ 2012 $ 1132 $ 1565 $ 2240 $ 536 $ 1671 84 Lap Sleeve Gastrectomy DRG 621 $ 20421 $ 20815 $ 12105 $ 13230 $ 14600 $ 17800 $ 15710 30 Colonoscopy and biopsy 45380 $ 3075 $ 3071 $ 2013 $ 1244 $ 1972 $ 859 $ 536 $ 1616 90 Diagnostic Colonoscopy 45378 6 $ 3075 $ 2805 $ 2013 $ 1244 $ 1972 $ 859 $ 536 $ 1572 96 Radiology MRI Brain w amp wo dye 70553 2 $ 1238 $ 1468 $ 1117 $ 967 $ 2805 $ 1052 $ 1482 -16 MRI Joint of Lower Extremity wo dye 73721 2 $ 1238 $ 1398 $ 1042 $ 967 $ 925 $ 557 $ 978 27 MRI Abdomen w amp wo dye 74183 2 $ 1238 $ 1468 $ 1106 $ 967 $ 2805 $ 836 $ 1436 -14 X-ray Chest 71020 $ 115 $ 266 $ 305 $ 279 $ 375 $ 72 $ 259 -56 CT Thorax wo dye 71250 $ 882 $ 810 $ 505 $ 491 $ 579 $ 319 $ 541 63 Ultrasound Abdomen Complete 76700 $ 397 $ 538 $ 545 $ 195 $ 190 $ 168 $ 327 21 Mammogram Screening G0202 2 $ 141 $ 328 $ 431 $ 294 $ 425 $ 168 $ 231 $ 313 -55 Computer Detection Add-on 77052 2 $ 112 $ 99 $ 41 $ 15 $ 45 $ 23 $ 14 $ 39 183 Lab Comp Metabolic Panel 80053 8 $ 56 $ 15 $ 24 $ 56 $ 51 $ 25 $ 13 $ 22 $ 29 88 Tissue Exam by Pathologist 88305 8 $ 236 $ 307 $ 80 $ 152 $ 78 $ 232 $ 188 $ 179 $ 174 36 Medical Cardiology Cardiovascular Stress Test 93017 $ 383 $ 432 $ 1299 $ 907 $ 717 $ 797 $ 830 -54 TTE w Doppler 93306 2 $ 960 $ 1566 $ 1388 $ 1173 $ 1125 $ 1157 $ 1282 -25 Obstetrics Vaginal Delivery DRG 755 $ 7290 $ 5730 $ 4654 $ 4607 $ 5855 $ 4688 $ 5107 43 EampM Office Visit new pt 99203 4 $ 248 $ 118 $ 159 $ 139 78 Colonoscopy and biopsy (HOSPITAL ONLY) 45380 Surg 2530 $ 307591 Diagnostic colonoscopy (HOSPITAL ONLY) 45378 Surg 2255 $ 307591 Upper gi endoscopy biopsy (HOSPITAL ONLY) 43239 Surg 1787 $ 307591 Knee Arthroscopy (HOSPITAL ONLY) 29881 Surg 10900 $ 506893 Arthroscopy Ligament Repair (HOSPITAL ONLY) 29888 Surg 10900 $ 506200 Key 1 Facility - Inpatient 2 Facility - Imaging 3 Physician - Imaging 4 Physician 5 Global - Imaging 6 Facility - Outpatient 8 Lab 41 Physician - Primary Care 42 Physician - Specialist
Blue Cross United - EJCH EUH EUHM WW United - SJH Non Options United - SJH Options Aetna - ASC TEC (HMO) Cigna - ASC TEC (HMO) Aetna - EJCH ESJH ECHM WW Cigna - EJCH (HMO) Cigna - ESJH EUHM (HMO) List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract Description CPT Code Charge Average Final Price (all plans) Emory Mark Up Reimbursement Method ( of charge or fixed) - 1713 Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Cardiovascular stress test 93017 Cardio $543 $ 425 28 of Charge 70 $ 380 of Charge 65 $ 353 of Charge 60 $ 326 of Charge 70 $ 380 of Charge 70 $ 380 of charge 100 $ 543 of Charge 70 $ 380 of charge 100 $ 543 of charge 100 $ 543 TTE wDoppler complete 93306 Cardio $1226 $ 960 28 of Charge 70 $ 858 of Charge 65 $ 797 of Charge 60 $ 736 of Charge 70 $ 858 of Charge 70 $ 858 of charge 100 $ 1226 of Charge 70 $ 858 of charge 100 $ 1226 of charge 100 $ 1226 Colonoscopy and biopsy (HOSPITAL ONLY) 45380 Surg $2530 $ 3076 -18 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 of Charge 70 $ 1771 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Diagnostic colonoscopy (HOSPITAL ONLY) 45378 Surg $2255 $ 3076 -27 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 of Charge 70 $ 1579 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Upper gi endoscopy biopsy (HOSPITAL ONLY) 43239 Surg $1787 $ 3076 -42 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Knee Arthroscopy (HOSPITAL ONLY) 29881 Surg $10900 $ 5069 115 Fixed Rate SC 4 $ 3865 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 449300 $ 4493 Fixed Rate $ 654700 $ 6547 of Charge 70 $ 7630 Fixed Rate $ 401000 $ 4010 of Charge 70 $ 7630 Fixed Rate $ 398300 $ 3983 Fixed Rate $ 398100 $ 3981 Arthroscopy Ligament Repair (HOSPITAL ONLY) 29888 Surg $10900 $ 5062 115 Fixed Rate SC 3 $ 3121 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 556900 $ 5569 Fixed Rate $ 770100 $ 7701 of Charge 70 $ 7630 Fixed Rate $ 323900 $ 3239 of Charge 70 $ 7630 Fixed Rate $ 321700 $ 3217 Fixed Rate $ 321400 $ 3214 Comp Metabolic Panel 80053 Lab $132 $ 56 138 RBRVS Fee (100) $ 1437 of Charge 65 $ 86 of Charge 65 $ 86 of Charge 65 $ 86 of Charge 70 $ 92 RBRVS Fee (100) $ 1437 $ 14 of Charge 70 $ 92 RBRVS Fee (100) $ 1437 $ 14 RBRVS Fee (100) $ 1437 $ 14 Surgical Path Tissue Exam 88305 Lab $326 $ 236 38 of Charge 150 $ 51 of Charge 65 $ 212 of Charge 65 $ 212 of Charge 65 $ 212 of Charge 70 $ 228 of charge 100 $ 326 of Charge 70 $ 228 of charge 100 $ 326 of charge 100 $ 326 MRI Abdomen 74183 Radiology $6960 $ 1238 462 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 MRI Brain 70553 Radiology $6804 $ 1238 450 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 MRI Joint Lower Extremity 73721 Radiology $3067 $ 1238 148 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 CT Thorax wo contrast 71250 Radiology $2199 $ 882 149 Fixed Rate $ 771 Fixed Rate $ 47100 $ 471 Fixed Rate $ 81700 $ 817 Fixed Rate $ 116000 $ 1160 of Charge 70 $ 1539 Fixed Rate $ 80100 $ 801 Fixed Rate $ 79200 $ 792 Fixed Rate $ 79300 $ 793 Fixed Rate $ 79500 $ 795 X-ray Chest 71020 Radiology $280 $ 115 142 of Charge 150 $ 25 of Charge 65 $ 182 of Charge 60 $ 168 of Charge 70 $ 196 of Charge 70 $ 196 RBRVS Fee (150) $ 2534 $ 25 of Charge 70 $ 196 RBRVS Fee (150) $ 2534 $ 25 RBRVS Fee (150) $ 2534 $ 25 Screening mammography G0202 Radiology $279 $ 141 98 Fixed Rate $ 128 Fixed Rate $ 13100 $ 131 Fixed Rate $ 14300 $ 143 Fixed Rate $ 16100 $ 161 of Charge 70 $ 195 Fixed Rate $ 13300 $ 133 Fixed Rate $ 13500 $ 135 Fixed Rate $ 13000 $ 130 Fixed Rate $ 11200 $ 112 Mammo Computer Aided 77052 Radiology $75 $ 112 -33 Fixed Rate $ 9 Fixed Rate $ 13100 $ 131 Fixed Rate $ 14300 $ 143 Fixed Rate $ 16100 $ 161 of Charge 70 $ 53 Fixed Rate $ 13300 $ 133 Fixed Rate $ 13500 $ 135 Fixed Rate $ 13000 $ 130 Fixed Rate $ 11200 $ 112 US Abdomen Complete 76700 Radiology $917 $ 397 131 of Charge 150 $ 125 of Charge 65 $ 596 of Charge 60 $ 550 of Charge 70 $ 642 of Charge 70 $ 642 RBRVS Fee (150) $ 12519 $ 125 of Charge 70 $ 642 RBRVS Fee (150) $ 12519 $ 125 RBRVS Fee (150) $ 12519 $ 125 Officeoutpatient visit new pt 30 min (TEC) 99203 EampM $316 $ 248 28 of Charge 70 $ 221 of Charge 65 $ 205 of Charge 60 $ 190 of Charge 70 $ 221 of Charge 70 $ 221 of charge 100 $ 316 of Charge 70 $ 221 of charge 100 $ 316 of charge 100 $ 316 Vaginal delivery 59409 Surg $14484 $ 7290 99 Fixed Rate DRG - 775 $ 5437 2 Day Case Rate + LOC 561700 $ 5617 BaseCMS Weight 584741 $ 5847 BaseCMS Weight 726146 $ 7261 No IP Terms $ - 0 No IP BaseCMS Weight 659343 $ 6593 BaseContract Weight 479451 100 $ 14484 BaseCMS Weight 579110 $ 5791 Lap Sleeve Gastrectomy 43775 Surg $29961 $ 20421 47 Fixed Rate DRG - 621 $ 14872 BaseCMS Weight 1810697 $ 18107 BaseCMS Weight 1835178 $ 18352 BaseCMS Weight 2278911 $ 22789 No IP Terms $ - 0 No IP BaseCMS Weight 2069315 $ 20693 BaseCMS Weight 1730442 100 $ 29961 BaseCMS Weight 1817507 $ 18175 105 Colonoscopy and biopsy (ASC ONLY) Surg $ 219200 $ 2181 Diagnostic colonoscopy (ASC ONLY) Surg $ 267100 $ 2348 Upper gi endoscopy biopsy (ASC ONLY) Surg $ 207500 $ 2758 Knee Arthroscopy (ASC ONLY) Surg $ 417900 $ 3467 Arthroscopy Ligament Repair (ASC ONLY) Surg $ 504800 $ 3386
Cpt Code CPT Description Procedure Category Claims Min 25thNtile 50thNtile Emorys Rates 75thNtile 90thNtile Max 20 Below 50th Ntile 20 Above 50th Ntile 93017 CARDIOVASCULAR STRESS TEST 5 82 $80 $125 $321 $382 $568 $791 $930 $257 $386 71020 CHEST X-RAY 2 2638 $11 $45 $152 $115 $289 $373 $585 $122 $182 71020 CHEST X-RAY 5 8106 $25 $34 $38 $54 $57 $69 $30 $46 45380 COLONOSCOPY AND BIOPSY 6 1256 $541 $560 $572 $2877 $1000 $2024 $3289 $458 $686 77052 COMP SCREEN MAMMOGRAM ADD-ON 2 194 $13 $15 $25 $38 $47 $134 $20 $30 77052 COMP SCREEN MAMMOGRAM ADD-ON 5 2411 $13 $16 $20 $23 $26 $28 $16 $24 80053 COMPREHEN METABOLIC PANEL 8 13019 $9 $19 $23 $55 $24 $25 $69 $19 $28 71250 CT THORAX WO DYE 2 302 $165 $372 $545 $878 $1658 $2067 $436 $654 71250 CT THORAX WO DYE 5 209 $53 $127 $203 $289 $419 $534 $162 $244 45378 DIAGNOSTIC COLONOSCOPY 6 1479 $484 $515 $536 $2914 $831 $1971 $2828 $428 $643 29881 KNEE ARTHROSCOPYSURGERY 6 152 $1650 $1826 $2036 $5235 $3054 $4216 $6461 $1629 $2443 29888 KNEE ARTHROSCOPYSURGERY 6 82 $1682 $3615 $5081 $5145 $7553 $12924 $18532 $4065 $6097 43644 LAP GASTRIC BYPASSROUX-EN-Y 1 21 $11821 $13873 $17050 $18391 $25029 $31079 $13640 $20460 43775 LAP SLEEVE GASTRECTOMY 1 38 $4215 $8250 $13253 $20421 $19197 $21509 $24260 $10602 $15903 74183 MRI ABDOMEN WO amp WDYE 2 120 $919 $987 $1015 $1237 $1252 $2534 $3177 $812 $1218 74183 MRI ABDOMEN WO amp WDYE 5 112 $475 $490 $521 $1154 $1337 $1696 $417 $625 70553 MRI BRAIN WO amp WDYE 2 324 $633 $987 $1142 $1237 $1706 $2805 $3331 $914 $1370 70553 MRI BRAIN WO amp WDYE 5 467 $280 $539 $1023 $1277 $1363 $1726 $818 $1228 73721 MRI JNT OF LWR EXTRE WO DYE 2 304 $804 $859 $967 $1237 $1063 $1598 $2485 $774 $1160 73721 MRI JNT OF LWR EXTRE WO DYE 5 1130 $500 $520 $530 $628 $679 $859 $424 $636 59400 OBSTETRICAL CARE 1 494 $3699 $4402 $4969 $6655 $7307 $8613 $3975 $5963 99203 OFFICEOUTPATIENT VISIT NEW 4 6776 $88 $101 $112 $138 $155 $169 $90 $134 G0202 Screeningmammographydigital 2 7444 $123 $206 $285 $380 $425 $479 $228 $342 G0202 Screeningmammographydigital 5 2754 $117 $165 $195 $230 $247 $252 $156 $234 88305 TISSUE EXAM BY PATHOLOGIST 8 20834 $51 $74 $112 $235 $168 $261 $478 $90 $134 93306 TTE WDOPPLER COMPLETE 2 931 $194 $377 $739 $960 $1267 $1480 $1849 $591 $887 93306 TTE WDOPPLER COMPLETE 5 2299 $151 $296 $373 $538 $573 $834 $298 $448 43239 UPPER GI ENDOSCOPY BIOPSY 6 1264 $424 $514 $550 $800 $1838 $2833 $440 $660 76700 US EXAM ABDOM COMPLETE 2 321 $96 $165 $271 $509 $584 $857 $217 $325 76700 US EXAM ABDOM COMPLETE 5 444 $111 $129 $147 $156 $220 $279 $118 $176 Key 1 Facility - Inpatient 2 Facility - Imaging 3 Physician - Imaging 4 Physician 5 Global - Imaging 6 Facility - Outpatient 8 Lab 41 Physician - Primary Care 42 Physician - Specialist Cardiovascular stress test $ 38279 TTE wDoppler complete $ 96037 Colonoscopy and biopsy $ 287709 Diagnostic colonoscopy $ 291434 Upper gi endoscopy biopsy $ 300526 Knee Arthroscopy $ 523584 Arthroscopy Ligament Repair $ 514501 Comp Metabolic Panel $ 5552 Surgical Path Tissue Exam $ 23570 MRI Abdomen $ 123786 MRI Brain $ 123786 MRI Joint Lower Extremity $ 123786 CT Thorax wo contrast $ 88213 X-ray Chest $ 11548 Screening mammography $ 14098 Mammo Computer Aided $ 11179 US Abdomen Complete $ 39695 Officeoutpatient visit new pt 30 min $ 24753 Vaginal delivery $ 729025 Lap Sleeve Gastrectomy $ 2042124
Page 10
DC with providers to secure improved pricing
COE through a carve-out provider
COE within the health plans
Source Willis Towers Watson 23rd Annual Best Practices in Health Care Employer Survey Full report and high-performance insights httpswwwwillistowerswatsoncom-mediaWTWPDFInsights201812willis-towers-watson-23rd-annual-best-practices-in-health-care-employer-survey-full-reportpdf 2018
Trends in Direct Contracting amp COE
According to Willis Towers Watsonrsquos survey employers are using COEs mostly through their health plans however direct contracting considerations are expected to grow considerably
6
7
48
2
2
7
14
13
20
0 20 40 60 80
Action taken or tactic used in 2018
Planning for 2019
Considering for 2020
bull Almost 50 use COEs in 18rsquo expected to rise to 2 out of 3 by 2020
bull Employers engaging employees in multiple ways to use COE bull Ongoing communications bull Reducing member cost share
to use bull Increasing member cost
share when not using bull Mandatory use
9
16
12
18
9
3
6
2
50
39
19
22
26
11
10
15
19
31
30
31
22
11
Transplants
Bariatric Surgery
Knees hips or spine
Cardiovascularcardiac
Cancer
Fertility
Other Procedures
Yes with incentives Yes but no incentives No but considering
10
A 2015 survey by the National Business Group on Health shows the status of large employersrsquo contracts with COEs (note reflects all COEs not specifically direct contracts)
Source Large Employersrsquo 2016 Health Plan Design Survey copy 2015 National Business Group on Health
Other centers of excellence programs include maternity NICU sleep apnea pancreas cornea and kidney
National Business Group on Healthrsquos Large Employers 2019 Health Care Strategy and Plan Design Survey showed DC arrangements between employers and bull Health systemsproviders will
increase from 3 in 2018 to 11 in 20191
bull COEs will increase from 12 in 2018 to 18 in 20191
bull Cancer cardiovascular and fertility COEs are experiencing the greatest growth
Source National Business Group on Health ldquoLarge US Employers Eye Changes to Health Care Delivery System as Cost to Provide Health Benefits Nears $15000 per Employeerdquo August 2018
10
Trends in Direct Contracting amp COE
Outcomes amp Benefits bull Employers with COE arrangements are seeing reduction in procedures
bull Walmart (15rsquo-18rsquo) 50+ of spine surgeries amp 20 of kneehip procedures recommended by local providers were determined lsquonot necessaryrsquo by COE (see table)
bull Employers like Walmart amp Boeing continue to sign new providers which suggest (employersrsquo) continued interest in pursuing DC arrangements2 However Boeing and Providence Swedish did end relationship due to inability to capture enoughright data to estimate cost of care3
bull John Hopkinsrsquo Bayview campus COE emerging metrics4
bull 121 referrals in the first three months
bull 352 referrals and 183 surgeries over 18 months
bull 23 of all joint replacement volumes at facility now attributed to travel program
bull 96 of patients said they would recommend this program to family friends coworkers
bull Bingham Memorial in Idaho direct contracting emerging metrics4
bull 17 companies participating covering over 5000 lives
bull +3000 new patients as of October 2018
bull +$3M Revenue from new patients
11
1 How Employers Are Fixing Health Care Harvard Business Review March 2019 2 httpswwwhealthleadersmediacomstrategywalmart-escalates-strategy-solve-employee-healthcare Health Leaders Media Nov 18rsquo 3 Do Providers Have the Data chops to Success with Direct Contract Modern Healthcare August 2018 4 Re-Igniting the Growth Engine Part 2 Winning Increased Share of Lucrative Patient Volumes Advisory Board 5 httpswwwautonewscomarticle20180806OEM180809831gm-signs-major-health-care-services-deal-for-salaried-employees
Walmart COE Programs1
Program Key Benefits
Spin
e Su
rger
y 2300 EEs 50 COE approved of those applied
bull 95 lower readmission bull 14 less time in hospital bull 1 COE vs 5 non-COE patients discharged to SNF bull Returned to work sooner reducing 20 of OOO
time bull More-effective less dangerous amp less expensive bull The COE surgery ldquopricerdquo is 8 higher but value in
earlier discharge lower readmission rates far less utilization of SNF faster return to work
Join
t
1836 EEs 18 COE approved of those applied
bull 32 less time in hospital bull 70 less likely to be readmitted than non-COE
patients bull Fewer postsurgical complications bull 0 COE vs 5 non-COE patients discharged to SNF bull COE patients returned to work a 15 weeks sooner bull Cost of surgery is 15 less at COE hospitals
Baria
tric
300+ EEs
bull Preliminary data suggests the weight loss from surgery reduces absenteeism or presentism (working while sick)
bull Dramatically cuts pharmacy amp medical costs Complications of obesity drop sharply as does the need for medication
bull GMrsquos direct contract benefit plans with Henry Ford allows it to offer similarly designed plans to that of Blue Cross with savings in monthly EE contributions ranging from $300-$19805
Walmartrsquos Travel (Surgery) Program
Mem
ber F
eedb
ack
12
Looking beyond traditional cost management techniques Walmart designed a program to address wild variations in cost and become directly in improving quality of care for its employees FIRST SELECTING PROVIDERS 1 Identify providers with high volume and high quality 2 Target regions in country to support Walmartrsquos employees 3Focus on Integrated Health Systems Hospitals within these systems were best aligned to Walmarts mission could take on risks associated with bundling 4 Eliminate systems unwilling to do bundled payments model were
PROVIDERS VALUE IN PARICIPATING
Build Bundles bull Define bundles and negotiate price (typically 10-15 below FFS ) bull Definitions of service limit disputes of what is covered vs not (covers
entryexit of facility SNF not part of bundle) bull Contract flexibility covers unforeseen testcosts and reinforces
Walmarthealth system partnership bull Warrantees if further treatment - can return in 30 days no
additional cost to Walmart bull Strict criteria and providers with track record of clinically sound
decisions are included to mitigate any incentivizing of volume Business bull 100 travelaccom brings
new volume of patients from outside of market
bull More stable payments for services (vs Medicare or commercial FFS)
bull Increased visibility and attract new business
Clinical bull lsquoHalorsquo effect ndash Building a highly
efficient multidiscipline program brings improvements throughout health system
bull Onsite collaboration among health systems allows sharing of outcomesbest practices
Source How Employers Are Fixing Health Care Harvard Business Review March 2019
5000 participants in the program
95 satisfiedvery satisfied
Denied by care because not deemed necessary by COE Treatment denied due to lifestyle weightsmoking
The Member Experience
13
Engagement begins when employee on clear
path to surgery
Patient contacts with COE TPA
TPA team triages and ensures basic criteria
met
Employee put in touch with nurse team
Car pick-up Flight Hotel all arranged by
TPA
Navigators and nurse coordinators help
throughout the stay
Patient visits to hospital to understand
exceptions of procedure and meet treatment
team
Surgery occurs typically next day
Stay length according to procedure typically a
few days
Discharged from facility Travel home COE team updates local
PCP and discuss follow up care
COE provider checks in with local physician
frequently Revert back to standard coverage
Source How Employers Are Fixing Health Care Harvard Business Review March 2019
Case Study 1
Case study 1 ndash Pop Health Approach bull ProblemCircumstance Large multi-employer group needs to
evaluate benefit design disease prevalence health spend and utilization to manage their population
bull ConsiderationsValue Prop Unique industry and geography drive chronic conditions and utilization patterns
bull Solution Provide opportunity assessment comparing this population to other benchmarks to understand where to target intervention and management as well as assess efforts already taken
15
Market Comparison Preference Sensitive Procedures
16
Legend vs
Mt States vs
National gt120 gt110
110-120 105-110 lt80 lt90
Source Multi-payer commercial benchmark Results are weighted by AgeGender Broader market area includes multi-payer data from the mountain regions
Preference Sensitive Procedures Benchmark Comparison
Dartmouth Atlas Preference Sensitive Procedures
IP allowed dollars ALOS Employer vs
Mt States Employer
vs National FY 2017 FY 2018 FY 2017 FY 2018
Hysterectomy for Uterine Fibroids Rate $569354 $436932 45 54 124 140 CABG Rate $1800260 $2400608 53 60 218 130 Cholycystectomy Rate $832675 $755565 68 39 92 120 C-Section Rate 116 110 HighTech Radiology Rate 103 101 PCIPTCA Rate $934486 $1133708 37 55 82 80 Back Surgery Rate $3237613 $4003212 39 57 52 70 Knee Replacement Rate $3086693 $2177334 41 48 50 64 Total Hip Replacement Rate $1023675 $747491 45 64 37 34
Strengths (+)
Employer compares favorably for orthopedic procedures (back hip knee)
Opportunity (-)
Employer has higher than expected rates for CABG and hysterectomy (Note Low PTCA rate combined with high CABG rate may suggest provider practice patterns favoring CABG)
0 50 100 150 200 250
Total Hip Replacement
Knee Replacement
Back Surgery
PCIPTCA
Cholycystectomy
HighTech Radiology
C-Section
CABG
Culinary VsNational
Culinary Vs MtStates
Employer vs Mt States
Employer vs National
Market Comparison Condition Prevalence
17 Source Multi-payer commercial benchmark Results are weighted by AgeGender Broader market area includes multi-payer data from the mountain regions
Condition Prevalence Benchmark Comparison
Condition Employer vs
Mt States Employer vs
National Prevalence Diabetes Rate 229 219 Prevalence Hyperlipidemia Rate 259 207 Prevalence Kidney Disease Rate 143 174 Prevalence Migraine Rate 166 164 Prevalence Low Back Pain Rate 136 139 Prevalence Hypertension Rate 156 134 Prevalence Asthma Rate 146 128 Prevalence CAD Rate 175 115 Prevalence Pregnancy Rate 110 109 Prevalence Adult Preventive Screening Rate 114 91 Prevalence Depression Rate 63 60
Strengths (+)
Rate of depression is low (Note May be due to incomplete behavioral health claims)
Opportunity (-)
Employer has a higher prevalence of most chronic conditions including asthma CAD diabetes hypertension hyperlipidemia Kidney Disease LBP and migraines
0
100
200
300Hyperlipidemia
Diabetes
CAD
Migraine
Hypertension
AsthmaKidney Disease
Low Back Pain
Pregnancy
Depression
Employer vsMt States
Employer vsNational Legend
vs Mt States
vs National
gt120 gt110 110-120 105-110
lt80 lt90
Market Comparison Utilization Rates
18
A higher preventive office visit rate is better Source Multi-payer commercial benchmark Results are weighted by AgeGender Broader market area includes multi-payer data from the mountain regions
Strengths (+)
Lower than average utilization of ED and high dollar patient rate
Opportunity (-)
Higher LOS lengthy admits avoidable admits and readmissions which all drive significantly more spend
Utilization Benchmark Comparison
Condition Employer vs
Mt States Employer vs
National Avoidable Admit Rate 142 144 Lengthy Admit Rate 175 136 Outpatient Problem Focused Office Rate 146 131 Readmission Rate (readmitadmit) 135 126 Average LOS 125 116 One Day Admit Rate 76 103 Office Visit Rate 106 96 Acute Admit Rate 80 95 Avoidable ED Rate 68 86 ED Rate 54 69 Preventive Office Rate 95 68 High Dollar Patient Rate 49 51 Frequent ED User (gt3 times) Rate 24 36
Legend vs
Mt States vs
National gt120 gt110
110-120 105-110 lt80 lt90
0 50 100 150 200
Frequent ED User (gt3 times)
High Dollar Patient
Preventive Office
ED
Avoidable ED
Acute Admit
Office Visit
One Day Admit
Average LOS
Readmissionhellip
Outpt Problem Focusedhellip
Lengthy Admit
Avoidable Admit
Employer vsNational
Employer vsMt States
ED and Avoidable ED
19
Potentially Avoidable ED - Trend View Overall ED
Period Change FY 2017 FY 2018 Count Rate
Measure Mbrs Rate Mbrs Rate Overall ED 16394 12626 13820 10745 -16 -15 FREQUENT ED UTILIZER (mbr1k) 1581 1218 1468 1141 -7 -6 AVOIDABLE ED 6371 4907 5288 4111 -17 -16 Potentially Avoidable ED
Period Change FY 2017 FY 2018 Count Rate
Avoid ED Condition Mbrs Rate Mbrs Rate ABDOMINAL_PAIN 1092 841 895 696 -18 -17 ENT_INFECTION 854 658 742 577 -13 -12 FEVER 715 551 700 544 -2 -1 URINARY 650 501 468 364 -28 -27 HEADACHE 558 430 434 337 -22 -21 BACK_PAIN 414 319 423 329 2 3 NAUSEA 394 303 271 211 -31 -31 ASTHMA 294 226 209 162 -29 -28 CELLULITIS 210 162 198 154 -6 -5 GASTROENTERITIS 254 196 171 133 -33 -32 OTITIS_MEDIA 201 155 160 124 -20 -20 COPD 132 102 108 084 -18 -17 DIABETES 123 095 91 071 -26 -25 BACT_PNEUMONIA 111 085 86 067 -23 -22 DENTAL 93 072 83 065 -11 -10 DEHYDRATION 98 075 81 063 -17 -17 HYPERTENSION 16 012 24 019 50 51 CHF 4 003 3 002 -25 -24 ANGINA 8 006 3 002 -63 -62 IMMUNIZATION_RELATED 2 002 0 000 -100 -100 Grand Total 6371 4907 5288 4111 -17 -16
AHRQ avoidable ED visits are based on the logic for ambulatory care sensitive ED visits from AHRQ and diagnosis code driven
696
577
544 364
337
329
211 162
154 133 ABDOMINAL_PAIN
ENT_INFECTION
FEVER
URINARY
HEADACHE
BACK_PAIN
NAUSEA
- 200 400 600 800
1000 1200
2017 Members 2018 Members
Top Ten 2018 Conditions by Rate
Top Ten Conditions by Member Count
ED Avoidable ED and the impact of new on-site clinic
20
0
1000
2000
3000
4000
5000
6000
0200400600800
10001200140016001800
Clinic Visits ED Visits
Avoidable ED VisitsED Visits (non-avoidable)Clinic EampM Visits
0
500000
1000000
1500000
2000000
2500000
3000000
3500000
$s
Clinic EampM Profess DollarsAvoidable ED Dollars
bull Clinic visits have a clear impact on ED and avoidable ED use and spend
bull Combined ED visits are down on average 157 in FY 18 from FY 17
bull Combined ED spend is down 128 in FY 18 from FY 17
Clinic Live 62017
Pitfalls and Challenges bull Face many of the challenges similar to startup health
plan bull Critical to determine how you will deliver value and
communicate the value to potential customers and brokersconsultants
bull Care management bull Network
21
Considerations in Offering Development bull Care Management Model
bull Traditional care model bull Case management bull Utilization management bull Disease management
bull Longitudinal care model with value based care philosophy bull Primary care driven bull Local care management
bull Predictive analytics and risk stratification model bull Claims history and ongoing data bull EMR data
22
Case Study 2
Case study 2 ndash Large Employer bull Business Problem Large employer wants to contract
directly with 2 major hospital systems developing professional fee schedules
bull ConsiderationsValue Prop Fee schedule should be competitive but also nuanced to minimize gap relative to current reimbursement at physician level
bull Solution Data-driven approach using current market-wide reimbursement distinguished by service level
24
Evaluate Provider Spend Top 25 Service Lines by Allowable Spend
Evaluate Provider Spend Top 20 Professional CPTs by Total Spend
Understand relative market pricing position
27
21
-1
-28
14 10
28
-22
-11 -13
24
3
20 21
8
-20
13
3 9
-39
56
-26
4
-42
60
MRI Colonoscopy Cardiac Cath Lab - OrganPanel
Memorial Hospital Beta Hospital Delta Hospital Charlie Hospital Echo Hospital Alpha Medical Center
ndash25 5 -15 10 0 39
State Charges as a Percent of Peer Average Weighted Averages for MRI Colonoscopy Cardiology and Lab
Total Percent Above Below Market Average2
Memorial Hospital Beta Hospital Delta Hospital Charlie Hospital Echo Hospital Alpha Medical Center
Develop fee schedule relative to market
28
Service Line Procedure CPT CodeDRG
Memorial Hospital
Beta Hosptial
Charlie Hospital
Delta Hospital
Echo Hospital
Alpha Medical Center
Arthroscopy Ligament Repair 29888 $ 5062 $ 9557 $ 5983 $ 10096 $ 7519 $ 2502 Knee Arthroscopy 29881 $ 5069 $ 4185 $ 3837 $ 3022 $ 3729 $ 2266 Upper GI Endoscopy 43239 $ 3075 $ 2539 $ 2012 $ 1132 $ 1565 $ 2240 Lap Sleeve Gastrectomy DRG 621 $ 20421 $ 20815 $ 12105 $ 13230 $ 14600 $ 17800 Colonoscopy and biopsy 45380 $ 3075 $ 3071 $ 2013 $ 1244 $ 1972 $ 859 Diagnostic Colonoscopy 45378 $ 3075 $ 2805 $ 2013 $ 1244 $ 1972 $ 859 MRI Brain w amp wo dye 70553 $ 1238 $ 1468 $ 1117 $ 967 $ 2805 $ 1052 MRI Joint of Lower Extremity wo dye 73721 $ 1238 $ 1398 $ 1042 $ 967 $ 925 $ 557 MRI Abdomen w amp wo dye 74183 $ 1238 $ 1468 $ 1106 $ 967 $ 2805 $ 836 X-ray Chest 71020 $ 115 $ 266 $ 305 $ 279 $ 375 $ 72 CT Thorax wo dye 71250 $ 882 $ 810 $ 505 $ 491 $ 579 $ 319 Ultrasound Abdomen Complete 76700 $ 397 $ 538 $ 545 $ 195 $ 190 $ 168 Mammogram Screening G0202 $ 141 $ 328 $ 431 $ 294 $ 425 $ 168 Computer Detection Add-on 77052 $ 112 $ 99 $ 41 $ 15 $ 45 $ 23 Comp Metabolic Panel 80053 $ 56 $ 15 $ 24 $ 56 $ 51 $ 25 Tissue Exam by Pathologist 88305 $ 236 $ 307 $ 80 $ 152 $ 78 $ 232 Cardiovascular Stress Test 93017 $ 383 $ 432 $ 1299 $ 907 $ 717 $ 797 TTE w Doppler 93306 $ 960 $ 1566 $ 1388 $ 1173 $ 1125 $ 1157
Obstetrics Vaginal Delivery DRG 755 7290$ 5730$ 4654$ 4607$ 5855$ 4688$
GI
Lab
Radiology
Medical Cardiology
Orthopedics
KEY OBSERVA TIONS bull Potential exposure on GI bull Opportunity to align price and acuity in MRI bull Opportunity to raise rates on chest x-ray and mammogram
Percentile Bands Emory Allowables Heatmap TEC ASC Heatmap Allowable Comp Analysis Portal Pricing Sheet1 image1png A few words on Bundled Payments bull Bundled payments are growing as a type of direct contracting bull In some cases third parties match-make between employers
and providers bull Contracts may vary in definitions prepost admission
coverage duration readmission cause (ie all-cause vs medically related) outlier provisions LOS caps andor per diems
bull Providers need to be strategic in pricing to enable profitable growth of market share
29
Considerations in Offering Development bull Network Development
bull Build off existing structure eg health system employee plan network bull How does this fit into your broader value based care strategy bull Employed and independent physicians bull How do you want to approach the buildout of high performance
network bull Quality focus bull Cost efficiency
bull Integrated behavioral health bull Wrap network for other markets
30
Considerations in Offering Development bull Target Market
bull Consideration of employer profile in market bull Fully-insured vs ASO bull Total cost of care vs bundled services
bull Distribution bull Direct marketing bull Brokerconsultant community
bull Plan designs bull Standard designs vs flexible ndash Dependent on target market
bull Claims administration bull Data sharing amp analytics
31
Considerations in Offering Development bull Other components of comprehensive offering
bull Pharmacy bull Preventive health bull Onsite clinics bull Wellness programs bull Technology platform
32
Sample Bundle Analysis
33
Cover page Dotson Hazelrigs Nation Mainly of charge of fixed Cardiovascular stress test TTE wDoppler complete Colonoscopy and biopsy (Combined) Diagnostic colonoscopy (Combined) Upper gi endoscopy biopsy (Combined) Knee Arthroscopy (Combined) Arthroscopy Ligament Repair Comp Metabolic Panel Surgical Path Tissue Exam MRI Abdomen MRI Brain MRI Joint Lower Extremity CT Thorax wo contrast X-ray Chest Screening mammography Mammo Computer Aided US Abdomen Complete Officeoutpatient visit new pt 30 min Vaginal delivery Lap Sleeve Gastrectomy
Piedmont Piedmont Piedmont Piedmont Northside Northside Northside Northside Gwinnett Gwinnett Gwinnett Gwinnett WellStar WellStar WellStar WellStar AMC - Tenet AMC - Tenet AMC - Tenet AMC - Tenet CPT Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing 29881 $11312 $10872 NA NA $7476 $9338 NA $23655 $11856 $3668 NA $17871 $12253 NA NA $15645 $5490 NA NA $23039 29888 NA NA NA NA NA NA NA $23784 NA $8261 NA $18000 NA NA NA $15774 NA NA NA $23168 43239 NA $4408 NA NA NA NA $5997 $8852 NA $3304 NA $7424 $1267 NA NA $9230 NA $2458 NA $8274 43644 $26468 NA NA NA $3382 $12050 NA $1861 NA NA NA $1316 $7841 NA NA $3444 $18892 $27950 NA $979 43775 NA NA NA NA NA NA NA $352 NA NA NA $302 NA NA NA $413 NA NA NA $83 45378 $2705 $2530 NA NA $4381 $3676 $4496 $1022 $2938 $2138 NA $695 $5504 NA NA $2036 NA NA NA $372 45380 $3075 $2600 NA NA $4723 $3527 $3012 $1757 $4215 $2285 NA NA $5298 NA NA $3268 NA NA NA $627 59400 $6160 NA NA NA NA $5100 NA $1851 NA NA NA $1304 $9035 NA NA $3427 $9116 $5150 NA $966 70553 $2985 NA $1153 NA $2182 NA $1192 $492 NA NA $803 $489 $1512 NA $985 $1187 NA NA NA $197 71020 $61 $69 $43 NA $113 $319 $307 NA $183 $59 $32 NA $213 $66 $40 NA $83 $53 NA NA 71250 $1837 $621 $989 NA $1490 $931 $755 NA NA $745 $401 NA $1067 $982 $616 NA NA $304 NA NA 73721 NA $1098 $1153 NA $2042 $1065 $1192 NA NA $998 $803 NA NA $1275 $985 NA NA $644 NA $178 74183 $2971 $1144 NA NA NA $1092 $1192 $6884 NA $1098 $803 NA $2960 $1197 $985 $5454 NA NA NA $7607 76700 $364 $247 $207 NA $427 $708 $614 $13267 $428 $214 $152 NA $747 $263 $189 $9139 NA $235 NA NA 77052 NA NA NA NA NA NA NA $4744 NA NA NA NA NA NA NA $3070 NA NA NA $5611 93306 $1220 $1117 NA NA $1877 $1657 $2100 $4605 $1433 $413 $945 NA $1336 $1434 $1951 $2931 NA $2399 NA $5472 G0202 $262 $187 NA NA $431 NA NA $4605 $292 NA NA NA $530 $281 NA $2931 $327 NA NA $5472
Provider Group 29881_6 29888_6 43239_6 43644_1 43775_1 45378_6 45380_6 59400_1 70553_2 71020_2 71250_2 73721_2 74183_2 76700_2 77052_2 77052_5 80053_8 88305_8 93306_2 99203_4 G0202_2 G0202_5 93017_2 Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Atlanta Gastroenterology Associates $2399 $536 348 $1628 $536 204 $2400 $536 348 Atlanta Medical Center $24889 $2266 999 $25897 $2502 935 $11449 $2240 411 $81927 $15300 435 $75815 $17800 326 $7317 $859 752 $7317 $859 752 $12821 $4688 173 $6581 $1052 526 $645 $72 796 $3265 $319 925 $3450 $557 519 $7398 $836 785 $1576 $133 1084 $73 $23 217 $635 $25 2440 $891 $232 285 $2967 $1157 156 $344 $168 105 $1265 $797 59 Atlanta Womens Health Physicians Group $29 $14 107 $40 $13 208 $396 $188 111 $278 $118 135 $450 $231 95 Gwinnett Hospital $11941 $3022 295 $21654 $10096 114 $3551 $1132 214 $34384 $10800 218 $56472 $13230 327 $3003 $1244 141 $3533 $1244 184 $8984 $4607 95 $3901 $967 303 $417 $279 49 $2247 $491 358 $4000 $967 314 $3755 $967 288 $1593 $195 717 $50 $15 233 $186 $56 233 $505 $152 233 $1750 $1173 49 $418 $294 42 $1396 $907 54 Northside Hospital $15482 $4185 270 $21651 $9557 127 $4885 $2539 92 $35176 $17000 107 $35233 $20815 69 $3883 $2805 38 $5256 $3071 71 $10911 $5730 90 $4856 $1468 231 $443 $266 67 $2379 $810 194 $3776 $1398 170 $5105 $1468 248 $942 $538 75 $167 $99 69 $379 $15 2427 $433 $307 41 $2252 $1566 44 $459 $328 40 $576 $432 33 Piedmont Hospital $14772 $3837 285 $35493 $5983 493 $5069 $2012 152 $38320 $17750 116 $37125 $12105 207 $3485 $2013 73 $4993 $2013 148 $10143 $4654 118 $5939 $1117 432 $542 $305 78 $2983 $505 491 $3410 $1042 227 $6067 $1106 449 $1364 $545 150 $75 $41 85 $231 $24 863 $657 $80 721 $2041 $1388 47 $490 $431 14 $1780 $1299 37 Piedmont Physicians Group $42 $22 87 $318 $179 78 $239 $159 50 Resurgens $8558 $2036 320 $9293 $2258 312 $4638 $2067 124 $4039 $2164 87 $4392 $2164 103 $2252 $1371 64 $459 $330 39 Wellstar Hospital $9330 $3729 150 $17479 $7519 132 $5261 $1565 236 $35794 $18200 97 $46780 $14600 220 $3707 $1972 88 $4928 $1972 150 $13549 $5855 131 $5054 $2805 80 $528 $375 41 $3222 $579 457 $3694 $925 299 $5495 $2805 96 $1355 $190 615 $66 $45 46 $73 $51 43 $133 $78 71 $1785 $1125 59 $599 $425 41 $1010 $717 41 Avg Mark UpProcedure Atlanta Medical Center 634 Gwinnett Hospital 223 Northside Hospital 233 Piedmont Hospital 259 Wellstar Hospital 155 Emory 105
Atlanta Gastroenterology Associates Atlanta Medical Center Atlanta Womens Health Gwinnett Hospital Northside Hospital Piedmont Hospital Piedmont Physicians Group Resurgens Wellstar Hospital CPT Code CPT Proc Cat Comp Avg Allow Allow Allow Allow Allow Allow Allow Allow Allow 29881 KNEE ARTHROSCOPYSURGERY 6 $3179 $2266 $3022 $4185 $3837 $2036 $3729 29888 KNEE ARTHROSCOPYSURGERY 6 $6319 $2502 $10096 $9557 $5983 $2258 $7519 43239 UPPER GI ENDOSCOPY BIOPSY 6 $1727 $536 $2240 $1132 $2539 $2012 $2067 $1565 43644 LAP GASTRIC BYPASSROUX-EN-Y 1 $15810 $15300 $10800 $17000 $17750 $18200 43775 LAP SLEEVE GASTRECTOMY 1 $17800 $13230 $20815 $12105 $14600 45378 DIAGNOSTIC COLONOSCOPY 6 $1656 $536 $859 $1244 $2805 $2013 $2164 $1972 45380 COLONOSCOPY AND BIOPSY 6 $1694 $536 $859 $1244 $3071 $2013 $2164 $1972 59400 OBSTETRICAL CARE 1 $5107 $4688 $4607 $5730 $4654 $5855 70553 MRI BRAIN WO amp WDYE 2 $1482 $1052 $967 $1468 $1117 $2805 71020 CHEST X-RAY 2 $259 $72 $279 $266 $305 $375 71250 CT THORAX WO DYE 2 $541 $319 $491 $810 $505 $579 73721 MRI JNT OF LWR EXTRE WO DYE 2 $978 $557 $967 $1398 $1042 $925 74183 MRI ABDOMEN WO amp WDYE 2 $1436 $836 $967 $1468 $1106 $2805 76700 US EXAM ABDOM COMPLETE 2 $320 $133 $195 $538 $545 $190 77052 COMP SCREEN MAMMOGRAM ADD-ON 2 $45 $23 $15 $99 $41 $45 77052 COMP SCREEN MAMMOGRAM ADD-ON 5 $14 $14 80053 COMPREHEN METABOLIC PANEL 8 $29 $25 $13 $56 $15 $24 $22 $51 88305 TISSUE EXAM BY PATHOLOGIST 8 $174 $232 $188 $152 $307 $80 $179 $78 93306 TTE WDOPPLER COMPLETE 2 $1297 $1157 $1173 $1566 $1388 $1371 $1125 93017 STRESS TEST 5 $830 $797 $907 $432 $1299 $717 99203 OFFICEOUTPATIENT VISIT NEW 4 $139 $118 $159 G0202 Screeningmammographydigital 2 $329 $168 $294 $328 $431 $330 $425 G0202 Screeningmammographydigital 5 $231 $231
Service Line Procedure CPT Code Emory Atlanta Gastroenterology Associates Resurgens Atlanta Womens Health Piedmont Physicians Group Orthopedics (ASC) Knee Arthroscopy 29881 $3467 $2036 Arthroscopy Ligament Repair 29888 $3386 $2258 GI (ASC) Upper GI Endoscopy 43239 $2758 $536 Diagnostic Colonoscopy 45378 $2348 $536 Colonoscopy and biopsy 45380 $2181 $536 Radiology Mammogram Screening G0202 $164 $231 Computer Detection Add-on 77052 $93 $14 Lab Comp Metabolic Panel 80053 $53 $13 $22 Tissue Exam by Pathologist 88305 $277 $188 $179 EampM (TEC) Office Visit new pt 99203 $269 $118 $159
Service Line Procedure CPT CodeDRG Memorial Hospital Beta Hosptial Charlie Hospital Delta Hospital Echo Hospital Alpha Medical Center Atlanta Gastroenterology Associates Resurgens Atlanta Womens Health Piedmont Physicians Group Market Avg Emory abovebelow Orthopedics Arthroscopy Ligament Repair 29888 $ 5062 $ 9557 $ 5983 $ 10096 $ 7519 $ 2502 $ 2258 $ 6319 -20 Knee Arthroscopy 29881 6 $ 5069 $ 4185 $ 3837 $ 3022 $ 3729 $ 2266 $ 2036 $ 3179 59 GI Upper GI Endoscopy 43239 6 $ 3075 $ 2539 $ 2012 $ 1132 $ 1565 $ 2240 $ 536 $ 1671 84 Lap Sleeve Gastrectomy DRG 621 $ 20421 $ 20815 $ 12105 $ 13230 $ 14600 $ 17800 $ 15710 30 Colonoscopy and biopsy 45380 $ 3075 $ 3071 $ 2013 $ 1244 $ 1972 $ 859 $ 536 $ 1616 90 Diagnostic Colonoscopy 45378 6 $ 3075 $ 2805 $ 2013 $ 1244 $ 1972 $ 859 $ 536 $ 1572 96 Radiology MRI Brain w amp wo dye 70553 2 $ 1238 $ 1468 $ 1117 $ 967 $ 2805 $ 1052 $ 1482 -16 MRI Joint of Lower Extremity wo dye 73721 2 $ 1238 $ 1398 $ 1042 $ 967 $ 925 $ 557 $ 978 27 MRI Abdomen w amp wo dye 74183 2 $ 1238 $ 1468 $ 1106 $ 967 $ 2805 $ 836 $ 1436 -14 X-ray Chest 71020 $ 115 $ 266 $ 305 $ 279 $ 375 $ 72 $ 259 -56 CT Thorax wo dye 71250 $ 882 $ 810 $ 505 $ 491 $ 579 $ 319 $ 541 63 Ultrasound Abdomen Complete 76700 $ 397 $ 538 $ 545 $ 195 $ 190 $ 168 $ 327 21 Mammogram Screening G0202 2 $ 141 $ 328 $ 431 $ 294 $ 425 $ 168 $ 231 $ 313 -55 Computer Detection Add-on 77052 2 $ 112 $ 99 $ 41 $ 15 $ 45 $ 23 $ 14 $ 39 183 Lab Comp Metabolic Panel 80053 8 $ 56 $ 15 $ 24 $ 56 $ 51 $ 25 $ 13 $ 22 $ 29 88 Tissue Exam by Pathologist 88305 8 $ 236 $ 307 $ 80 $ 152 $ 78 $ 232 $ 188 $ 179 $ 174 36 Medical Cardiology Cardiovascular Stress Test 93017 $ 383 $ 432 $ 1299 $ 907 $ 717 $ 797 $ 830 -54 TTE w Doppler 93306 2 $ 960 $ 1566 $ 1388 $ 1173 $ 1125 $ 1157 $ 1282 -25 Obstetrics Vaginal Delivery DRG 755 $ 7290 $ 5730 $ 4654 $ 4607 $ 5855 $ 4688 $ 5107 43 EampM Office Visit new pt 99203 4 $ 248 $ 118 $ 159 $ 139 78 Colonoscopy and biopsy (HOSPITAL ONLY) 45380 Surg 2530 $ 307591 Diagnostic colonoscopy (HOSPITAL ONLY) 45378 Surg 2255 $ 307591 Upper gi endoscopy biopsy (HOSPITAL ONLY) 43239 Surg 1787 $ 307591 Knee Arthroscopy (HOSPITAL ONLY) 29881 Surg 10900 $ 506893 Arthroscopy Ligament Repair (HOSPITAL ONLY) 29888 Surg 10900 $ 506200 Key 1 Facility - Inpatient 2 Facility - Imaging 3 Physician - Imaging 4 Physician 5 Global - Imaging 6 Facility - Outpatient 8 Lab 41 Physician - Primary Care 42 Physician - Specialist
Blue Cross United - EJCH EUH EUHM WW United - SJH Non Options United - SJH Options Aetna - ASC TEC (HMO) Cigna - ASC TEC (HMO) Aetna - EJCH ESJH ECHM WW Cigna - EJCH (HMO) Cigna - ESJH EUHM (HMO) List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract Description CPT Code Charge Average Final Price (all plans) Emory Mark Up Reimbursement Method ( of charge or fixed) - 1713 Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Cardiovascular stress test 93017 Cardio $543 $ 425 28 of Charge 70 $ 380 of Charge 65 $ 353 of Charge 60 $ 326 of Charge 70 $ 380 of Charge 70 $ 380 of charge 100 $ 543 of Charge 70 $ 380 of charge 100 $ 543 of charge 100 $ 543 TTE wDoppler complete 93306 Cardio $1226 $ 960 28 of Charge 70 $ 858 of Charge 65 $ 797 of Charge 60 $ 736 of Charge 70 $ 858 of Charge 70 $ 858 of charge 100 $ 1226 of Charge 70 $ 858 of charge 100 $ 1226 of charge 100 $ 1226 Colonoscopy and biopsy (HOSPITAL ONLY) 45380 Surg $2530 $ 3076 -18 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 of Charge 70 $ 1771 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Diagnostic colonoscopy (HOSPITAL ONLY) 45378 Surg $2255 $ 3076 -27 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 of Charge 70 $ 1579 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Upper gi endoscopy biopsy (HOSPITAL ONLY) 43239 Surg $1787 $ 3076 -42 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Knee Arthroscopy (HOSPITAL ONLY) 29881 Surg $10900 $ 5069 115 Fixed Rate SC 4 $ 3865 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 449300 $ 4493 Fixed Rate $ 654700 $ 6547 of Charge 70 $ 7630 Fixed Rate $ 401000 $ 4010 of Charge 70 $ 7630 Fixed Rate $ 398300 $ 3983 Fixed Rate $ 398100 $ 3981 Arthroscopy Ligament Repair (HOSPITAL ONLY) 29888 Surg $10900 $ 5062 115 Fixed Rate SC 3 $ 3121 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 556900 $ 5569 Fixed Rate $ 770100 $ 7701 of Charge 70 $ 7630 Fixed Rate $ 323900 $ 3239 of Charge 70 $ 7630 Fixed Rate $ 321700 $ 3217 Fixed Rate $ 321400 $ 3214 Comp Metabolic Panel 80053 Lab $132 $ 56 138 RBRVS Fee (100) $ 1437 of Charge 65 $ 86 of Charge 65 $ 86 of Charge 65 $ 86 of Charge 70 $ 92 RBRVS Fee (100) $ 1437 $ 14 of Charge 70 $ 92 RBRVS Fee (100) $ 1437 $ 14 RBRVS Fee (100) $ 1437 $ 14 Surgical Path Tissue Exam 88305 Lab $326 $ 236 38 of Charge 150 $ 51 of Charge 65 $ 212 of Charge 65 $ 212 of Charge 65 $ 212 of Charge 70 $ 228 of charge 100 $ 326 of Charge 70 $ 228 of charge 100 $ 326 of charge 100 $ 326 MRI Abdomen 74183 Radiology $6960 $ 1238 462 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 MRI Brain 70553 Radiology $6804 $ 1238 450 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 MRI Joint Lower Extremity 73721 Radiology $3067 $ 1238 148 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 CT Thorax wo contrast 71250 Radiology $2199 $ 882 149 Fixed Rate $ 771 Fixed Rate $ 47100 $ 471 Fixed Rate $ 81700 $ 817 Fixed Rate $ 116000 $ 1160 of Charge 70 $ 1539 Fixed Rate $ 80100 $ 801 Fixed Rate $ 79200 $ 792 Fixed Rate $ 79300 $ 793 Fixed Rate $ 79500 $ 795 X-ray Chest 71020 Radiology $280 $ 115 142 of Charge 150 $ 25 of Charge 65 $ 182 of Charge 60 $ 168 of Charge 70 $ 196 of Charge 70 $ 196 RBRVS Fee (150) $ 2534 $ 25 of Charge 70 $ 196 RBRVS Fee (150) $ 2534 $ 25 RBRVS Fee (150) $ 2534 $ 25 Screening mammography G0202 Radiology $279 $ 141 98 Fixed Rate $ 128 Fixed Rate $ 13100 $ 131 Fixed Rate $ 14300 $ 143 Fixed Rate $ 16100 $ 161 of Charge 70 $ 195 Fixed Rate $ 13300 $ 133 Fixed Rate $ 13500 $ 135 Fixed Rate $ 13000 $ 130 Fixed Rate $ 11200 $ 112 Mammo Computer Aided 77052 Radiology $75 $ 112 -33 Fixed Rate $ 9 Fixed Rate $ 13100 $ 131 Fixed Rate $ 14300 $ 143 Fixed Rate $ 16100 $ 161 of Charge 70 $ 53 Fixed Rate $ 13300 $ 133 Fixed Rate $ 13500 $ 135 Fixed Rate $ 13000 $ 130 Fixed Rate $ 11200 $ 112 US Abdomen Complete 76700 Radiology $917 $ 397 131 of Charge 150 $ 125 of Charge 65 $ 596 of Charge 60 $ 550 of Charge 70 $ 642 of Charge 70 $ 642 RBRVS Fee (150) $ 12519 $ 125 of Charge 70 $ 642 RBRVS Fee (150) $ 12519 $ 125 RBRVS Fee (150) $ 12519 $ 125 Officeoutpatient visit new pt 30 min (TEC) 99203 EampM $316 $ 248 28 of Charge 70 $ 221 of Charge 65 $ 205 of Charge 60 $ 190 of Charge 70 $ 221 of Charge 70 $ 221 of charge 100 $ 316 of Charge 70 $ 221 of charge 100 $ 316 of charge 100 $ 316 Vaginal delivery 59409 Surg $14484 $ 7290 99 Fixed Rate DRG - 775 $ 5437 2 Day Case Rate + LOC 561700 $ 5617 BaseCMS Weight 584741 $ 5847 BaseCMS Weight 726146 $ 7261 No IP Terms $ - 0 No IP BaseCMS Weight 659343 $ 6593 BaseContract Weight 479451 100 $ 14484 BaseCMS Weight 579110 $ 5791 Lap Sleeve Gastrectomy 43775 Surg $29961 $ 20421 47 Fixed Rate DRG - 621 $ 14872 BaseCMS Weight 1810697 $ 18107 BaseCMS Weight 1835178 $ 18352 BaseCMS Weight 2278911 $ 22789 No IP Terms $ - 0 No IP BaseCMS Weight 2069315 $ 20693 BaseCMS Weight 1730442 100 $ 29961 BaseCMS Weight 1817507 $ 18175 105 Colonoscopy and biopsy (ASC ONLY) Surg $ 219200 $ 2181 Diagnostic colonoscopy (ASC ONLY) Surg $ 267100 $ 2348 Upper gi endoscopy biopsy (ASC ONLY) Surg $ 207500 $ 2758 Knee Arthroscopy (ASC ONLY) Surg $ 417900 $ 3467 Arthroscopy Ligament Repair (ASC ONLY) Surg $ 504800 $ 3386
Cpt Code CPT Description Procedure Category Claims Min 25thNtile 50thNtile Emorys Rates 75thNtile 90thNtile Max 20 Below 50th Ntile 20 Above 50th Ntile 93017 CARDIOVASCULAR STRESS TEST 5 82 $80 $125 $321 $382 $568 $791 $930 $257 $386 71020 CHEST X-RAY 2 2638 $11 $45 $152 $115 $289 $373 $585 $122 $182 71020 CHEST X-RAY 5 8106 $25 $34 $38 $54 $57 $69 $30 $46 45380 COLONOSCOPY AND BIOPSY 6 1256 $541 $560 $572 $2877 $1000 $2024 $3289 $458 $686 77052 COMP SCREEN MAMMOGRAM ADD-ON 2 194 $13 $15 $25 $38 $47 $134 $20 $30 77052 COMP SCREEN MAMMOGRAM ADD-ON 5 2411 $13 $16 $20 $23 $26 $28 $16 $24 80053 COMPREHEN METABOLIC PANEL 8 13019 $9 $19 $23 $55 $24 $25 $69 $19 $28 71250 CT THORAX WO DYE 2 302 $165 $372 $545 $878 $1658 $2067 $436 $654 71250 CT THORAX WO DYE 5 209 $53 $127 $203 $289 $419 $534 $162 $244 45378 DIAGNOSTIC COLONOSCOPY 6 1479 $484 $515 $536 $2914 $831 $1971 $2828 $428 $643 29881 KNEE ARTHROSCOPYSURGERY 6 152 $1650 $1826 $2036 $5235 $3054 $4216 $6461 $1629 $2443 29888 KNEE ARTHROSCOPYSURGERY 6 82 $1682 $3615 $5081 $5145 $7553 $12924 $18532 $4065 $6097 43644 LAP GASTRIC BYPASSROUX-EN-Y 1 21 $11821 $13873 $17050 $18391 $25029 $31079 $13640 $20460 43775 LAP SLEEVE GASTRECTOMY 1 38 $4215 $8250 $13253 $20421 $19197 $21509 $24260 $10602 $15903 74183 MRI ABDOMEN WO amp WDYE 2 120 $919 $987 $1015 $1237 $1252 $2534 $3177 $812 $1218 74183 MRI ABDOMEN WO amp WDYE 5 112 $475 $490 $521 $1154 $1337 $1696 $417 $625 70553 MRI BRAIN WO amp WDYE 2 324 $633 $987 $1142 $1237 $1706 $2805 $3331 $914 $1370 70553 MRI BRAIN WO amp WDYE 5 467 $280 $539 $1023 $1277 $1363 $1726 $818 $1228 73721 MRI JNT OF LWR EXTRE WO DYE 2 304 $804 $859 $967 $1237 $1063 $1598 $2485 $774 $1160 73721 MRI JNT OF LWR EXTRE WO DYE 5 1130 $500 $520 $530 $628 $679 $859 $424 $636 59400 OBSTETRICAL CARE 1 494 $3699 $4402 $4969 $6655 $7307 $8613 $3975 $5963 99203 OFFICEOUTPATIENT VISIT NEW 4 6776 $88 $101 $112 $138 $155 $169 $90 $134 G0202 Screeningmammographydigital 2 7444 $123 $206 $285 $380 $425 $479 $228 $342 G0202 Screeningmammographydigital 5 2754 $117 $165 $195 $230 $247 $252 $156 $234 88305 TISSUE EXAM BY PATHOLOGIST 8 20834 $51 $74 $112 $235 $168 $261 $478 $90 $134 93306 TTE WDOPPLER COMPLETE 2 931 $194 $377 $739 $960 $1267 $1480 $1849 $591 $887 93306 TTE WDOPPLER COMPLETE 5 2299 $151 $296 $373 $538 $573 $834 $298 $448 43239 UPPER GI ENDOSCOPY BIOPSY 6 1264 $424 $514 $550 $800 $1838 $2833 $440 $660 76700 US EXAM ABDOM COMPLETE 2 321 $96 $165 $271 $509 $584 $857 $217 $325 76700 US EXAM ABDOM COMPLETE 5 444 $111 $129 $147 $156 $220 $279 $118 $176 Key 1 Facility - Inpatient 2 Facility - Imaging 3 Physician - Imaging 4 Physician 5 Global - Imaging 6 Facility - Outpatient 8 Lab 41 Physician - Primary Care 42 Physician - Specialist Cardiovascular stress test $ 38279 TTE wDoppler complete $ 96037 Colonoscopy and biopsy $ 287709 Diagnostic colonoscopy $ 291434 Upper gi endoscopy biopsy $ 300526 Knee Arthroscopy $ 523584 Arthroscopy Ligament Repair $ 514501 Comp Metabolic Panel $ 5552 Surgical Path Tissue Exam $ 23570 MRI Abdomen $ 123786 MRI Brain $ 123786 MRI Joint Lower Extremity $ 123786 CT Thorax wo contrast $ 88213 X-ray Chest $ 11548 Screening mammography $ 14098 Mammo Computer Aided $ 11179 US Abdomen Complete $ 39695 Officeoutpatient visit new pt 30 min $ 24753 Vaginal delivery $ 729025 Lap Sleeve Gastrectomy $ 2042124
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Transplants
Bariatric Surgery
Knees hips or spine
Cardiovascularcardiac
Cancer
Fertility
Other Procedures
Yes with incentives Yes but no incentives No but considering
10
A 2015 survey by the National Business Group on Health shows the status of large employersrsquo contracts with COEs (note reflects all COEs not specifically direct contracts)
Source Large Employersrsquo 2016 Health Plan Design Survey copy 2015 National Business Group on Health
Other centers of excellence programs include maternity NICU sleep apnea pancreas cornea and kidney
National Business Group on Healthrsquos Large Employers 2019 Health Care Strategy and Plan Design Survey showed DC arrangements between employers and bull Health systemsproviders will
increase from 3 in 2018 to 11 in 20191
bull COEs will increase from 12 in 2018 to 18 in 20191
bull Cancer cardiovascular and fertility COEs are experiencing the greatest growth
Source National Business Group on Health ldquoLarge US Employers Eye Changes to Health Care Delivery System as Cost to Provide Health Benefits Nears $15000 per Employeerdquo August 2018
10
Trends in Direct Contracting amp COE
Outcomes amp Benefits bull Employers with COE arrangements are seeing reduction in procedures
bull Walmart (15rsquo-18rsquo) 50+ of spine surgeries amp 20 of kneehip procedures recommended by local providers were determined lsquonot necessaryrsquo by COE (see table)
bull Employers like Walmart amp Boeing continue to sign new providers which suggest (employersrsquo) continued interest in pursuing DC arrangements2 However Boeing and Providence Swedish did end relationship due to inability to capture enoughright data to estimate cost of care3
bull John Hopkinsrsquo Bayview campus COE emerging metrics4
bull 121 referrals in the first three months
bull 352 referrals and 183 surgeries over 18 months
bull 23 of all joint replacement volumes at facility now attributed to travel program
bull 96 of patients said they would recommend this program to family friends coworkers
bull Bingham Memorial in Idaho direct contracting emerging metrics4
bull 17 companies participating covering over 5000 lives
bull +3000 new patients as of October 2018
bull +$3M Revenue from new patients
11
1 How Employers Are Fixing Health Care Harvard Business Review March 2019 2 httpswwwhealthleadersmediacomstrategywalmart-escalates-strategy-solve-employee-healthcare Health Leaders Media Nov 18rsquo 3 Do Providers Have the Data chops to Success with Direct Contract Modern Healthcare August 2018 4 Re-Igniting the Growth Engine Part 2 Winning Increased Share of Lucrative Patient Volumes Advisory Board 5 httpswwwautonewscomarticle20180806OEM180809831gm-signs-major-health-care-services-deal-for-salaried-employees
Walmart COE Programs1
Program Key Benefits
Spin
e Su
rger
y 2300 EEs 50 COE approved of those applied
bull 95 lower readmission bull 14 less time in hospital bull 1 COE vs 5 non-COE patients discharged to SNF bull Returned to work sooner reducing 20 of OOO
time bull More-effective less dangerous amp less expensive bull The COE surgery ldquopricerdquo is 8 higher but value in
earlier discharge lower readmission rates far less utilization of SNF faster return to work
Join
t
1836 EEs 18 COE approved of those applied
bull 32 less time in hospital bull 70 less likely to be readmitted than non-COE
patients bull Fewer postsurgical complications bull 0 COE vs 5 non-COE patients discharged to SNF bull COE patients returned to work a 15 weeks sooner bull Cost of surgery is 15 less at COE hospitals
Baria
tric
300+ EEs
bull Preliminary data suggests the weight loss from surgery reduces absenteeism or presentism (working while sick)
bull Dramatically cuts pharmacy amp medical costs Complications of obesity drop sharply as does the need for medication
bull GMrsquos direct contract benefit plans with Henry Ford allows it to offer similarly designed plans to that of Blue Cross with savings in monthly EE contributions ranging from $300-$19805
Walmartrsquos Travel (Surgery) Program
Mem
ber F
eedb
ack
12
Looking beyond traditional cost management techniques Walmart designed a program to address wild variations in cost and become directly in improving quality of care for its employees FIRST SELECTING PROVIDERS 1 Identify providers with high volume and high quality 2 Target regions in country to support Walmartrsquos employees 3Focus on Integrated Health Systems Hospitals within these systems were best aligned to Walmarts mission could take on risks associated with bundling 4 Eliminate systems unwilling to do bundled payments model were
PROVIDERS VALUE IN PARICIPATING
Build Bundles bull Define bundles and negotiate price (typically 10-15 below FFS ) bull Definitions of service limit disputes of what is covered vs not (covers
entryexit of facility SNF not part of bundle) bull Contract flexibility covers unforeseen testcosts and reinforces
Walmarthealth system partnership bull Warrantees if further treatment - can return in 30 days no
additional cost to Walmart bull Strict criteria and providers with track record of clinically sound
decisions are included to mitigate any incentivizing of volume Business bull 100 travelaccom brings
new volume of patients from outside of market
bull More stable payments for services (vs Medicare or commercial FFS)
bull Increased visibility and attract new business
Clinical bull lsquoHalorsquo effect ndash Building a highly
efficient multidiscipline program brings improvements throughout health system
bull Onsite collaboration among health systems allows sharing of outcomesbest practices
Source How Employers Are Fixing Health Care Harvard Business Review March 2019
5000 participants in the program
95 satisfiedvery satisfied
Denied by care because not deemed necessary by COE Treatment denied due to lifestyle weightsmoking
The Member Experience
13
Engagement begins when employee on clear
path to surgery
Patient contacts with COE TPA
TPA team triages and ensures basic criteria
met
Employee put in touch with nurse team
Car pick-up Flight Hotel all arranged by
TPA
Navigators and nurse coordinators help
throughout the stay
Patient visits to hospital to understand
exceptions of procedure and meet treatment
team
Surgery occurs typically next day
Stay length according to procedure typically a
few days
Discharged from facility Travel home COE team updates local
PCP and discuss follow up care
COE provider checks in with local physician
frequently Revert back to standard coverage
Source How Employers Are Fixing Health Care Harvard Business Review March 2019
Case Study 1
Case study 1 ndash Pop Health Approach bull ProblemCircumstance Large multi-employer group needs to
evaluate benefit design disease prevalence health spend and utilization to manage their population
bull ConsiderationsValue Prop Unique industry and geography drive chronic conditions and utilization patterns
bull Solution Provide opportunity assessment comparing this population to other benchmarks to understand where to target intervention and management as well as assess efforts already taken
15
Market Comparison Preference Sensitive Procedures
16
Legend vs
Mt States vs
National gt120 gt110
110-120 105-110 lt80 lt90
Source Multi-payer commercial benchmark Results are weighted by AgeGender Broader market area includes multi-payer data from the mountain regions
Preference Sensitive Procedures Benchmark Comparison
Dartmouth Atlas Preference Sensitive Procedures
IP allowed dollars ALOS Employer vs
Mt States Employer
vs National FY 2017 FY 2018 FY 2017 FY 2018
Hysterectomy for Uterine Fibroids Rate $569354 $436932 45 54 124 140 CABG Rate $1800260 $2400608 53 60 218 130 Cholycystectomy Rate $832675 $755565 68 39 92 120 C-Section Rate 116 110 HighTech Radiology Rate 103 101 PCIPTCA Rate $934486 $1133708 37 55 82 80 Back Surgery Rate $3237613 $4003212 39 57 52 70 Knee Replacement Rate $3086693 $2177334 41 48 50 64 Total Hip Replacement Rate $1023675 $747491 45 64 37 34
Strengths (+)
Employer compares favorably for orthopedic procedures (back hip knee)
Opportunity (-)
Employer has higher than expected rates for CABG and hysterectomy (Note Low PTCA rate combined with high CABG rate may suggest provider practice patterns favoring CABG)
0 50 100 150 200 250
Total Hip Replacement
Knee Replacement
Back Surgery
PCIPTCA
Cholycystectomy
HighTech Radiology
C-Section
CABG
Culinary VsNational
Culinary Vs MtStates
Employer vs Mt States
Employer vs National
Market Comparison Condition Prevalence
17 Source Multi-payer commercial benchmark Results are weighted by AgeGender Broader market area includes multi-payer data from the mountain regions
Condition Prevalence Benchmark Comparison
Condition Employer vs
Mt States Employer vs
National Prevalence Diabetes Rate 229 219 Prevalence Hyperlipidemia Rate 259 207 Prevalence Kidney Disease Rate 143 174 Prevalence Migraine Rate 166 164 Prevalence Low Back Pain Rate 136 139 Prevalence Hypertension Rate 156 134 Prevalence Asthma Rate 146 128 Prevalence CAD Rate 175 115 Prevalence Pregnancy Rate 110 109 Prevalence Adult Preventive Screening Rate 114 91 Prevalence Depression Rate 63 60
Strengths (+)
Rate of depression is low (Note May be due to incomplete behavioral health claims)
Opportunity (-)
Employer has a higher prevalence of most chronic conditions including asthma CAD diabetes hypertension hyperlipidemia Kidney Disease LBP and migraines
0
100
200
300Hyperlipidemia
Diabetes
CAD
Migraine
Hypertension
AsthmaKidney Disease
Low Back Pain
Pregnancy
Depression
Employer vsMt States
Employer vsNational Legend
vs Mt States
vs National
gt120 gt110 110-120 105-110
lt80 lt90
Market Comparison Utilization Rates
18
A higher preventive office visit rate is better Source Multi-payer commercial benchmark Results are weighted by AgeGender Broader market area includes multi-payer data from the mountain regions
Strengths (+)
Lower than average utilization of ED and high dollar patient rate
Opportunity (-)
Higher LOS lengthy admits avoidable admits and readmissions which all drive significantly more spend
Utilization Benchmark Comparison
Condition Employer vs
Mt States Employer vs
National Avoidable Admit Rate 142 144 Lengthy Admit Rate 175 136 Outpatient Problem Focused Office Rate 146 131 Readmission Rate (readmitadmit) 135 126 Average LOS 125 116 One Day Admit Rate 76 103 Office Visit Rate 106 96 Acute Admit Rate 80 95 Avoidable ED Rate 68 86 ED Rate 54 69 Preventive Office Rate 95 68 High Dollar Patient Rate 49 51 Frequent ED User (gt3 times) Rate 24 36
Legend vs
Mt States vs
National gt120 gt110
110-120 105-110 lt80 lt90
0 50 100 150 200
Frequent ED User (gt3 times)
High Dollar Patient
Preventive Office
ED
Avoidable ED
Acute Admit
Office Visit
One Day Admit
Average LOS
Readmissionhellip
Outpt Problem Focusedhellip
Lengthy Admit
Avoidable Admit
Employer vsNational
Employer vsMt States
ED and Avoidable ED
19
Potentially Avoidable ED - Trend View Overall ED
Period Change FY 2017 FY 2018 Count Rate
Measure Mbrs Rate Mbrs Rate Overall ED 16394 12626 13820 10745 -16 -15 FREQUENT ED UTILIZER (mbr1k) 1581 1218 1468 1141 -7 -6 AVOIDABLE ED 6371 4907 5288 4111 -17 -16 Potentially Avoidable ED
Period Change FY 2017 FY 2018 Count Rate
Avoid ED Condition Mbrs Rate Mbrs Rate ABDOMINAL_PAIN 1092 841 895 696 -18 -17 ENT_INFECTION 854 658 742 577 -13 -12 FEVER 715 551 700 544 -2 -1 URINARY 650 501 468 364 -28 -27 HEADACHE 558 430 434 337 -22 -21 BACK_PAIN 414 319 423 329 2 3 NAUSEA 394 303 271 211 -31 -31 ASTHMA 294 226 209 162 -29 -28 CELLULITIS 210 162 198 154 -6 -5 GASTROENTERITIS 254 196 171 133 -33 -32 OTITIS_MEDIA 201 155 160 124 -20 -20 COPD 132 102 108 084 -18 -17 DIABETES 123 095 91 071 -26 -25 BACT_PNEUMONIA 111 085 86 067 -23 -22 DENTAL 93 072 83 065 -11 -10 DEHYDRATION 98 075 81 063 -17 -17 HYPERTENSION 16 012 24 019 50 51 CHF 4 003 3 002 -25 -24 ANGINA 8 006 3 002 -63 -62 IMMUNIZATION_RELATED 2 002 0 000 -100 -100 Grand Total 6371 4907 5288 4111 -17 -16
AHRQ avoidable ED visits are based on the logic for ambulatory care sensitive ED visits from AHRQ and diagnosis code driven
696
577
544 364
337
329
211 162
154 133 ABDOMINAL_PAIN
ENT_INFECTION
FEVER
URINARY
HEADACHE
BACK_PAIN
NAUSEA
- 200 400 600 800
1000 1200
2017 Members 2018 Members
Top Ten 2018 Conditions by Rate
Top Ten Conditions by Member Count
ED Avoidable ED and the impact of new on-site clinic
20
0
1000
2000
3000
4000
5000
6000
0200400600800
10001200140016001800
Clinic Visits ED Visits
Avoidable ED VisitsED Visits (non-avoidable)Clinic EampM Visits
0
500000
1000000
1500000
2000000
2500000
3000000
3500000
$s
Clinic EampM Profess DollarsAvoidable ED Dollars
bull Clinic visits have a clear impact on ED and avoidable ED use and spend
bull Combined ED visits are down on average 157 in FY 18 from FY 17
bull Combined ED spend is down 128 in FY 18 from FY 17
Clinic Live 62017
Pitfalls and Challenges bull Face many of the challenges similar to startup health
plan bull Critical to determine how you will deliver value and
communicate the value to potential customers and brokersconsultants
bull Care management bull Network
21
Considerations in Offering Development bull Care Management Model
bull Traditional care model bull Case management bull Utilization management bull Disease management
bull Longitudinal care model with value based care philosophy bull Primary care driven bull Local care management
bull Predictive analytics and risk stratification model bull Claims history and ongoing data bull EMR data
22
Case Study 2
Case study 2 ndash Large Employer bull Business Problem Large employer wants to contract
directly with 2 major hospital systems developing professional fee schedules
bull ConsiderationsValue Prop Fee schedule should be competitive but also nuanced to minimize gap relative to current reimbursement at physician level
bull Solution Data-driven approach using current market-wide reimbursement distinguished by service level
24
Evaluate Provider Spend Top 25 Service Lines by Allowable Spend
Evaluate Provider Spend Top 20 Professional CPTs by Total Spend
Understand relative market pricing position
27
21
-1
-28
14 10
28
-22
-11 -13
24
3
20 21
8
-20
13
3 9
-39
56
-26
4
-42
60
MRI Colonoscopy Cardiac Cath Lab - OrganPanel
Memorial Hospital Beta Hospital Delta Hospital Charlie Hospital Echo Hospital Alpha Medical Center
ndash25 5 -15 10 0 39
State Charges as a Percent of Peer Average Weighted Averages for MRI Colonoscopy Cardiology and Lab
Total Percent Above Below Market Average2
Memorial Hospital Beta Hospital Delta Hospital Charlie Hospital Echo Hospital Alpha Medical Center
Develop fee schedule relative to market
28
Service Line Procedure CPT CodeDRG
Memorial Hospital
Beta Hosptial
Charlie Hospital
Delta Hospital
Echo Hospital
Alpha Medical Center
Arthroscopy Ligament Repair 29888 $ 5062 $ 9557 $ 5983 $ 10096 $ 7519 $ 2502 Knee Arthroscopy 29881 $ 5069 $ 4185 $ 3837 $ 3022 $ 3729 $ 2266 Upper GI Endoscopy 43239 $ 3075 $ 2539 $ 2012 $ 1132 $ 1565 $ 2240 Lap Sleeve Gastrectomy DRG 621 $ 20421 $ 20815 $ 12105 $ 13230 $ 14600 $ 17800 Colonoscopy and biopsy 45380 $ 3075 $ 3071 $ 2013 $ 1244 $ 1972 $ 859 Diagnostic Colonoscopy 45378 $ 3075 $ 2805 $ 2013 $ 1244 $ 1972 $ 859 MRI Brain w amp wo dye 70553 $ 1238 $ 1468 $ 1117 $ 967 $ 2805 $ 1052 MRI Joint of Lower Extremity wo dye 73721 $ 1238 $ 1398 $ 1042 $ 967 $ 925 $ 557 MRI Abdomen w amp wo dye 74183 $ 1238 $ 1468 $ 1106 $ 967 $ 2805 $ 836 X-ray Chest 71020 $ 115 $ 266 $ 305 $ 279 $ 375 $ 72 CT Thorax wo dye 71250 $ 882 $ 810 $ 505 $ 491 $ 579 $ 319 Ultrasound Abdomen Complete 76700 $ 397 $ 538 $ 545 $ 195 $ 190 $ 168 Mammogram Screening G0202 $ 141 $ 328 $ 431 $ 294 $ 425 $ 168 Computer Detection Add-on 77052 $ 112 $ 99 $ 41 $ 15 $ 45 $ 23 Comp Metabolic Panel 80053 $ 56 $ 15 $ 24 $ 56 $ 51 $ 25 Tissue Exam by Pathologist 88305 $ 236 $ 307 $ 80 $ 152 $ 78 $ 232 Cardiovascular Stress Test 93017 $ 383 $ 432 $ 1299 $ 907 $ 717 $ 797 TTE w Doppler 93306 $ 960 $ 1566 $ 1388 $ 1173 $ 1125 $ 1157
Obstetrics Vaginal Delivery DRG 755 7290$ 5730$ 4654$ 4607$ 5855$ 4688$
GI
Lab
Radiology
Medical Cardiology
Orthopedics
KEY OBSERVA TIONS bull Potential exposure on GI bull Opportunity to align price and acuity in MRI bull Opportunity to raise rates on chest x-ray and mammogram
Percentile Bands Emory Allowables Heatmap TEC ASC Heatmap Allowable Comp Analysis Portal Pricing Sheet1 image1png A few words on Bundled Payments bull Bundled payments are growing as a type of direct contracting bull In some cases third parties match-make between employers
and providers bull Contracts may vary in definitions prepost admission
coverage duration readmission cause (ie all-cause vs medically related) outlier provisions LOS caps andor per diems
bull Providers need to be strategic in pricing to enable profitable growth of market share
29
Considerations in Offering Development bull Network Development
bull Build off existing structure eg health system employee plan network bull How does this fit into your broader value based care strategy bull Employed and independent physicians bull How do you want to approach the buildout of high performance
network bull Quality focus bull Cost efficiency
bull Integrated behavioral health bull Wrap network for other markets
30
Considerations in Offering Development bull Target Market
bull Consideration of employer profile in market bull Fully-insured vs ASO bull Total cost of care vs bundled services
bull Distribution bull Direct marketing bull Brokerconsultant community
bull Plan designs bull Standard designs vs flexible ndash Dependent on target market
bull Claims administration bull Data sharing amp analytics
31
Considerations in Offering Development bull Other components of comprehensive offering
bull Pharmacy bull Preventive health bull Onsite clinics bull Wellness programs bull Technology platform
32
Sample Bundle Analysis
33
Cover page Dotson Hazelrigs Nation Mainly of charge of fixed Cardiovascular stress test TTE wDoppler complete Colonoscopy and biopsy (Combined) Diagnostic colonoscopy (Combined) Upper gi endoscopy biopsy (Combined) Knee Arthroscopy (Combined) Arthroscopy Ligament Repair Comp Metabolic Panel Surgical Path Tissue Exam MRI Abdomen MRI Brain MRI Joint Lower Extremity CT Thorax wo contrast X-ray Chest Screening mammography Mammo Computer Aided US Abdomen Complete Officeoutpatient visit new pt 30 min Vaginal delivery Lap Sleeve Gastrectomy
Piedmont Piedmont Piedmont Piedmont Northside Northside Northside Northside Gwinnett Gwinnett Gwinnett Gwinnett WellStar WellStar WellStar WellStar AMC - Tenet AMC - Tenet AMC - Tenet AMC - Tenet CPT Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing 29881 $11312 $10872 NA NA $7476 $9338 NA $23655 $11856 $3668 NA $17871 $12253 NA NA $15645 $5490 NA NA $23039 29888 NA NA NA NA NA NA NA $23784 NA $8261 NA $18000 NA NA NA $15774 NA NA NA $23168 43239 NA $4408 NA NA NA NA $5997 $8852 NA $3304 NA $7424 $1267 NA NA $9230 NA $2458 NA $8274 43644 $26468 NA NA NA $3382 $12050 NA $1861 NA NA NA $1316 $7841 NA NA $3444 $18892 $27950 NA $979 43775 NA NA NA NA NA NA NA $352 NA NA NA $302 NA NA NA $413 NA NA NA $83 45378 $2705 $2530 NA NA $4381 $3676 $4496 $1022 $2938 $2138 NA $695 $5504 NA NA $2036 NA NA NA $372 45380 $3075 $2600 NA NA $4723 $3527 $3012 $1757 $4215 $2285 NA NA $5298 NA NA $3268 NA NA NA $627 59400 $6160 NA NA NA NA $5100 NA $1851 NA NA NA $1304 $9035 NA NA $3427 $9116 $5150 NA $966 70553 $2985 NA $1153 NA $2182 NA $1192 $492 NA NA $803 $489 $1512 NA $985 $1187 NA NA NA $197 71020 $61 $69 $43 NA $113 $319 $307 NA $183 $59 $32 NA $213 $66 $40 NA $83 $53 NA NA 71250 $1837 $621 $989 NA $1490 $931 $755 NA NA $745 $401 NA $1067 $982 $616 NA NA $304 NA NA 73721 NA $1098 $1153 NA $2042 $1065 $1192 NA NA $998 $803 NA NA $1275 $985 NA NA $644 NA $178 74183 $2971 $1144 NA NA NA $1092 $1192 $6884 NA $1098 $803 NA $2960 $1197 $985 $5454 NA NA NA $7607 76700 $364 $247 $207 NA $427 $708 $614 $13267 $428 $214 $152 NA $747 $263 $189 $9139 NA $235 NA NA 77052 NA NA NA NA NA NA NA $4744 NA NA NA NA NA NA NA $3070 NA NA NA $5611 93306 $1220 $1117 NA NA $1877 $1657 $2100 $4605 $1433 $413 $945 NA $1336 $1434 $1951 $2931 NA $2399 NA $5472 G0202 $262 $187 NA NA $431 NA NA $4605 $292 NA NA NA $530 $281 NA $2931 $327 NA NA $5472
Provider Group 29881_6 29888_6 43239_6 43644_1 43775_1 45378_6 45380_6 59400_1 70553_2 71020_2 71250_2 73721_2 74183_2 76700_2 77052_2 77052_5 80053_8 88305_8 93306_2 99203_4 G0202_2 G0202_5 93017_2 Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Atlanta Gastroenterology Associates $2399 $536 348 $1628 $536 204 $2400 $536 348 Atlanta Medical Center $24889 $2266 999 $25897 $2502 935 $11449 $2240 411 $81927 $15300 435 $75815 $17800 326 $7317 $859 752 $7317 $859 752 $12821 $4688 173 $6581 $1052 526 $645 $72 796 $3265 $319 925 $3450 $557 519 $7398 $836 785 $1576 $133 1084 $73 $23 217 $635 $25 2440 $891 $232 285 $2967 $1157 156 $344 $168 105 $1265 $797 59 Atlanta Womens Health Physicians Group $29 $14 107 $40 $13 208 $396 $188 111 $278 $118 135 $450 $231 95 Gwinnett Hospital $11941 $3022 295 $21654 $10096 114 $3551 $1132 214 $34384 $10800 218 $56472 $13230 327 $3003 $1244 141 $3533 $1244 184 $8984 $4607 95 $3901 $967 303 $417 $279 49 $2247 $491 358 $4000 $967 314 $3755 $967 288 $1593 $195 717 $50 $15 233 $186 $56 233 $505 $152 233 $1750 $1173 49 $418 $294 42 $1396 $907 54 Northside Hospital $15482 $4185 270 $21651 $9557 127 $4885 $2539 92 $35176 $17000 107 $35233 $20815 69 $3883 $2805 38 $5256 $3071 71 $10911 $5730 90 $4856 $1468 231 $443 $266 67 $2379 $810 194 $3776 $1398 170 $5105 $1468 248 $942 $538 75 $167 $99 69 $379 $15 2427 $433 $307 41 $2252 $1566 44 $459 $328 40 $576 $432 33 Piedmont Hospital $14772 $3837 285 $35493 $5983 493 $5069 $2012 152 $38320 $17750 116 $37125 $12105 207 $3485 $2013 73 $4993 $2013 148 $10143 $4654 118 $5939 $1117 432 $542 $305 78 $2983 $505 491 $3410 $1042 227 $6067 $1106 449 $1364 $545 150 $75 $41 85 $231 $24 863 $657 $80 721 $2041 $1388 47 $490 $431 14 $1780 $1299 37 Piedmont Physicians Group $42 $22 87 $318 $179 78 $239 $159 50 Resurgens $8558 $2036 320 $9293 $2258 312 $4638 $2067 124 $4039 $2164 87 $4392 $2164 103 $2252 $1371 64 $459 $330 39 Wellstar Hospital $9330 $3729 150 $17479 $7519 132 $5261 $1565 236 $35794 $18200 97 $46780 $14600 220 $3707 $1972 88 $4928 $1972 150 $13549 $5855 131 $5054 $2805 80 $528 $375 41 $3222 $579 457 $3694 $925 299 $5495 $2805 96 $1355 $190 615 $66 $45 46 $73 $51 43 $133 $78 71 $1785 $1125 59 $599 $425 41 $1010 $717 41 Avg Mark UpProcedure Atlanta Medical Center 634 Gwinnett Hospital 223 Northside Hospital 233 Piedmont Hospital 259 Wellstar Hospital 155 Emory 105
Atlanta Gastroenterology Associates Atlanta Medical Center Atlanta Womens Health Gwinnett Hospital Northside Hospital Piedmont Hospital Piedmont Physicians Group Resurgens Wellstar Hospital CPT Code CPT Proc Cat Comp Avg Allow Allow Allow Allow Allow Allow Allow Allow Allow 29881 KNEE ARTHROSCOPYSURGERY 6 $3179 $2266 $3022 $4185 $3837 $2036 $3729 29888 KNEE ARTHROSCOPYSURGERY 6 $6319 $2502 $10096 $9557 $5983 $2258 $7519 43239 UPPER GI ENDOSCOPY BIOPSY 6 $1727 $536 $2240 $1132 $2539 $2012 $2067 $1565 43644 LAP GASTRIC BYPASSROUX-EN-Y 1 $15810 $15300 $10800 $17000 $17750 $18200 43775 LAP SLEEVE GASTRECTOMY 1 $17800 $13230 $20815 $12105 $14600 45378 DIAGNOSTIC COLONOSCOPY 6 $1656 $536 $859 $1244 $2805 $2013 $2164 $1972 45380 COLONOSCOPY AND BIOPSY 6 $1694 $536 $859 $1244 $3071 $2013 $2164 $1972 59400 OBSTETRICAL CARE 1 $5107 $4688 $4607 $5730 $4654 $5855 70553 MRI BRAIN WO amp WDYE 2 $1482 $1052 $967 $1468 $1117 $2805 71020 CHEST X-RAY 2 $259 $72 $279 $266 $305 $375 71250 CT THORAX WO DYE 2 $541 $319 $491 $810 $505 $579 73721 MRI JNT OF LWR EXTRE WO DYE 2 $978 $557 $967 $1398 $1042 $925 74183 MRI ABDOMEN WO amp WDYE 2 $1436 $836 $967 $1468 $1106 $2805 76700 US EXAM ABDOM COMPLETE 2 $320 $133 $195 $538 $545 $190 77052 COMP SCREEN MAMMOGRAM ADD-ON 2 $45 $23 $15 $99 $41 $45 77052 COMP SCREEN MAMMOGRAM ADD-ON 5 $14 $14 80053 COMPREHEN METABOLIC PANEL 8 $29 $25 $13 $56 $15 $24 $22 $51 88305 TISSUE EXAM BY PATHOLOGIST 8 $174 $232 $188 $152 $307 $80 $179 $78 93306 TTE WDOPPLER COMPLETE 2 $1297 $1157 $1173 $1566 $1388 $1371 $1125 93017 STRESS TEST 5 $830 $797 $907 $432 $1299 $717 99203 OFFICEOUTPATIENT VISIT NEW 4 $139 $118 $159 G0202 Screeningmammographydigital 2 $329 $168 $294 $328 $431 $330 $425 G0202 Screeningmammographydigital 5 $231 $231
Service Line Procedure CPT Code Emory Atlanta Gastroenterology Associates Resurgens Atlanta Womens Health Piedmont Physicians Group Orthopedics (ASC) Knee Arthroscopy 29881 $3467 $2036 Arthroscopy Ligament Repair 29888 $3386 $2258 GI (ASC) Upper GI Endoscopy 43239 $2758 $536 Diagnostic Colonoscopy 45378 $2348 $536 Colonoscopy and biopsy 45380 $2181 $536 Radiology Mammogram Screening G0202 $164 $231 Computer Detection Add-on 77052 $93 $14 Lab Comp Metabolic Panel 80053 $53 $13 $22 Tissue Exam by Pathologist 88305 $277 $188 $179 EampM (TEC) Office Visit new pt 99203 $269 $118 $159
Service Line Procedure CPT CodeDRG Memorial Hospital Beta Hosptial Charlie Hospital Delta Hospital Echo Hospital Alpha Medical Center Atlanta Gastroenterology Associates Resurgens Atlanta Womens Health Piedmont Physicians Group Market Avg Emory abovebelow Orthopedics Arthroscopy Ligament Repair 29888 $ 5062 $ 9557 $ 5983 $ 10096 $ 7519 $ 2502 $ 2258 $ 6319 -20 Knee Arthroscopy 29881 6 $ 5069 $ 4185 $ 3837 $ 3022 $ 3729 $ 2266 $ 2036 $ 3179 59 GI Upper GI Endoscopy 43239 6 $ 3075 $ 2539 $ 2012 $ 1132 $ 1565 $ 2240 $ 536 $ 1671 84 Lap Sleeve Gastrectomy DRG 621 $ 20421 $ 20815 $ 12105 $ 13230 $ 14600 $ 17800 $ 15710 30 Colonoscopy and biopsy 45380 $ 3075 $ 3071 $ 2013 $ 1244 $ 1972 $ 859 $ 536 $ 1616 90 Diagnostic Colonoscopy 45378 6 $ 3075 $ 2805 $ 2013 $ 1244 $ 1972 $ 859 $ 536 $ 1572 96 Radiology MRI Brain w amp wo dye 70553 2 $ 1238 $ 1468 $ 1117 $ 967 $ 2805 $ 1052 $ 1482 -16 MRI Joint of Lower Extremity wo dye 73721 2 $ 1238 $ 1398 $ 1042 $ 967 $ 925 $ 557 $ 978 27 MRI Abdomen w amp wo dye 74183 2 $ 1238 $ 1468 $ 1106 $ 967 $ 2805 $ 836 $ 1436 -14 X-ray Chest 71020 $ 115 $ 266 $ 305 $ 279 $ 375 $ 72 $ 259 -56 CT Thorax wo dye 71250 $ 882 $ 810 $ 505 $ 491 $ 579 $ 319 $ 541 63 Ultrasound Abdomen Complete 76700 $ 397 $ 538 $ 545 $ 195 $ 190 $ 168 $ 327 21 Mammogram Screening G0202 2 $ 141 $ 328 $ 431 $ 294 $ 425 $ 168 $ 231 $ 313 -55 Computer Detection Add-on 77052 2 $ 112 $ 99 $ 41 $ 15 $ 45 $ 23 $ 14 $ 39 183 Lab Comp Metabolic Panel 80053 8 $ 56 $ 15 $ 24 $ 56 $ 51 $ 25 $ 13 $ 22 $ 29 88 Tissue Exam by Pathologist 88305 8 $ 236 $ 307 $ 80 $ 152 $ 78 $ 232 $ 188 $ 179 $ 174 36 Medical Cardiology Cardiovascular Stress Test 93017 $ 383 $ 432 $ 1299 $ 907 $ 717 $ 797 $ 830 -54 TTE w Doppler 93306 2 $ 960 $ 1566 $ 1388 $ 1173 $ 1125 $ 1157 $ 1282 -25 Obstetrics Vaginal Delivery DRG 755 $ 7290 $ 5730 $ 4654 $ 4607 $ 5855 $ 4688 $ 5107 43 EampM Office Visit new pt 99203 4 $ 248 $ 118 $ 159 $ 139 78 Colonoscopy and biopsy (HOSPITAL ONLY) 45380 Surg 2530 $ 307591 Diagnostic colonoscopy (HOSPITAL ONLY) 45378 Surg 2255 $ 307591 Upper gi endoscopy biopsy (HOSPITAL ONLY) 43239 Surg 1787 $ 307591 Knee Arthroscopy (HOSPITAL ONLY) 29881 Surg 10900 $ 506893 Arthroscopy Ligament Repair (HOSPITAL ONLY) 29888 Surg 10900 $ 506200 Key 1 Facility - Inpatient 2 Facility - Imaging 3 Physician - Imaging 4 Physician 5 Global - Imaging 6 Facility - Outpatient 8 Lab 41 Physician - Primary Care 42 Physician - Specialist
Blue Cross United - EJCH EUH EUHM WW United - SJH Non Options United - SJH Options Aetna - ASC TEC (HMO) Cigna - ASC TEC (HMO) Aetna - EJCH ESJH ECHM WW Cigna - EJCH (HMO) Cigna - ESJH EUHM (HMO) List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract Description CPT Code Charge Average Final Price (all plans) Emory Mark Up Reimbursement Method ( of charge or fixed) - 1713 Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Cardiovascular stress test 93017 Cardio $543 $ 425 28 of Charge 70 $ 380 of Charge 65 $ 353 of Charge 60 $ 326 of Charge 70 $ 380 of Charge 70 $ 380 of charge 100 $ 543 of Charge 70 $ 380 of charge 100 $ 543 of charge 100 $ 543 TTE wDoppler complete 93306 Cardio $1226 $ 960 28 of Charge 70 $ 858 of Charge 65 $ 797 of Charge 60 $ 736 of Charge 70 $ 858 of Charge 70 $ 858 of charge 100 $ 1226 of Charge 70 $ 858 of charge 100 $ 1226 of charge 100 $ 1226 Colonoscopy and biopsy (HOSPITAL ONLY) 45380 Surg $2530 $ 3076 -18 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 of Charge 70 $ 1771 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Diagnostic colonoscopy (HOSPITAL ONLY) 45378 Surg $2255 $ 3076 -27 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 of Charge 70 $ 1579 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Upper gi endoscopy biopsy (HOSPITAL ONLY) 43239 Surg $1787 $ 3076 -42 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Knee Arthroscopy (HOSPITAL ONLY) 29881 Surg $10900 $ 5069 115 Fixed Rate SC 4 $ 3865 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 449300 $ 4493 Fixed Rate $ 654700 $ 6547 of Charge 70 $ 7630 Fixed Rate $ 401000 $ 4010 of Charge 70 $ 7630 Fixed Rate $ 398300 $ 3983 Fixed Rate $ 398100 $ 3981 Arthroscopy Ligament Repair (HOSPITAL ONLY) 29888 Surg $10900 $ 5062 115 Fixed Rate SC 3 $ 3121 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 556900 $ 5569 Fixed Rate $ 770100 $ 7701 of Charge 70 $ 7630 Fixed Rate $ 323900 $ 3239 of Charge 70 $ 7630 Fixed Rate $ 321700 $ 3217 Fixed Rate $ 321400 $ 3214 Comp Metabolic Panel 80053 Lab $132 $ 56 138 RBRVS Fee (100) $ 1437 of Charge 65 $ 86 of Charge 65 $ 86 of Charge 65 $ 86 of Charge 70 $ 92 RBRVS Fee (100) $ 1437 $ 14 of Charge 70 $ 92 RBRVS Fee (100) $ 1437 $ 14 RBRVS Fee (100) $ 1437 $ 14 Surgical Path Tissue Exam 88305 Lab $326 $ 236 38 of Charge 150 $ 51 of Charge 65 $ 212 of Charge 65 $ 212 of Charge 65 $ 212 of Charge 70 $ 228 of charge 100 $ 326 of Charge 70 $ 228 of charge 100 $ 326 of charge 100 $ 326 MRI Abdomen 74183 Radiology $6960 $ 1238 462 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 MRI Brain 70553 Radiology $6804 $ 1238 450 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 MRI Joint Lower Extremity 73721 Radiology $3067 $ 1238 148 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 CT Thorax wo contrast 71250 Radiology $2199 $ 882 149 Fixed Rate $ 771 Fixed Rate $ 47100 $ 471 Fixed Rate $ 81700 $ 817 Fixed Rate $ 116000 $ 1160 of Charge 70 $ 1539 Fixed Rate $ 80100 $ 801 Fixed Rate $ 79200 $ 792 Fixed Rate $ 79300 $ 793 Fixed Rate $ 79500 $ 795 X-ray Chest 71020 Radiology $280 $ 115 142 of Charge 150 $ 25 of Charge 65 $ 182 of Charge 60 $ 168 of Charge 70 $ 196 of Charge 70 $ 196 RBRVS Fee (150) $ 2534 $ 25 of Charge 70 $ 196 RBRVS Fee (150) $ 2534 $ 25 RBRVS Fee (150) $ 2534 $ 25 Screening mammography G0202 Radiology $279 $ 141 98 Fixed Rate $ 128 Fixed Rate $ 13100 $ 131 Fixed Rate $ 14300 $ 143 Fixed Rate $ 16100 $ 161 of Charge 70 $ 195 Fixed Rate $ 13300 $ 133 Fixed Rate $ 13500 $ 135 Fixed Rate $ 13000 $ 130 Fixed Rate $ 11200 $ 112 Mammo Computer Aided 77052 Radiology $75 $ 112 -33 Fixed Rate $ 9 Fixed Rate $ 13100 $ 131 Fixed Rate $ 14300 $ 143 Fixed Rate $ 16100 $ 161 of Charge 70 $ 53 Fixed Rate $ 13300 $ 133 Fixed Rate $ 13500 $ 135 Fixed Rate $ 13000 $ 130 Fixed Rate $ 11200 $ 112 US Abdomen Complete 76700 Radiology $917 $ 397 131 of Charge 150 $ 125 of Charge 65 $ 596 of Charge 60 $ 550 of Charge 70 $ 642 of Charge 70 $ 642 RBRVS Fee (150) $ 12519 $ 125 of Charge 70 $ 642 RBRVS Fee (150) $ 12519 $ 125 RBRVS Fee (150) $ 12519 $ 125 Officeoutpatient visit new pt 30 min (TEC) 99203 EampM $316 $ 248 28 of Charge 70 $ 221 of Charge 65 $ 205 of Charge 60 $ 190 of Charge 70 $ 221 of Charge 70 $ 221 of charge 100 $ 316 of Charge 70 $ 221 of charge 100 $ 316 of charge 100 $ 316 Vaginal delivery 59409 Surg $14484 $ 7290 99 Fixed Rate DRG - 775 $ 5437 2 Day Case Rate + LOC 561700 $ 5617 BaseCMS Weight 584741 $ 5847 BaseCMS Weight 726146 $ 7261 No IP Terms $ - 0 No IP BaseCMS Weight 659343 $ 6593 BaseContract Weight 479451 100 $ 14484 BaseCMS Weight 579110 $ 5791 Lap Sleeve Gastrectomy 43775 Surg $29961 $ 20421 47 Fixed Rate DRG - 621 $ 14872 BaseCMS Weight 1810697 $ 18107 BaseCMS Weight 1835178 $ 18352 BaseCMS Weight 2278911 $ 22789 No IP Terms $ - 0 No IP BaseCMS Weight 2069315 $ 20693 BaseCMS Weight 1730442 100 $ 29961 BaseCMS Weight 1817507 $ 18175 105 Colonoscopy and biopsy (ASC ONLY) Surg $ 219200 $ 2181 Diagnostic colonoscopy (ASC ONLY) Surg $ 267100 $ 2348 Upper gi endoscopy biopsy (ASC ONLY) Surg $ 207500 $ 2758 Knee Arthroscopy (ASC ONLY) Surg $ 417900 $ 3467 Arthroscopy Ligament Repair (ASC ONLY) Surg $ 504800 $ 3386
Cpt Code CPT Description Procedure Category Claims Min 25thNtile 50thNtile Emorys Rates 75thNtile 90thNtile Max 20 Below 50th Ntile 20 Above 50th Ntile 93017 CARDIOVASCULAR STRESS TEST 5 82 $80 $125 $321 $382 $568 $791 $930 $257 $386 71020 CHEST X-RAY 2 2638 $11 $45 $152 $115 $289 $373 $585 $122 $182 71020 CHEST X-RAY 5 8106 $25 $34 $38 $54 $57 $69 $30 $46 45380 COLONOSCOPY AND BIOPSY 6 1256 $541 $560 $572 $2877 $1000 $2024 $3289 $458 $686 77052 COMP SCREEN MAMMOGRAM ADD-ON 2 194 $13 $15 $25 $38 $47 $134 $20 $30 77052 COMP SCREEN MAMMOGRAM ADD-ON 5 2411 $13 $16 $20 $23 $26 $28 $16 $24 80053 COMPREHEN METABOLIC PANEL 8 13019 $9 $19 $23 $55 $24 $25 $69 $19 $28 71250 CT THORAX WO DYE 2 302 $165 $372 $545 $878 $1658 $2067 $436 $654 71250 CT THORAX WO DYE 5 209 $53 $127 $203 $289 $419 $534 $162 $244 45378 DIAGNOSTIC COLONOSCOPY 6 1479 $484 $515 $536 $2914 $831 $1971 $2828 $428 $643 29881 KNEE ARTHROSCOPYSURGERY 6 152 $1650 $1826 $2036 $5235 $3054 $4216 $6461 $1629 $2443 29888 KNEE ARTHROSCOPYSURGERY 6 82 $1682 $3615 $5081 $5145 $7553 $12924 $18532 $4065 $6097 43644 LAP GASTRIC BYPASSROUX-EN-Y 1 21 $11821 $13873 $17050 $18391 $25029 $31079 $13640 $20460 43775 LAP SLEEVE GASTRECTOMY 1 38 $4215 $8250 $13253 $20421 $19197 $21509 $24260 $10602 $15903 74183 MRI ABDOMEN WO amp WDYE 2 120 $919 $987 $1015 $1237 $1252 $2534 $3177 $812 $1218 74183 MRI ABDOMEN WO amp WDYE 5 112 $475 $490 $521 $1154 $1337 $1696 $417 $625 70553 MRI BRAIN WO amp WDYE 2 324 $633 $987 $1142 $1237 $1706 $2805 $3331 $914 $1370 70553 MRI BRAIN WO amp WDYE 5 467 $280 $539 $1023 $1277 $1363 $1726 $818 $1228 73721 MRI JNT OF LWR EXTRE WO DYE 2 304 $804 $859 $967 $1237 $1063 $1598 $2485 $774 $1160 73721 MRI JNT OF LWR EXTRE WO DYE 5 1130 $500 $520 $530 $628 $679 $859 $424 $636 59400 OBSTETRICAL CARE 1 494 $3699 $4402 $4969 $6655 $7307 $8613 $3975 $5963 99203 OFFICEOUTPATIENT VISIT NEW 4 6776 $88 $101 $112 $138 $155 $169 $90 $134 G0202 Screeningmammographydigital 2 7444 $123 $206 $285 $380 $425 $479 $228 $342 G0202 Screeningmammographydigital 5 2754 $117 $165 $195 $230 $247 $252 $156 $234 88305 TISSUE EXAM BY PATHOLOGIST 8 20834 $51 $74 $112 $235 $168 $261 $478 $90 $134 93306 TTE WDOPPLER COMPLETE 2 931 $194 $377 $739 $960 $1267 $1480 $1849 $591 $887 93306 TTE WDOPPLER COMPLETE 5 2299 $151 $296 $373 $538 $573 $834 $298 $448 43239 UPPER GI ENDOSCOPY BIOPSY 6 1264 $424 $514 $550 $800 $1838 $2833 $440 $660 76700 US EXAM ABDOM COMPLETE 2 321 $96 $165 $271 $509 $584 $857 $217 $325 76700 US EXAM ABDOM COMPLETE 5 444 $111 $129 $147 $156 $220 $279 $118 $176 Key 1 Facility - Inpatient 2 Facility - Imaging 3 Physician - Imaging 4 Physician 5 Global - Imaging 6 Facility - Outpatient 8 Lab 41 Physician - Primary Care 42 Physician - Specialist Cardiovascular stress test $ 38279 TTE wDoppler complete $ 96037 Colonoscopy and biopsy $ 287709 Diagnostic colonoscopy $ 291434 Upper gi endoscopy biopsy $ 300526 Knee Arthroscopy $ 523584 Arthroscopy Ligament Repair $ 514501 Comp Metabolic Panel $ 5552 Surgical Path Tissue Exam $ 23570 MRI Abdomen $ 123786 MRI Brain $ 123786 MRI Joint Lower Extremity $ 123786 CT Thorax wo contrast $ 88213 X-ray Chest $ 11548 Screening mammography $ 14098 Mammo Computer Aided $ 11179 US Abdomen Complete $ 39695 Officeoutpatient visit new pt 30 min $ 24753 Vaginal delivery $ 729025 Lap Sleeve Gastrectomy $ 2042124
Page 12
Outcomes amp Benefits bull Employers with COE arrangements are seeing reduction in procedures
bull Walmart (15rsquo-18rsquo) 50+ of spine surgeries amp 20 of kneehip procedures recommended by local providers were determined lsquonot necessaryrsquo by COE (see table)
bull Employers like Walmart amp Boeing continue to sign new providers which suggest (employersrsquo) continued interest in pursuing DC arrangements2 However Boeing and Providence Swedish did end relationship due to inability to capture enoughright data to estimate cost of care3
bull John Hopkinsrsquo Bayview campus COE emerging metrics4
bull 121 referrals in the first three months
bull 352 referrals and 183 surgeries over 18 months
bull 23 of all joint replacement volumes at facility now attributed to travel program
bull 96 of patients said they would recommend this program to family friends coworkers
bull Bingham Memorial in Idaho direct contracting emerging metrics4
bull 17 companies participating covering over 5000 lives
bull +3000 new patients as of October 2018
bull +$3M Revenue from new patients
11
1 How Employers Are Fixing Health Care Harvard Business Review March 2019 2 httpswwwhealthleadersmediacomstrategywalmart-escalates-strategy-solve-employee-healthcare Health Leaders Media Nov 18rsquo 3 Do Providers Have the Data chops to Success with Direct Contract Modern Healthcare August 2018 4 Re-Igniting the Growth Engine Part 2 Winning Increased Share of Lucrative Patient Volumes Advisory Board 5 httpswwwautonewscomarticle20180806OEM180809831gm-signs-major-health-care-services-deal-for-salaried-employees
Walmart COE Programs1
Program Key Benefits
Spin
e Su
rger
y 2300 EEs 50 COE approved of those applied
bull 95 lower readmission bull 14 less time in hospital bull 1 COE vs 5 non-COE patients discharged to SNF bull Returned to work sooner reducing 20 of OOO
time bull More-effective less dangerous amp less expensive bull The COE surgery ldquopricerdquo is 8 higher but value in
earlier discharge lower readmission rates far less utilization of SNF faster return to work
Join
t
1836 EEs 18 COE approved of those applied
bull 32 less time in hospital bull 70 less likely to be readmitted than non-COE
patients bull Fewer postsurgical complications bull 0 COE vs 5 non-COE patients discharged to SNF bull COE patients returned to work a 15 weeks sooner bull Cost of surgery is 15 less at COE hospitals
Baria
tric
300+ EEs
bull Preliminary data suggests the weight loss from surgery reduces absenteeism or presentism (working while sick)
bull Dramatically cuts pharmacy amp medical costs Complications of obesity drop sharply as does the need for medication
bull GMrsquos direct contract benefit plans with Henry Ford allows it to offer similarly designed plans to that of Blue Cross with savings in monthly EE contributions ranging from $300-$19805
Walmartrsquos Travel (Surgery) Program
Mem
ber F
eedb
ack
12
Looking beyond traditional cost management techniques Walmart designed a program to address wild variations in cost and become directly in improving quality of care for its employees FIRST SELECTING PROVIDERS 1 Identify providers with high volume and high quality 2 Target regions in country to support Walmartrsquos employees 3Focus on Integrated Health Systems Hospitals within these systems were best aligned to Walmarts mission could take on risks associated with bundling 4 Eliminate systems unwilling to do bundled payments model were
PROVIDERS VALUE IN PARICIPATING
Build Bundles bull Define bundles and negotiate price (typically 10-15 below FFS ) bull Definitions of service limit disputes of what is covered vs not (covers
entryexit of facility SNF not part of bundle) bull Contract flexibility covers unforeseen testcosts and reinforces
Walmarthealth system partnership bull Warrantees if further treatment - can return in 30 days no
additional cost to Walmart bull Strict criteria and providers with track record of clinically sound
decisions are included to mitigate any incentivizing of volume Business bull 100 travelaccom brings
new volume of patients from outside of market
bull More stable payments for services (vs Medicare or commercial FFS)
bull Increased visibility and attract new business
Clinical bull lsquoHalorsquo effect ndash Building a highly
efficient multidiscipline program brings improvements throughout health system
bull Onsite collaboration among health systems allows sharing of outcomesbest practices
Source How Employers Are Fixing Health Care Harvard Business Review March 2019
5000 participants in the program
95 satisfiedvery satisfied
Denied by care because not deemed necessary by COE Treatment denied due to lifestyle weightsmoking
The Member Experience
13
Engagement begins when employee on clear
path to surgery
Patient contacts with COE TPA
TPA team triages and ensures basic criteria
met
Employee put in touch with nurse team
Car pick-up Flight Hotel all arranged by
TPA
Navigators and nurse coordinators help
throughout the stay
Patient visits to hospital to understand
exceptions of procedure and meet treatment
team
Surgery occurs typically next day
Stay length according to procedure typically a
few days
Discharged from facility Travel home COE team updates local
PCP and discuss follow up care
COE provider checks in with local physician
frequently Revert back to standard coverage
Source How Employers Are Fixing Health Care Harvard Business Review March 2019
Case Study 1
Case study 1 ndash Pop Health Approach bull ProblemCircumstance Large multi-employer group needs to
evaluate benefit design disease prevalence health spend and utilization to manage their population
bull ConsiderationsValue Prop Unique industry and geography drive chronic conditions and utilization patterns
bull Solution Provide opportunity assessment comparing this population to other benchmarks to understand where to target intervention and management as well as assess efforts already taken
15
Market Comparison Preference Sensitive Procedures
16
Legend vs
Mt States vs
National gt120 gt110
110-120 105-110 lt80 lt90
Source Multi-payer commercial benchmark Results are weighted by AgeGender Broader market area includes multi-payer data from the mountain regions
Preference Sensitive Procedures Benchmark Comparison
Dartmouth Atlas Preference Sensitive Procedures
IP allowed dollars ALOS Employer vs
Mt States Employer
vs National FY 2017 FY 2018 FY 2017 FY 2018
Hysterectomy for Uterine Fibroids Rate $569354 $436932 45 54 124 140 CABG Rate $1800260 $2400608 53 60 218 130 Cholycystectomy Rate $832675 $755565 68 39 92 120 C-Section Rate 116 110 HighTech Radiology Rate 103 101 PCIPTCA Rate $934486 $1133708 37 55 82 80 Back Surgery Rate $3237613 $4003212 39 57 52 70 Knee Replacement Rate $3086693 $2177334 41 48 50 64 Total Hip Replacement Rate $1023675 $747491 45 64 37 34
Strengths (+)
Employer compares favorably for orthopedic procedures (back hip knee)
Opportunity (-)
Employer has higher than expected rates for CABG and hysterectomy (Note Low PTCA rate combined with high CABG rate may suggest provider practice patterns favoring CABG)
0 50 100 150 200 250
Total Hip Replacement
Knee Replacement
Back Surgery
PCIPTCA
Cholycystectomy
HighTech Radiology
C-Section
CABG
Culinary VsNational
Culinary Vs MtStates
Employer vs Mt States
Employer vs National
Market Comparison Condition Prevalence
17 Source Multi-payer commercial benchmark Results are weighted by AgeGender Broader market area includes multi-payer data from the mountain regions
Condition Prevalence Benchmark Comparison
Condition Employer vs
Mt States Employer vs
National Prevalence Diabetes Rate 229 219 Prevalence Hyperlipidemia Rate 259 207 Prevalence Kidney Disease Rate 143 174 Prevalence Migraine Rate 166 164 Prevalence Low Back Pain Rate 136 139 Prevalence Hypertension Rate 156 134 Prevalence Asthma Rate 146 128 Prevalence CAD Rate 175 115 Prevalence Pregnancy Rate 110 109 Prevalence Adult Preventive Screening Rate 114 91 Prevalence Depression Rate 63 60
Strengths (+)
Rate of depression is low (Note May be due to incomplete behavioral health claims)
Opportunity (-)
Employer has a higher prevalence of most chronic conditions including asthma CAD diabetes hypertension hyperlipidemia Kidney Disease LBP and migraines
0
100
200
300Hyperlipidemia
Diabetes
CAD
Migraine
Hypertension
AsthmaKidney Disease
Low Back Pain
Pregnancy
Depression
Employer vsMt States
Employer vsNational Legend
vs Mt States
vs National
gt120 gt110 110-120 105-110
lt80 lt90
Market Comparison Utilization Rates
18
A higher preventive office visit rate is better Source Multi-payer commercial benchmark Results are weighted by AgeGender Broader market area includes multi-payer data from the mountain regions
Strengths (+)
Lower than average utilization of ED and high dollar patient rate
Opportunity (-)
Higher LOS lengthy admits avoidable admits and readmissions which all drive significantly more spend
Utilization Benchmark Comparison
Condition Employer vs
Mt States Employer vs
National Avoidable Admit Rate 142 144 Lengthy Admit Rate 175 136 Outpatient Problem Focused Office Rate 146 131 Readmission Rate (readmitadmit) 135 126 Average LOS 125 116 One Day Admit Rate 76 103 Office Visit Rate 106 96 Acute Admit Rate 80 95 Avoidable ED Rate 68 86 ED Rate 54 69 Preventive Office Rate 95 68 High Dollar Patient Rate 49 51 Frequent ED User (gt3 times) Rate 24 36
Legend vs
Mt States vs
National gt120 gt110
110-120 105-110 lt80 lt90
0 50 100 150 200
Frequent ED User (gt3 times)
High Dollar Patient
Preventive Office
ED
Avoidable ED
Acute Admit
Office Visit
One Day Admit
Average LOS
Readmissionhellip
Outpt Problem Focusedhellip
Lengthy Admit
Avoidable Admit
Employer vsNational
Employer vsMt States
ED and Avoidable ED
19
Potentially Avoidable ED - Trend View Overall ED
Period Change FY 2017 FY 2018 Count Rate
Measure Mbrs Rate Mbrs Rate Overall ED 16394 12626 13820 10745 -16 -15 FREQUENT ED UTILIZER (mbr1k) 1581 1218 1468 1141 -7 -6 AVOIDABLE ED 6371 4907 5288 4111 -17 -16 Potentially Avoidable ED
Period Change FY 2017 FY 2018 Count Rate
Avoid ED Condition Mbrs Rate Mbrs Rate ABDOMINAL_PAIN 1092 841 895 696 -18 -17 ENT_INFECTION 854 658 742 577 -13 -12 FEVER 715 551 700 544 -2 -1 URINARY 650 501 468 364 -28 -27 HEADACHE 558 430 434 337 -22 -21 BACK_PAIN 414 319 423 329 2 3 NAUSEA 394 303 271 211 -31 -31 ASTHMA 294 226 209 162 -29 -28 CELLULITIS 210 162 198 154 -6 -5 GASTROENTERITIS 254 196 171 133 -33 -32 OTITIS_MEDIA 201 155 160 124 -20 -20 COPD 132 102 108 084 -18 -17 DIABETES 123 095 91 071 -26 -25 BACT_PNEUMONIA 111 085 86 067 -23 -22 DENTAL 93 072 83 065 -11 -10 DEHYDRATION 98 075 81 063 -17 -17 HYPERTENSION 16 012 24 019 50 51 CHF 4 003 3 002 -25 -24 ANGINA 8 006 3 002 -63 -62 IMMUNIZATION_RELATED 2 002 0 000 -100 -100 Grand Total 6371 4907 5288 4111 -17 -16
AHRQ avoidable ED visits are based on the logic for ambulatory care sensitive ED visits from AHRQ and diagnosis code driven
696
577
544 364
337
329
211 162
154 133 ABDOMINAL_PAIN
ENT_INFECTION
FEVER
URINARY
HEADACHE
BACK_PAIN
NAUSEA
- 200 400 600 800
1000 1200
2017 Members 2018 Members
Top Ten 2018 Conditions by Rate
Top Ten Conditions by Member Count
ED Avoidable ED and the impact of new on-site clinic
20
0
1000
2000
3000
4000
5000
6000
0200400600800
10001200140016001800
Clinic Visits ED Visits
Avoidable ED VisitsED Visits (non-avoidable)Clinic EampM Visits
0
500000
1000000
1500000
2000000
2500000
3000000
3500000
$s
Clinic EampM Profess DollarsAvoidable ED Dollars
bull Clinic visits have a clear impact on ED and avoidable ED use and spend
bull Combined ED visits are down on average 157 in FY 18 from FY 17
bull Combined ED spend is down 128 in FY 18 from FY 17
Clinic Live 62017
Pitfalls and Challenges bull Face many of the challenges similar to startup health
plan bull Critical to determine how you will deliver value and
communicate the value to potential customers and brokersconsultants
bull Care management bull Network
21
Considerations in Offering Development bull Care Management Model
bull Traditional care model bull Case management bull Utilization management bull Disease management
bull Longitudinal care model with value based care philosophy bull Primary care driven bull Local care management
bull Predictive analytics and risk stratification model bull Claims history and ongoing data bull EMR data
22
Case Study 2
Case study 2 ndash Large Employer bull Business Problem Large employer wants to contract
directly with 2 major hospital systems developing professional fee schedules
bull ConsiderationsValue Prop Fee schedule should be competitive but also nuanced to minimize gap relative to current reimbursement at physician level
bull Solution Data-driven approach using current market-wide reimbursement distinguished by service level
24
Evaluate Provider Spend Top 25 Service Lines by Allowable Spend
Evaluate Provider Spend Top 20 Professional CPTs by Total Spend
Understand relative market pricing position
27
21
-1
-28
14 10
28
-22
-11 -13
24
3
20 21
8
-20
13
3 9
-39
56
-26
4
-42
60
MRI Colonoscopy Cardiac Cath Lab - OrganPanel
Memorial Hospital Beta Hospital Delta Hospital Charlie Hospital Echo Hospital Alpha Medical Center
ndash25 5 -15 10 0 39
State Charges as a Percent of Peer Average Weighted Averages for MRI Colonoscopy Cardiology and Lab
Total Percent Above Below Market Average2
Memorial Hospital Beta Hospital Delta Hospital Charlie Hospital Echo Hospital Alpha Medical Center
Develop fee schedule relative to market
28
Service Line Procedure CPT CodeDRG
Memorial Hospital
Beta Hosptial
Charlie Hospital
Delta Hospital
Echo Hospital
Alpha Medical Center
Arthroscopy Ligament Repair 29888 $ 5062 $ 9557 $ 5983 $ 10096 $ 7519 $ 2502 Knee Arthroscopy 29881 $ 5069 $ 4185 $ 3837 $ 3022 $ 3729 $ 2266 Upper GI Endoscopy 43239 $ 3075 $ 2539 $ 2012 $ 1132 $ 1565 $ 2240 Lap Sleeve Gastrectomy DRG 621 $ 20421 $ 20815 $ 12105 $ 13230 $ 14600 $ 17800 Colonoscopy and biopsy 45380 $ 3075 $ 3071 $ 2013 $ 1244 $ 1972 $ 859 Diagnostic Colonoscopy 45378 $ 3075 $ 2805 $ 2013 $ 1244 $ 1972 $ 859 MRI Brain w amp wo dye 70553 $ 1238 $ 1468 $ 1117 $ 967 $ 2805 $ 1052 MRI Joint of Lower Extremity wo dye 73721 $ 1238 $ 1398 $ 1042 $ 967 $ 925 $ 557 MRI Abdomen w amp wo dye 74183 $ 1238 $ 1468 $ 1106 $ 967 $ 2805 $ 836 X-ray Chest 71020 $ 115 $ 266 $ 305 $ 279 $ 375 $ 72 CT Thorax wo dye 71250 $ 882 $ 810 $ 505 $ 491 $ 579 $ 319 Ultrasound Abdomen Complete 76700 $ 397 $ 538 $ 545 $ 195 $ 190 $ 168 Mammogram Screening G0202 $ 141 $ 328 $ 431 $ 294 $ 425 $ 168 Computer Detection Add-on 77052 $ 112 $ 99 $ 41 $ 15 $ 45 $ 23 Comp Metabolic Panel 80053 $ 56 $ 15 $ 24 $ 56 $ 51 $ 25 Tissue Exam by Pathologist 88305 $ 236 $ 307 $ 80 $ 152 $ 78 $ 232 Cardiovascular Stress Test 93017 $ 383 $ 432 $ 1299 $ 907 $ 717 $ 797 TTE w Doppler 93306 $ 960 $ 1566 $ 1388 $ 1173 $ 1125 $ 1157
Obstetrics Vaginal Delivery DRG 755 7290$ 5730$ 4654$ 4607$ 5855$ 4688$
GI
Lab
Radiology
Medical Cardiology
Orthopedics
KEY OBSERVA TIONS bull Potential exposure on GI bull Opportunity to align price and acuity in MRI bull Opportunity to raise rates on chest x-ray and mammogram
Percentile Bands Emory Allowables Heatmap TEC ASC Heatmap Allowable Comp Analysis Portal Pricing Sheet1 image1png A few words on Bundled Payments bull Bundled payments are growing as a type of direct contracting bull In some cases third parties match-make between employers
and providers bull Contracts may vary in definitions prepost admission
coverage duration readmission cause (ie all-cause vs medically related) outlier provisions LOS caps andor per diems
bull Providers need to be strategic in pricing to enable profitable growth of market share
29
Considerations in Offering Development bull Network Development
bull Build off existing structure eg health system employee plan network bull How does this fit into your broader value based care strategy bull Employed and independent physicians bull How do you want to approach the buildout of high performance
network bull Quality focus bull Cost efficiency
bull Integrated behavioral health bull Wrap network for other markets
30
Considerations in Offering Development bull Target Market
bull Consideration of employer profile in market bull Fully-insured vs ASO bull Total cost of care vs bundled services
bull Distribution bull Direct marketing bull Brokerconsultant community
bull Plan designs bull Standard designs vs flexible ndash Dependent on target market
bull Claims administration bull Data sharing amp analytics
31
Considerations in Offering Development bull Other components of comprehensive offering
bull Pharmacy bull Preventive health bull Onsite clinics bull Wellness programs bull Technology platform
32
Sample Bundle Analysis
33
Cover page Dotson Hazelrigs Nation Mainly of charge of fixed Cardiovascular stress test TTE wDoppler complete Colonoscopy and biopsy (Combined) Diagnostic colonoscopy (Combined) Upper gi endoscopy biopsy (Combined) Knee Arthroscopy (Combined) Arthroscopy Ligament Repair Comp Metabolic Panel Surgical Path Tissue Exam MRI Abdomen MRI Brain MRI Joint Lower Extremity CT Thorax wo contrast X-ray Chest Screening mammography Mammo Computer Aided US Abdomen Complete Officeoutpatient visit new pt 30 min Vaginal delivery Lap Sleeve Gastrectomy
Piedmont Piedmont Piedmont Piedmont Northside Northside Northside Northside Gwinnett Gwinnett Gwinnett Gwinnett WellStar WellStar WellStar WellStar AMC - Tenet AMC - Tenet AMC - Tenet AMC - Tenet CPT Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing 29881 $11312 $10872 NA NA $7476 $9338 NA $23655 $11856 $3668 NA $17871 $12253 NA NA $15645 $5490 NA NA $23039 29888 NA NA NA NA NA NA NA $23784 NA $8261 NA $18000 NA NA NA $15774 NA NA NA $23168 43239 NA $4408 NA NA NA NA $5997 $8852 NA $3304 NA $7424 $1267 NA NA $9230 NA $2458 NA $8274 43644 $26468 NA NA NA $3382 $12050 NA $1861 NA NA NA $1316 $7841 NA NA $3444 $18892 $27950 NA $979 43775 NA NA NA NA NA NA NA $352 NA NA NA $302 NA NA NA $413 NA NA NA $83 45378 $2705 $2530 NA NA $4381 $3676 $4496 $1022 $2938 $2138 NA $695 $5504 NA NA $2036 NA NA NA $372 45380 $3075 $2600 NA NA $4723 $3527 $3012 $1757 $4215 $2285 NA NA $5298 NA NA $3268 NA NA NA $627 59400 $6160 NA NA NA NA $5100 NA $1851 NA NA NA $1304 $9035 NA NA $3427 $9116 $5150 NA $966 70553 $2985 NA $1153 NA $2182 NA $1192 $492 NA NA $803 $489 $1512 NA $985 $1187 NA NA NA $197 71020 $61 $69 $43 NA $113 $319 $307 NA $183 $59 $32 NA $213 $66 $40 NA $83 $53 NA NA 71250 $1837 $621 $989 NA $1490 $931 $755 NA NA $745 $401 NA $1067 $982 $616 NA NA $304 NA NA 73721 NA $1098 $1153 NA $2042 $1065 $1192 NA NA $998 $803 NA NA $1275 $985 NA NA $644 NA $178 74183 $2971 $1144 NA NA NA $1092 $1192 $6884 NA $1098 $803 NA $2960 $1197 $985 $5454 NA NA NA $7607 76700 $364 $247 $207 NA $427 $708 $614 $13267 $428 $214 $152 NA $747 $263 $189 $9139 NA $235 NA NA 77052 NA NA NA NA NA NA NA $4744 NA NA NA NA NA NA NA $3070 NA NA NA $5611 93306 $1220 $1117 NA NA $1877 $1657 $2100 $4605 $1433 $413 $945 NA $1336 $1434 $1951 $2931 NA $2399 NA $5472 G0202 $262 $187 NA NA $431 NA NA $4605 $292 NA NA NA $530 $281 NA $2931 $327 NA NA $5472
Provider Group 29881_6 29888_6 43239_6 43644_1 43775_1 45378_6 45380_6 59400_1 70553_2 71020_2 71250_2 73721_2 74183_2 76700_2 77052_2 77052_5 80053_8 88305_8 93306_2 99203_4 G0202_2 G0202_5 93017_2 Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Atlanta Gastroenterology Associates $2399 $536 348 $1628 $536 204 $2400 $536 348 Atlanta Medical Center $24889 $2266 999 $25897 $2502 935 $11449 $2240 411 $81927 $15300 435 $75815 $17800 326 $7317 $859 752 $7317 $859 752 $12821 $4688 173 $6581 $1052 526 $645 $72 796 $3265 $319 925 $3450 $557 519 $7398 $836 785 $1576 $133 1084 $73 $23 217 $635 $25 2440 $891 $232 285 $2967 $1157 156 $344 $168 105 $1265 $797 59 Atlanta Womens Health Physicians Group $29 $14 107 $40 $13 208 $396 $188 111 $278 $118 135 $450 $231 95 Gwinnett Hospital $11941 $3022 295 $21654 $10096 114 $3551 $1132 214 $34384 $10800 218 $56472 $13230 327 $3003 $1244 141 $3533 $1244 184 $8984 $4607 95 $3901 $967 303 $417 $279 49 $2247 $491 358 $4000 $967 314 $3755 $967 288 $1593 $195 717 $50 $15 233 $186 $56 233 $505 $152 233 $1750 $1173 49 $418 $294 42 $1396 $907 54 Northside Hospital $15482 $4185 270 $21651 $9557 127 $4885 $2539 92 $35176 $17000 107 $35233 $20815 69 $3883 $2805 38 $5256 $3071 71 $10911 $5730 90 $4856 $1468 231 $443 $266 67 $2379 $810 194 $3776 $1398 170 $5105 $1468 248 $942 $538 75 $167 $99 69 $379 $15 2427 $433 $307 41 $2252 $1566 44 $459 $328 40 $576 $432 33 Piedmont Hospital $14772 $3837 285 $35493 $5983 493 $5069 $2012 152 $38320 $17750 116 $37125 $12105 207 $3485 $2013 73 $4993 $2013 148 $10143 $4654 118 $5939 $1117 432 $542 $305 78 $2983 $505 491 $3410 $1042 227 $6067 $1106 449 $1364 $545 150 $75 $41 85 $231 $24 863 $657 $80 721 $2041 $1388 47 $490 $431 14 $1780 $1299 37 Piedmont Physicians Group $42 $22 87 $318 $179 78 $239 $159 50 Resurgens $8558 $2036 320 $9293 $2258 312 $4638 $2067 124 $4039 $2164 87 $4392 $2164 103 $2252 $1371 64 $459 $330 39 Wellstar Hospital $9330 $3729 150 $17479 $7519 132 $5261 $1565 236 $35794 $18200 97 $46780 $14600 220 $3707 $1972 88 $4928 $1972 150 $13549 $5855 131 $5054 $2805 80 $528 $375 41 $3222 $579 457 $3694 $925 299 $5495 $2805 96 $1355 $190 615 $66 $45 46 $73 $51 43 $133 $78 71 $1785 $1125 59 $599 $425 41 $1010 $717 41 Avg Mark UpProcedure Atlanta Medical Center 634 Gwinnett Hospital 223 Northside Hospital 233 Piedmont Hospital 259 Wellstar Hospital 155 Emory 105
Atlanta Gastroenterology Associates Atlanta Medical Center Atlanta Womens Health Gwinnett Hospital Northside Hospital Piedmont Hospital Piedmont Physicians Group Resurgens Wellstar Hospital CPT Code CPT Proc Cat Comp Avg Allow Allow Allow Allow Allow Allow Allow Allow Allow 29881 KNEE ARTHROSCOPYSURGERY 6 $3179 $2266 $3022 $4185 $3837 $2036 $3729 29888 KNEE ARTHROSCOPYSURGERY 6 $6319 $2502 $10096 $9557 $5983 $2258 $7519 43239 UPPER GI ENDOSCOPY BIOPSY 6 $1727 $536 $2240 $1132 $2539 $2012 $2067 $1565 43644 LAP GASTRIC BYPASSROUX-EN-Y 1 $15810 $15300 $10800 $17000 $17750 $18200 43775 LAP SLEEVE GASTRECTOMY 1 $17800 $13230 $20815 $12105 $14600 45378 DIAGNOSTIC COLONOSCOPY 6 $1656 $536 $859 $1244 $2805 $2013 $2164 $1972 45380 COLONOSCOPY AND BIOPSY 6 $1694 $536 $859 $1244 $3071 $2013 $2164 $1972 59400 OBSTETRICAL CARE 1 $5107 $4688 $4607 $5730 $4654 $5855 70553 MRI BRAIN WO amp WDYE 2 $1482 $1052 $967 $1468 $1117 $2805 71020 CHEST X-RAY 2 $259 $72 $279 $266 $305 $375 71250 CT THORAX WO DYE 2 $541 $319 $491 $810 $505 $579 73721 MRI JNT OF LWR EXTRE WO DYE 2 $978 $557 $967 $1398 $1042 $925 74183 MRI ABDOMEN WO amp WDYE 2 $1436 $836 $967 $1468 $1106 $2805 76700 US EXAM ABDOM COMPLETE 2 $320 $133 $195 $538 $545 $190 77052 COMP SCREEN MAMMOGRAM ADD-ON 2 $45 $23 $15 $99 $41 $45 77052 COMP SCREEN MAMMOGRAM ADD-ON 5 $14 $14 80053 COMPREHEN METABOLIC PANEL 8 $29 $25 $13 $56 $15 $24 $22 $51 88305 TISSUE EXAM BY PATHOLOGIST 8 $174 $232 $188 $152 $307 $80 $179 $78 93306 TTE WDOPPLER COMPLETE 2 $1297 $1157 $1173 $1566 $1388 $1371 $1125 93017 STRESS TEST 5 $830 $797 $907 $432 $1299 $717 99203 OFFICEOUTPATIENT VISIT NEW 4 $139 $118 $159 G0202 Screeningmammographydigital 2 $329 $168 $294 $328 $431 $330 $425 G0202 Screeningmammographydigital 5 $231 $231
Service Line Procedure CPT Code Emory Atlanta Gastroenterology Associates Resurgens Atlanta Womens Health Piedmont Physicians Group Orthopedics (ASC) Knee Arthroscopy 29881 $3467 $2036 Arthroscopy Ligament Repair 29888 $3386 $2258 GI (ASC) Upper GI Endoscopy 43239 $2758 $536 Diagnostic Colonoscopy 45378 $2348 $536 Colonoscopy and biopsy 45380 $2181 $536 Radiology Mammogram Screening G0202 $164 $231 Computer Detection Add-on 77052 $93 $14 Lab Comp Metabolic Panel 80053 $53 $13 $22 Tissue Exam by Pathologist 88305 $277 $188 $179 EampM (TEC) Office Visit new pt 99203 $269 $118 $159
Service Line Procedure CPT CodeDRG Memorial Hospital Beta Hosptial Charlie Hospital Delta Hospital Echo Hospital Alpha Medical Center Atlanta Gastroenterology Associates Resurgens Atlanta Womens Health Piedmont Physicians Group Market Avg Emory abovebelow Orthopedics Arthroscopy Ligament Repair 29888 $ 5062 $ 9557 $ 5983 $ 10096 $ 7519 $ 2502 $ 2258 $ 6319 -20 Knee Arthroscopy 29881 6 $ 5069 $ 4185 $ 3837 $ 3022 $ 3729 $ 2266 $ 2036 $ 3179 59 GI Upper GI Endoscopy 43239 6 $ 3075 $ 2539 $ 2012 $ 1132 $ 1565 $ 2240 $ 536 $ 1671 84 Lap Sleeve Gastrectomy DRG 621 $ 20421 $ 20815 $ 12105 $ 13230 $ 14600 $ 17800 $ 15710 30 Colonoscopy and biopsy 45380 $ 3075 $ 3071 $ 2013 $ 1244 $ 1972 $ 859 $ 536 $ 1616 90 Diagnostic Colonoscopy 45378 6 $ 3075 $ 2805 $ 2013 $ 1244 $ 1972 $ 859 $ 536 $ 1572 96 Radiology MRI Brain w amp wo dye 70553 2 $ 1238 $ 1468 $ 1117 $ 967 $ 2805 $ 1052 $ 1482 -16 MRI Joint of Lower Extremity wo dye 73721 2 $ 1238 $ 1398 $ 1042 $ 967 $ 925 $ 557 $ 978 27 MRI Abdomen w amp wo dye 74183 2 $ 1238 $ 1468 $ 1106 $ 967 $ 2805 $ 836 $ 1436 -14 X-ray Chest 71020 $ 115 $ 266 $ 305 $ 279 $ 375 $ 72 $ 259 -56 CT Thorax wo dye 71250 $ 882 $ 810 $ 505 $ 491 $ 579 $ 319 $ 541 63 Ultrasound Abdomen Complete 76700 $ 397 $ 538 $ 545 $ 195 $ 190 $ 168 $ 327 21 Mammogram Screening G0202 2 $ 141 $ 328 $ 431 $ 294 $ 425 $ 168 $ 231 $ 313 -55 Computer Detection Add-on 77052 2 $ 112 $ 99 $ 41 $ 15 $ 45 $ 23 $ 14 $ 39 183 Lab Comp Metabolic Panel 80053 8 $ 56 $ 15 $ 24 $ 56 $ 51 $ 25 $ 13 $ 22 $ 29 88 Tissue Exam by Pathologist 88305 8 $ 236 $ 307 $ 80 $ 152 $ 78 $ 232 $ 188 $ 179 $ 174 36 Medical Cardiology Cardiovascular Stress Test 93017 $ 383 $ 432 $ 1299 $ 907 $ 717 $ 797 $ 830 -54 TTE w Doppler 93306 2 $ 960 $ 1566 $ 1388 $ 1173 $ 1125 $ 1157 $ 1282 -25 Obstetrics Vaginal Delivery DRG 755 $ 7290 $ 5730 $ 4654 $ 4607 $ 5855 $ 4688 $ 5107 43 EampM Office Visit new pt 99203 4 $ 248 $ 118 $ 159 $ 139 78 Colonoscopy and biopsy (HOSPITAL ONLY) 45380 Surg 2530 $ 307591 Diagnostic colonoscopy (HOSPITAL ONLY) 45378 Surg 2255 $ 307591 Upper gi endoscopy biopsy (HOSPITAL ONLY) 43239 Surg 1787 $ 307591 Knee Arthroscopy (HOSPITAL ONLY) 29881 Surg 10900 $ 506893 Arthroscopy Ligament Repair (HOSPITAL ONLY) 29888 Surg 10900 $ 506200 Key 1 Facility - Inpatient 2 Facility - Imaging 3 Physician - Imaging 4 Physician 5 Global - Imaging 6 Facility - Outpatient 8 Lab 41 Physician - Primary Care 42 Physician - Specialist
Blue Cross United - EJCH EUH EUHM WW United - SJH Non Options United - SJH Options Aetna - ASC TEC (HMO) Cigna - ASC TEC (HMO) Aetna - EJCH ESJH ECHM WW Cigna - EJCH (HMO) Cigna - ESJH EUHM (HMO) List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract Description CPT Code Charge Average Final Price (all plans) Emory Mark Up Reimbursement Method ( of charge or fixed) - 1713 Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Cardiovascular stress test 93017 Cardio $543 $ 425 28 of Charge 70 $ 380 of Charge 65 $ 353 of Charge 60 $ 326 of Charge 70 $ 380 of Charge 70 $ 380 of charge 100 $ 543 of Charge 70 $ 380 of charge 100 $ 543 of charge 100 $ 543 TTE wDoppler complete 93306 Cardio $1226 $ 960 28 of Charge 70 $ 858 of Charge 65 $ 797 of Charge 60 $ 736 of Charge 70 $ 858 of Charge 70 $ 858 of charge 100 $ 1226 of Charge 70 $ 858 of charge 100 $ 1226 of charge 100 $ 1226 Colonoscopy and biopsy (HOSPITAL ONLY) 45380 Surg $2530 $ 3076 -18 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 of Charge 70 $ 1771 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Diagnostic colonoscopy (HOSPITAL ONLY) 45378 Surg $2255 $ 3076 -27 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 of Charge 70 $ 1579 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Upper gi endoscopy biopsy (HOSPITAL ONLY) 43239 Surg $1787 $ 3076 -42 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Knee Arthroscopy (HOSPITAL ONLY) 29881 Surg $10900 $ 5069 115 Fixed Rate SC 4 $ 3865 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 449300 $ 4493 Fixed Rate $ 654700 $ 6547 of Charge 70 $ 7630 Fixed Rate $ 401000 $ 4010 of Charge 70 $ 7630 Fixed Rate $ 398300 $ 3983 Fixed Rate $ 398100 $ 3981 Arthroscopy Ligament Repair (HOSPITAL ONLY) 29888 Surg $10900 $ 5062 115 Fixed Rate SC 3 $ 3121 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 556900 $ 5569 Fixed Rate $ 770100 $ 7701 of Charge 70 $ 7630 Fixed Rate $ 323900 $ 3239 of Charge 70 $ 7630 Fixed Rate $ 321700 $ 3217 Fixed Rate $ 321400 $ 3214 Comp Metabolic Panel 80053 Lab $132 $ 56 138 RBRVS Fee (100) $ 1437 of Charge 65 $ 86 of Charge 65 $ 86 of Charge 65 $ 86 of Charge 70 $ 92 RBRVS Fee (100) $ 1437 $ 14 of Charge 70 $ 92 RBRVS Fee (100) $ 1437 $ 14 RBRVS Fee (100) $ 1437 $ 14 Surgical Path Tissue Exam 88305 Lab $326 $ 236 38 of Charge 150 $ 51 of Charge 65 $ 212 of Charge 65 $ 212 of Charge 65 $ 212 of Charge 70 $ 228 of charge 100 $ 326 of Charge 70 $ 228 of charge 100 $ 326 of charge 100 $ 326 MRI Abdomen 74183 Radiology $6960 $ 1238 462 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 MRI Brain 70553 Radiology $6804 $ 1238 450 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 MRI Joint Lower Extremity 73721 Radiology $3067 $ 1238 148 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 CT Thorax wo contrast 71250 Radiology $2199 $ 882 149 Fixed Rate $ 771 Fixed Rate $ 47100 $ 471 Fixed Rate $ 81700 $ 817 Fixed Rate $ 116000 $ 1160 of Charge 70 $ 1539 Fixed Rate $ 80100 $ 801 Fixed Rate $ 79200 $ 792 Fixed Rate $ 79300 $ 793 Fixed Rate $ 79500 $ 795 X-ray Chest 71020 Radiology $280 $ 115 142 of Charge 150 $ 25 of Charge 65 $ 182 of Charge 60 $ 168 of Charge 70 $ 196 of Charge 70 $ 196 RBRVS Fee (150) $ 2534 $ 25 of Charge 70 $ 196 RBRVS Fee (150) $ 2534 $ 25 RBRVS Fee (150) $ 2534 $ 25 Screening mammography G0202 Radiology $279 $ 141 98 Fixed Rate $ 128 Fixed Rate $ 13100 $ 131 Fixed Rate $ 14300 $ 143 Fixed Rate $ 16100 $ 161 of Charge 70 $ 195 Fixed Rate $ 13300 $ 133 Fixed Rate $ 13500 $ 135 Fixed Rate $ 13000 $ 130 Fixed Rate $ 11200 $ 112 Mammo Computer Aided 77052 Radiology $75 $ 112 -33 Fixed Rate $ 9 Fixed Rate $ 13100 $ 131 Fixed Rate $ 14300 $ 143 Fixed Rate $ 16100 $ 161 of Charge 70 $ 53 Fixed Rate $ 13300 $ 133 Fixed Rate $ 13500 $ 135 Fixed Rate $ 13000 $ 130 Fixed Rate $ 11200 $ 112 US Abdomen Complete 76700 Radiology $917 $ 397 131 of Charge 150 $ 125 of Charge 65 $ 596 of Charge 60 $ 550 of Charge 70 $ 642 of Charge 70 $ 642 RBRVS Fee (150) $ 12519 $ 125 of Charge 70 $ 642 RBRVS Fee (150) $ 12519 $ 125 RBRVS Fee (150) $ 12519 $ 125 Officeoutpatient visit new pt 30 min (TEC) 99203 EampM $316 $ 248 28 of Charge 70 $ 221 of Charge 65 $ 205 of Charge 60 $ 190 of Charge 70 $ 221 of Charge 70 $ 221 of charge 100 $ 316 of Charge 70 $ 221 of charge 100 $ 316 of charge 100 $ 316 Vaginal delivery 59409 Surg $14484 $ 7290 99 Fixed Rate DRG - 775 $ 5437 2 Day Case Rate + LOC 561700 $ 5617 BaseCMS Weight 584741 $ 5847 BaseCMS Weight 726146 $ 7261 No IP Terms $ - 0 No IP BaseCMS Weight 659343 $ 6593 BaseContract Weight 479451 100 $ 14484 BaseCMS Weight 579110 $ 5791 Lap Sleeve Gastrectomy 43775 Surg $29961 $ 20421 47 Fixed Rate DRG - 621 $ 14872 BaseCMS Weight 1810697 $ 18107 BaseCMS Weight 1835178 $ 18352 BaseCMS Weight 2278911 $ 22789 No IP Terms $ - 0 No IP BaseCMS Weight 2069315 $ 20693 BaseCMS Weight 1730442 100 $ 29961 BaseCMS Weight 1817507 $ 18175 105 Colonoscopy and biopsy (ASC ONLY) Surg $ 219200 $ 2181 Diagnostic colonoscopy (ASC ONLY) Surg $ 267100 $ 2348 Upper gi endoscopy biopsy (ASC ONLY) Surg $ 207500 $ 2758 Knee Arthroscopy (ASC ONLY) Surg $ 417900 $ 3467 Arthroscopy Ligament Repair (ASC ONLY) Surg $ 504800 $ 3386
Cpt Code CPT Description Procedure Category Claims Min 25thNtile 50thNtile Emorys Rates 75thNtile 90thNtile Max 20 Below 50th Ntile 20 Above 50th Ntile 93017 CARDIOVASCULAR STRESS TEST 5 82 $80 $125 $321 $382 $568 $791 $930 $257 $386 71020 CHEST X-RAY 2 2638 $11 $45 $152 $115 $289 $373 $585 $122 $182 71020 CHEST X-RAY 5 8106 $25 $34 $38 $54 $57 $69 $30 $46 45380 COLONOSCOPY AND BIOPSY 6 1256 $541 $560 $572 $2877 $1000 $2024 $3289 $458 $686 77052 COMP SCREEN MAMMOGRAM ADD-ON 2 194 $13 $15 $25 $38 $47 $134 $20 $30 77052 COMP SCREEN MAMMOGRAM ADD-ON 5 2411 $13 $16 $20 $23 $26 $28 $16 $24 80053 COMPREHEN METABOLIC PANEL 8 13019 $9 $19 $23 $55 $24 $25 $69 $19 $28 71250 CT THORAX WO DYE 2 302 $165 $372 $545 $878 $1658 $2067 $436 $654 71250 CT THORAX WO DYE 5 209 $53 $127 $203 $289 $419 $534 $162 $244 45378 DIAGNOSTIC COLONOSCOPY 6 1479 $484 $515 $536 $2914 $831 $1971 $2828 $428 $643 29881 KNEE ARTHROSCOPYSURGERY 6 152 $1650 $1826 $2036 $5235 $3054 $4216 $6461 $1629 $2443 29888 KNEE ARTHROSCOPYSURGERY 6 82 $1682 $3615 $5081 $5145 $7553 $12924 $18532 $4065 $6097 43644 LAP GASTRIC BYPASSROUX-EN-Y 1 21 $11821 $13873 $17050 $18391 $25029 $31079 $13640 $20460 43775 LAP SLEEVE GASTRECTOMY 1 38 $4215 $8250 $13253 $20421 $19197 $21509 $24260 $10602 $15903 74183 MRI ABDOMEN WO amp WDYE 2 120 $919 $987 $1015 $1237 $1252 $2534 $3177 $812 $1218 74183 MRI ABDOMEN WO amp WDYE 5 112 $475 $490 $521 $1154 $1337 $1696 $417 $625 70553 MRI BRAIN WO amp WDYE 2 324 $633 $987 $1142 $1237 $1706 $2805 $3331 $914 $1370 70553 MRI BRAIN WO amp WDYE 5 467 $280 $539 $1023 $1277 $1363 $1726 $818 $1228 73721 MRI JNT OF LWR EXTRE WO DYE 2 304 $804 $859 $967 $1237 $1063 $1598 $2485 $774 $1160 73721 MRI JNT OF LWR EXTRE WO DYE 5 1130 $500 $520 $530 $628 $679 $859 $424 $636 59400 OBSTETRICAL CARE 1 494 $3699 $4402 $4969 $6655 $7307 $8613 $3975 $5963 99203 OFFICEOUTPATIENT VISIT NEW 4 6776 $88 $101 $112 $138 $155 $169 $90 $134 G0202 Screeningmammographydigital 2 7444 $123 $206 $285 $380 $425 $479 $228 $342 G0202 Screeningmammographydigital 5 2754 $117 $165 $195 $230 $247 $252 $156 $234 88305 TISSUE EXAM BY PATHOLOGIST 8 20834 $51 $74 $112 $235 $168 $261 $478 $90 $134 93306 TTE WDOPPLER COMPLETE 2 931 $194 $377 $739 $960 $1267 $1480 $1849 $591 $887 93306 TTE WDOPPLER COMPLETE 5 2299 $151 $296 $373 $538 $573 $834 $298 $448 43239 UPPER GI ENDOSCOPY BIOPSY 6 1264 $424 $514 $550 $800 $1838 $2833 $440 $660 76700 US EXAM ABDOM COMPLETE 2 321 $96 $165 $271 $509 $584 $857 $217 $325 76700 US EXAM ABDOM COMPLETE 5 444 $111 $129 $147 $156 $220 $279 $118 $176 Key 1 Facility - Inpatient 2 Facility - Imaging 3 Physician - Imaging 4 Physician 5 Global - Imaging 6 Facility - Outpatient 8 Lab 41 Physician - Primary Care 42 Physician - Specialist Cardiovascular stress test $ 38279 TTE wDoppler complete $ 96037 Colonoscopy and biopsy $ 287709 Diagnostic colonoscopy $ 291434 Upper gi endoscopy biopsy $ 300526 Knee Arthroscopy $ 523584 Arthroscopy Ligament Repair $ 514501 Comp Metabolic Panel $ 5552 Surgical Path Tissue Exam $ 23570 MRI Abdomen $ 123786 MRI Brain $ 123786 MRI Joint Lower Extremity $ 123786 CT Thorax wo contrast $ 88213 X-ray Chest $ 11548 Screening mammography $ 14098 Mammo Computer Aided $ 11179 US Abdomen Complete $ 39695 Officeoutpatient visit new pt 30 min $ 24753 Vaginal delivery $ 729025 Lap Sleeve Gastrectomy $ 2042124
Page 13
Walmartrsquos Travel (Surgery) Program
Mem
ber F
eedb
ack
12
Looking beyond traditional cost management techniques Walmart designed a program to address wild variations in cost and become directly in improving quality of care for its employees FIRST SELECTING PROVIDERS 1 Identify providers with high volume and high quality 2 Target regions in country to support Walmartrsquos employees 3Focus on Integrated Health Systems Hospitals within these systems were best aligned to Walmarts mission could take on risks associated with bundling 4 Eliminate systems unwilling to do bundled payments model were
PROVIDERS VALUE IN PARICIPATING
Build Bundles bull Define bundles and negotiate price (typically 10-15 below FFS ) bull Definitions of service limit disputes of what is covered vs not (covers
entryexit of facility SNF not part of bundle) bull Contract flexibility covers unforeseen testcosts and reinforces
Walmarthealth system partnership bull Warrantees if further treatment - can return in 30 days no
additional cost to Walmart bull Strict criteria and providers with track record of clinically sound
decisions are included to mitigate any incentivizing of volume Business bull 100 travelaccom brings
new volume of patients from outside of market
bull More stable payments for services (vs Medicare or commercial FFS)
bull Increased visibility and attract new business
Clinical bull lsquoHalorsquo effect ndash Building a highly
efficient multidiscipline program brings improvements throughout health system
bull Onsite collaboration among health systems allows sharing of outcomesbest practices
Source How Employers Are Fixing Health Care Harvard Business Review March 2019
5000 participants in the program
95 satisfiedvery satisfied
Denied by care because not deemed necessary by COE Treatment denied due to lifestyle weightsmoking
The Member Experience
13
Engagement begins when employee on clear
path to surgery
Patient contacts with COE TPA
TPA team triages and ensures basic criteria
met
Employee put in touch with nurse team
Car pick-up Flight Hotel all arranged by
TPA
Navigators and nurse coordinators help
throughout the stay
Patient visits to hospital to understand
exceptions of procedure and meet treatment
team
Surgery occurs typically next day
Stay length according to procedure typically a
few days
Discharged from facility Travel home COE team updates local
PCP and discuss follow up care
COE provider checks in with local physician
frequently Revert back to standard coverage
Source How Employers Are Fixing Health Care Harvard Business Review March 2019
Case Study 1
Case study 1 ndash Pop Health Approach bull ProblemCircumstance Large multi-employer group needs to
evaluate benefit design disease prevalence health spend and utilization to manage their population
bull ConsiderationsValue Prop Unique industry and geography drive chronic conditions and utilization patterns
bull Solution Provide opportunity assessment comparing this population to other benchmarks to understand where to target intervention and management as well as assess efforts already taken
15
Market Comparison Preference Sensitive Procedures
16
Legend vs
Mt States vs
National gt120 gt110
110-120 105-110 lt80 lt90
Source Multi-payer commercial benchmark Results are weighted by AgeGender Broader market area includes multi-payer data from the mountain regions
Preference Sensitive Procedures Benchmark Comparison
Dartmouth Atlas Preference Sensitive Procedures
IP allowed dollars ALOS Employer vs
Mt States Employer
vs National FY 2017 FY 2018 FY 2017 FY 2018
Hysterectomy for Uterine Fibroids Rate $569354 $436932 45 54 124 140 CABG Rate $1800260 $2400608 53 60 218 130 Cholycystectomy Rate $832675 $755565 68 39 92 120 C-Section Rate 116 110 HighTech Radiology Rate 103 101 PCIPTCA Rate $934486 $1133708 37 55 82 80 Back Surgery Rate $3237613 $4003212 39 57 52 70 Knee Replacement Rate $3086693 $2177334 41 48 50 64 Total Hip Replacement Rate $1023675 $747491 45 64 37 34
Strengths (+)
Employer compares favorably for orthopedic procedures (back hip knee)
Opportunity (-)
Employer has higher than expected rates for CABG and hysterectomy (Note Low PTCA rate combined with high CABG rate may suggest provider practice patterns favoring CABG)
0 50 100 150 200 250
Total Hip Replacement
Knee Replacement
Back Surgery
PCIPTCA
Cholycystectomy
HighTech Radiology
C-Section
CABG
Culinary VsNational
Culinary Vs MtStates
Employer vs Mt States
Employer vs National
Market Comparison Condition Prevalence
17 Source Multi-payer commercial benchmark Results are weighted by AgeGender Broader market area includes multi-payer data from the mountain regions
Condition Prevalence Benchmark Comparison
Condition Employer vs
Mt States Employer vs
National Prevalence Diabetes Rate 229 219 Prevalence Hyperlipidemia Rate 259 207 Prevalence Kidney Disease Rate 143 174 Prevalence Migraine Rate 166 164 Prevalence Low Back Pain Rate 136 139 Prevalence Hypertension Rate 156 134 Prevalence Asthma Rate 146 128 Prevalence CAD Rate 175 115 Prevalence Pregnancy Rate 110 109 Prevalence Adult Preventive Screening Rate 114 91 Prevalence Depression Rate 63 60
Strengths (+)
Rate of depression is low (Note May be due to incomplete behavioral health claims)
Opportunity (-)
Employer has a higher prevalence of most chronic conditions including asthma CAD diabetes hypertension hyperlipidemia Kidney Disease LBP and migraines
0
100
200
300Hyperlipidemia
Diabetes
CAD
Migraine
Hypertension
AsthmaKidney Disease
Low Back Pain
Pregnancy
Depression
Employer vsMt States
Employer vsNational Legend
vs Mt States
vs National
gt120 gt110 110-120 105-110
lt80 lt90
Market Comparison Utilization Rates
18
A higher preventive office visit rate is better Source Multi-payer commercial benchmark Results are weighted by AgeGender Broader market area includes multi-payer data from the mountain regions
Strengths (+)
Lower than average utilization of ED and high dollar patient rate
Opportunity (-)
Higher LOS lengthy admits avoidable admits and readmissions which all drive significantly more spend
Utilization Benchmark Comparison
Condition Employer vs
Mt States Employer vs
National Avoidable Admit Rate 142 144 Lengthy Admit Rate 175 136 Outpatient Problem Focused Office Rate 146 131 Readmission Rate (readmitadmit) 135 126 Average LOS 125 116 One Day Admit Rate 76 103 Office Visit Rate 106 96 Acute Admit Rate 80 95 Avoidable ED Rate 68 86 ED Rate 54 69 Preventive Office Rate 95 68 High Dollar Patient Rate 49 51 Frequent ED User (gt3 times) Rate 24 36
Legend vs
Mt States vs
National gt120 gt110
110-120 105-110 lt80 lt90
0 50 100 150 200
Frequent ED User (gt3 times)
High Dollar Patient
Preventive Office
ED
Avoidable ED
Acute Admit
Office Visit
One Day Admit
Average LOS
Readmissionhellip
Outpt Problem Focusedhellip
Lengthy Admit
Avoidable Admit
Employer vsNational
Employer vsMt States
ED and Avoidable ED
19
Potentially Avoidable ED - Trend View Overall ED
Period Change FY 2017 FY 2018 Count Rate
Measure Mbrs Rate Mbrs Rate Overall ED 16394 12626 13820 10745 -16 -15 FREQUENT ED UTILIZER (mbr1k) 1581 1218 1468 1141 -7 -6 AVOIDABLE ED 6371 4907 5288 4111 -17 -16 Potentially Avoidable ED
Period Change FY 2017 FY 2018 Count Rate
Avoid ED Condition Mbrs Rate Mbrs Rate ABDOMINAL_PAIN 1092 841 895 696 -18 -17 ENT_INFECTION 854 658 742 577 -13 -12 FEVER 715 551 700 544 -2 -1 URINARY 650 501 468 364 -28 -27 HEADACHE 558 430 434 337 -22 -21 BACK_PAIN 414 319 423 329 2 3 NAUSEA 394 303 271 211 -31 -31 ASTHMA 294 226 209 162 -29 -28 CELLULITIS 210 162 198 154 -6 -5 GASTROENTERITIS 254 196 171 133 -33 -32 OTITIS_MEDIA 201 155 160 124 -20 -20 COPD 132 102 108 084 -18 -17 DIABETES 123 095 91 071 -26 -25 BACT_PNEUMONIA 111 085 86 067 -23 -22 DENTAL 93 072 83 065 -11 -10 DEHYDRATION 98 075 81 063 -17 -17 HYPERTENSION 16 012 24 019 50 51 CHF 4 003 3 002 -25 -24 ANGINA 8 006 3 002 -63 -62 IMMUNIZATION_RELATED 2 002 0 000 -100 -100 Grand Total 6371 4907 5288 4111 -17 -16
AHRQ avoidable ED visits are based on the logic for ambulatory care sensitive ED visits from AHRQ and diagnosis code driven
696
577
544 364
337
329
211 162
154 133 ABDOMINAL_PAIN
ENT_INFECTION
FEVER
URINARY
HEADACHE
BACK_PAIN
NAUSEA
- 200 400 600 800
1000 1200
2017 Members 2018 Members
Top Ten 2018 Conditions by Rate
Top Ten Conditions by Member Count
ED Avoidable ED and the impact of new on-site clinic
20
0
1000
2000
3000
4000
5000
6000
0200400600800
10001200140016001800
Clinic Visits ED Visits
Avoidable ED VisitsED Visits (non-avoidable)Clinic EampM Visits
0
500000
1000000
1500000
2000000
2500000
3000000
3500000
$s
Clinic EampM Profess DollarsAvoidable ED Dollars
bull Clinic visits have a clear impact on ED and avoidable ED use and spend
bull Combined ED visits are down on average 157 in FY 18 from FY 17
bull Combined ED spend is down 128 in FY 18 from FY 17
Clinic Live 62017
Pitfalls and Challenges bull Face many of the challenges similar to startup health
plan bull Critical to determine how you will deliver value and
communicate the value to potential customers and brokersconsultants
bull Care management bull Network
21
Considerations in Offering Development bull Care Management Model
bull Traditional care model bull Case management bull Utilization management bull Disease management
bull Longitudinal care model with value based care philosophy bull Primary care driven bull Local care management
bull Predictive analytics and risk stratification model bull Claims history and ongoing data bull EMR data
22
Case Study 2
Case study 2 ndash Large Employer bull Business Problem Large employer wants to contract
directly with 2 major hospital systems developing professional fee schedules
bull ConsiderationsValue Prop Fee schedule should be competitive but also nuanced to minimize gap relative to current reimbursement at physician level
bull Solution Data-driven approach using current market-wide reimbursement distinguished by service level
24
Evaluate Provider Spend Top 25 Service Lines by Allowable Spend
Evaluate Provider Spend Top 20 Professional CPTs by Total Spend
Understand relative market pricing position
27
21
-1
-28
14 10
28
-22
-11 -13
24
3
20 21
8
-20
13
3 9
-39
56
-26
4
-42
60
MRI Colonoscopy Cardiac Cath Lab - OrganPanel
Memorial Hospital Beta Hospital Delta Hospital Charlie Hospital Echo Hospital Alpha Medical Center
ndash25 5 -15 10 0 39
State Charges as a Percent of Peer Average Weighted Averages for MRI Colonoscopy Cardiology and Lab
Total Percent Above Below Market Average2
Memorial Hospital Beta Hospital Delta Hospital Charlie Hospital Echo Hospital Alpha Medical Center
Develop fee schedule relative to market
28
Service Line Procedure CPT CodeDRG
Memorial Hospital
Beta Hosptial
Charlie Hospital
Delta Hospital
Echo Hospital
Alpha Medical Center
Arthroscopy Ligament Repair 29888 $ 5062 $ 9557 $ 5983 $ 10096 $ 7519 $ 2502 Knee Arthroscopy 29881 $ 5069 $ 4185 $ 3837 $ 3022 $ 3729 $ 2266 Upper GI Endoscopy 43239 $ 3075 $ 2539 $ 2012 $ 1132 $ 1565 $ 2240 Lap Sleeve Gastrectomy DRG 621 $ 20421 $ 20815 $ 12105 $ 13230 $ 14600 $ 17800 Colonoscopy and biopsy 45380 $ 3075 $ 3071 $ 2013 $ 1244 $ 1972 $ 859 Diagnostic Colonoscopy 45378 $ 3075 $ 2805 $ 2013 $ 1244 $ 1972 $ 859 MRI Brain w amp wo dye 70553 $ 1238 $ 1468 $ 1117 $ 967 $ 2805 $ 1052 MRI Joint of Lower Extremity wo dye 73721 $ 1238 $ 1398 $ 1042 $ 967 $ 925 $ 557 MRI Abdomen w amp wo dye 74183 $ 1238 $ 1468 $ 1106 $ 967 $ 2805 $ 836 X-ray Chest 71020 $ 115 $ 266 $ 305 $ 279 $ 375 $ 72 CT Thorax wo dye 71250 $ 882 $ 810 $ 505 $ 491 $ 579 $ 319 Ultrasound Abdomen Complete 76700 $ 397 $ 538 $ 545 $ 195 $ 190 $ 168 Mammogram Screening G0202 $ 141 $ 328 $ 431 $ 294 $ 425 $ 168 Computer Detection Add-on 77052 $ 112 $ 99 $ 41 $ 15 $ 45 $ 23 Comp Metabolic Panel 80053 $ 56 $ 15 $ 24 $ 56 $ 51 $ 25 Tissue Exam by Pathologist 88305 $ 236 $ 307 $ 80 $ 152 $ 78 $ 232 Cardiovascular Stress Test 93017 $ 383 $ 432 $ 1299 $ 907 $ 717 $ 797 TTE w Doppler 93306 $ 960 $ 1566 $ 1388 $ 1173 $ 1125 $ 1157
Obstetrics Vaginal Delivery DRG 755 7290$ 5730$ 4654$ 4607$ 5855$ 4688$
GI
Lab
Radiology
Medical Cardiology
Orthopedics
KEY OBSERVA TIONS bull Potential exposure on GI bull Opportunity to align price and acuity in MRI bull Opportunity to raise rates on chest x-ray and mammogram
Percentile Bands Emory Allowables Heatmap TEC ASC Heatmap Allowable Comp Analysis Portal Pricing Sheet1 image1png A few words on Bundled Payments bull Bundled payments are growing as a type of direct contracting bull In some cases third parties match-make between employers
and providers bull Contracts may vary in definitions prepost admission
coverage duration readmission cause (ie all-cause vs medically related) outlier provisions LOS caps andor per diems
bull Providers need to be strategic in pricing to enable profitable growth of market share
29
Considerations in Offering Development bull Network Development
bull Build off existing structure eg health system employee plan network bull How does this fit into your broader value based care strategy bull Employed and independent physicians bull How do you want to approach the buildout of high performance
network bull Quality focus bull Cost efficiency
bull Integrated behavioral health bull Wrap network for other markets
30
Considerations in Offering Development bull Target Market
bull Consideration of employer profile in market bull Fully-insured vs ASO bull Total cost of care vs bundled services
bull Distribution bull Direct marketing bull Brokerconsultant community
bull Plan designs bull Standard designs vs flexible ndash Dependent on target market
bull Claims administration bull Data sharing amp analytics
31
Considerations in Offering Development bull Other components of comprehensive offering
bull Pharmacy bull Preventive health bull Onsite clinics bull Wellness programs bull Technology platform
32
Sample Bundle Analysis
33
Cover page Dotson Hazelrigs Nation Mainly of charge of fixed Cardiovascular stress test TTE wDoppler complete Colonoscopy and biopsy (Combined) Diagnostic colonoscopy (Combined) Upper gi endoscopy biopsy (Combined) Knee Arthroscopy (Combined) Arthroscopy Ligament Repair Comp Metabolic Panel Surgical Path Tissue Exam MRI Abdomen MRI Brain MRI Joint Lower Extremity CT Thorax wo contrast X-ray Chest Screening mammography Mammo Computer Aided US Abdomen Complete Officeoutpatient visit new pt 30 min Vaginal delivery Lap Sleeve Gastrectomy
Piedmont Piedmont Piedmont Piedmont Northside Northside Northside Northside Gwinnett Gwinnett Gwinnett Gwinnett WellStar WellStar WellStar WellStar AMC - Tenet AMC - Tenet AMC - Tenet AMC - Tenet CPT Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing 29881 $11312 $10872 NA NA $7476 $9338 NA $23655 $11856 $3668 NA $17871 $12253 NA NA $15645 $5490 NA NA $23039 29888 NA NA NA NA NA NA NA $23784 NA $8261 NA $18000 NA NA NA $15774 NA NA NA $23168 43239 NA $4408 NA NA NA NA $5997 $8852 NA $3304 NA $7424 $1267 NA NA $9230 NA $2458 NA $8274 43644 $26468 NA NA NA $3382 $12050 NA $1861 NA NA NA $1316 $7841 NA NA $3444 $18892 $27950 NA $979 43775 NA NA NA NA NA NA NA $352 NA NA NA $302 NA NA NA $413 NA NA NA $83 45378 $2705 $2530 NA NA $4381 $3676 $4496 $1022 $2938 $2138 NA $695 $5504 NA NA $2036 NA NA NA $372 45380 $3075 $2600 NA NA $4723 $3527 $3012 $1757 $4215 $2285 NA NA $5298 NA NA $3268 NA NA NA $627 59400 $6160 NA NA NA NA $5100 NA $1851 NA NA NA $1304 $9035 NA NA $3427 $9116 $5150 NA $966 70553 $2985 NA $1153 NA $2182 NA $1192 $492 NA NA $803 $489 $1512 NA $985 $1187 NA NA NA $197 71020 $61 $69 $43 NA $113 $319 $307 NA $183 $59 $32 NA $213 $66 $40 NA $83 $53 NA NA 71250 $1837 $621 $989 NA $1490 $931 $755 NA NA $745 $401 NA $1067 $982 $616 NA NA $304 NA NA 73721 NA $1098 $1153 NA $2042 $1065 $1192 NA NA $998 $803 NA NA $1275 $985 NA NA $644 NA $178 74183 $2971 $1144 NA NA NA $1092 $1192 $6884 NA $1098 $803 NA $2960 $1197 $985 $5454 NA NA NA $7607 76700 $364 $247 $207 NA $427 $708 $614 $13267 $428 $214 $152 NA $747 $263 $189 $9139 NA $235 NA NA 77052 NA NA NA NA NA NA NA $4744 NA NA NA NA NA NA NA $3070 NA NA NA $5611 93306 $1220 $1117 NA NA $1877 $1657 $2100 $4605 $1433 $413 $945 NA $1336 $1434 $1951 $2931 NA $2399 NA $5472 G0202 $262 $187 NA NA $431 NA NA $4605 $292 NA NA NA $530 $281 NA $2931 $327 NA NA $5472
Provider Group 29881_6 29888_6 43239_6 43644_1 43775_1 45378_6 45380_6 59400_1 70553_2 71020_2 71250_2 73721_2 74183_2 76700_2 77052_2 77052_5 80053_8 88305_8 93306_2 99203_4 G0202_2 G0202_5 93017_2 Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Atlanta Gastroenterology Associates $2399 $536 348 $1628 $536 204 $2400 $536 348 Atlanta Medical Center $24889 $2266 999 $25897 $2502 935 $11449 $2240 411 $81927 $15300 435 $75815 $17800 326 $7317 $859 752 $7317 $859 752 $12821 $4688 173 $6581 $1052 526 $645 $72 796 $3265 $319 925 $3450 $557 519 $7398 $836 785 $1576 $133 1084 $73 $23 217 $635 $25 2440 $891 $232 285 $2967 $1157 156 $344 $168 105 $1265 $797 59 Atlanta Womens Health Physicians Group $29 $14 107 $40 $13 208 $396 $188 111 $278 $118 135 $450 $231 95 Gwinnett Hospital $11941 $3022 295 $21654 $10096 114 $3551 $1132 214 $34384 $10800 218 $56472 $13230 327 $3003 $1244 141 $3533 $1244 184 $8984 $4607 95 $3901 $967 303 $417 $279 49 $2247 $491 358 $4000 $967 314 $3755 $967 288 $1593 $195 717 $50 $15 233 $186 $56 233 $505 $152 233 $1750 $1173 49 $418 $294 42 $1396 $907 54 Northside Hospital $15482 $4185 270 $21651 $9557 127 $4885 $2539 92 $35176 $17000 107 $35233 $20815 69 $3883 $2805 38 $5256 $3071 71 $10911 $5730 90 $4856 $1468 231 $443 $266 67 $2379 $810 194 $3776 $1398 170 $5105 $1468 248 $942 $538 75 $167 $99 69 $379 $15 2427 $433 $307 41 $2252 $1566 44 $459 $328 40 $576 $432 33 Piedmont Hospital $14772 $3837 285 $35493 $5983 493 $5069 $2012 152 $38320 $17750 116 $37125 $12105 207 $3485 $2013 73 $4993 $2013 148 $10143 $4654 118 $5939 $1117 432 $542 $305 78 $2983 $505 491 $3410 $1042 227 $6067 $1106 449 $1364 $545 150 $75 $41 85 $231 $24 863 $657 $80 721 $2041 $1388 47 $490 $431 14 $1780 $1299 37 Piedmont Physicians Group $42 $22 87 $318 $179 78 $239 $159 50 Resurgens $8558 $2036 320 $9293 $2258 312 $4638 $2067 124 $4039 $2164 87 $4392 $2164 103 $2252 $1371 64 $459 $330 39 Wellstar Hospital $9330 $3729 150 $17479 $7519 132 $5261 $1565 236 $35794 $18200 97 $46780 $14600 220 $3707 $1972 88 $4928 $1972 150 $13549 $5855 131 $5054 $2805 80 $528 $375 41 $3222 $579 457 $3694 $925 299 $5495 $2805 96 $1355 $190 615 $66 $45 46 $73 $51 43 $133 $78 71 $1785 $1125 59 $599 $425 41 $1010 $717 41 Avg Mark UpProcedure Atlanta Medical Center 634 Gwinnett Hospital 223 Northside Hospital 233 Piedmont Hospital 259 Wellstar Hospital 155 Emory 105
Atlanta Gastroenterology Associates Atlanta Medical Center Atlanta Womens Health Gwinnett Hospital Northside Hospital Piedmont Hospital Piedmont Physicians Group Resurgens Wellstar Hospital CPT Code CPT Proc Cat Comp Avg Allow Allow Allow Allow Allow Allow Allow Allow Allow 29881 KNEE ARTHROSCOPYSURGERY 6 $3179 $2266 $3022 $4185 $3837 $2036 $3729 29888 KNEE ARTHROSCOPYSURGERY 6 $6319 $2502 $10096 $9557 $5983 $2258 $7519 43239 UPPER GI ENDOSCOPY BIOPSY 6 $1727 $536 $2240 $1132 $2539 $2012 $2067 $1565 43644 LAP GASTRIC BYPASSROUX-EN-Y 1 $15810 $15300 $10800 $17000 $17750 $18200 43775 LAP SLEEVE GASTRECTOMY 1 $17800 $13230 $20815 $12105 $14600 45378 DIAGNOSTIC COLONOSCOPY 6 $1656 $536 $859 $1244 $2805 $2013 $2164 $1972 45380 COLONOSCOPY AND BIOPSY 6 $1694 $536 $859 $1244 $3071 $2013 $2164 $1972 59400 OBSTETRICAL CARE 1 $5107 $4688 $4607 $5730 $4654 $5855 70553 MRI BRAIN WO amp WDYE 2 $1482 $1052 $967 $1468 $1117 $2805 71020 CHEST X-RAY 2 $259 $72 $279 $266 $305 $375 71250 CT THORAX WO DYE 2 $541 $319 $491 $810 $505 $579 73721 MRI JNT OF LWR EXTRE WO DYE 2 $978 $557 $967 $1398 $1042 $925 74183 MRI ABDOMEN WO amp WDYE 2 $1436 $836 $967 $1468 $1106 $2805 76700 US EXAM ABDOM COMPLETE 2 $320 $133 $195 $538 $545 $190 77052 COMP SCREEN MAMMOGRAM ADD-ON 2 $45 $23 $15 $99 $41 $45 77052 COMP SCREEN MAMMOGRAM ADD-ON 5 $14 $14 80053 COMPREHEN METABOLIC PANEL 8 $29 $25 $13 $56 $15 $24 $22 $51 88305 TISSUE EXAM BY PATHOLOGIST 8 $174 $232 $188 $152 $307 $80 $179 $78 93306 TTE WDOPPLER COMPLETE 2 $1297 $1157 $1173 $1566 $1388 $1371 $1125 93017 STRESS TEST 5 $830 $797 $907 $432 $1299 $717 99203 OFFICEOUTPATIENT VISIT NEW 4 $139 $118 $159 G0202 Screeningmammographydigital 2 $329 $168 $294 $328 $431 $330 $425 G0202 Screeningmammographydigital 5 $231 $231
Service Line Procedure CPT Code Emory Atlanta Gastroenterology Associates Resurgens Atlanta Womens Health Piedmont Physicians Group Orthopedics (ASC) Knee Arthroscopy 29881 $3467 $2036 Arthroscopy Ligament Repair 29888 $3386 $2258 GI (ASC) Upper GI Endoscopy 43239 $2758 $536 Diagnostic Colonoscopy 45378 $2348 $536 Colonoscopy and biopsy 45380 $2181 $536 Radiology Mammogram Screening G0202 $164 $231 Computer Detection Add-on 77052 $93 $14 Lab Comp Metabolic Panel 80053 $53 $13 $22 Tissue Exam by Pathologist 88305 $277 $188 $179 EampM (TEC) Office Visit new pt 99203 $269 $118 $159
Service Line Procedure CPT CodeDRG Memorial Hospital Beta Hosptial Charlie Hospital Delta Hospital Echo Hospital Alpha Medical Center Atlanta Gastroenterology Associates Resurgens Atlanta Womens Health Piedmont Physicians Group Market Avg Emory abovebelow Orthopedics Arthroscopy Ligament Repair 29888 $ 5062 $ 9557 $ 5983 $ 10096 $ 7519 $ 2502 $ 2258 $ 6319 -20 Knee Arthroscopy 29881 6 $ 5069 $ 4185 $ 3837 $ 3022 $ 3729 $ 2266 $ 2036 $ 3179 59 GI Upper GI Endoscopy 43239 6 $ 3075 $ 2539 $ 2012 $ 1132 $ 1565 $ 2240 $ 536 $ 1671 84 Lap Sleeve Gastrectomy DRG 621 $ 20421 $ 20815 $ 12105 $ 13230 $ 14600 $ 17800 $ 15710 30 Colonoscopy and biopsy 45380 $ 3075 $ 3071 $ 2013 $ 1244 $ 1972 $ 859 $ 536 $ 1616 90 Diagnostic Colonoscopy 45378 6 $ 3075 $ 2805 $ 2013 $ 1244 $ 1972 $ 859 $ 536 $ 1572 96 Radiology MRI Brain w amp wo dye 70553 2 $ 1238 $ 1468 $ 1117 $ 967 $ 2805 $ 1052 $ 1482 -16 MRI Joint of Lower Extremity wo dye 73721 2 $ 1238 $ 1398 $ 1042 $ 967 $ 925 $ 557 $ 978 27 MRI Abdomen w amp wo dye 74183 2 $ 1238 $ 1468 $ 1106 $ 967 $ 2805 $ 836 $ 1436 -14 X-ray Chest 71020 $ 115 $ 266 $ 305 $ 279 $ 375 $ 72 $ 259 -56 CT Thorax wo dye 71250 $ 882 $ 810 $ 505 $ 491 $ 579 $ 319 $ 541 63 Ultrasound Abdomen Complete 76700 $ 397 $ 538 $ 545 $ 195 $ 190 $ 168 $ 327 21 Mammogram Screening G0202 2 $ 141 $ 328 $ 431 $ 294 $ 425 $ 168 $ 231 $ 313 -55 Computer Detection Add-on 77052 2 $ 112 $ 99 $ 41 $ 15 $ 45 $ 23 $ 14 $ 39 183 Lab Comp Metabolic Panel 80053 8 $ 56 $ 15 $ 24 $ 56 $ 51 $ 25 $ 13 $ 22 $ 29 88 Tissue Exam by Pathologist 88305 8 $ 236 $ 307 $ 80 $ 152 $ 78 $ 232 $ 188 $ 179 $ 174 36 Medical Cardiology Cardiovascular Stress Test 93017 $ 383 $ 432 $ 1299 $ 907 $ 717 $ 797 $ 830 -54 TTE w Doppler 93306 2 $ 960 $ 1566 $ 1388 $ 1173 $ 1125 $ 1157 $ 1282 -25 Obstetrics Vaginal Delivery DRG 755 $ 7290 $ 5730 $ 4654 $ 4607 $ 5855 $ 4688 $ 5107 43 EampM Office Visit new pt 99203 4 $ 248 $ 118 $ 159 $ 139 78 Colonoscopy and biopsy (HOSPITAL ONLY) 45380 Surg 2530 $ 307591 Diagnostic colonoscopy (HOSPITAL ONLY) 45378 Surg 2255 $ 307591 Upper gi endoscopy biopsy (HOSPITAL ONLY) 43239 Surg 1787 $ 307591 Knee Arthroscopy (HOSPITAL ONLY) 29881 Surg 10900 $ 506893 Arthroscopy Ligament Repair (HOSPITAL ONLY) 29888 Surg 10900 $ 506200 Key 1 Facility - Inpatient 2 Facility - Imaging 3 Physician - Imaging 4 Physician 5 Global - Imaging 6 Facility - Outpatient 8 Lab 41 Physician - Primary Care 42 Physician - Specialist
Blue Cross United - EJCH EUH EUHM WW United - SJH Non Options United - SJH Options Aetna - ASC TEC (HMO) Cigna - ASC TEC (HMO) Aetna - EJCH ESJH ECHM WW Cigna - EJCH (HMO) Cigna - ESJH EUHM (HMO) List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract Description CPT Code Charge Average Final Price (all plans) Emory Mark Up Reimbursement Method ( of charge or fixed) - 1713 Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Cardiovascular stress test 93017 Cardio $543 $ 425 28 of Charge 70 $ 380 of Charge 65 $ 353 of Charge 60 $ 326 of Charge 70 $ 380 of Charge 70 $ 380 of charge 100 $ 543 of Charge 70 $ 380 of charge 100 $ 543 of charge 100 $ 543 TTE wDoppler complete 93306 Cardio $1226 $ 960 28 of Charge 70 $ 858 of Charge 65 $ 797 of Charge 60 $ 736 of Charge 70 $ 858 of Charge 70 $ 858 of charge 100 $ 1226 of Charge 70 $ 858 of charge 100 $ 1226 of charge 100 $ 1226 Colonoscopy and biopsy (HOSPITAL ONLY) 45380 Surg $2530 $ 3076 -18 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 of Charge 70 $ 1771 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Diagnostic colonoscopy (HOSPITAL ONLY) 45378 Surg $2255 $ 3076 -27 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 of Charge 70 $ 1579 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Upper gi endoscopy biopsy (HOSPITAL ONLY) 43239 Surg $1787 $ 3076 -42 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Knee Arthroscopy (HOSPITAL ONLY) 29881 Surg $10900 $ 5069 115 Fixed Rate SC 4 $ 3865 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 449300 $ 4493 Fixed Rate $ 654700 $ 6547 of Charge 70 $ 7630 Fixed Rate $ 401000 $ 4010 of Charge 70 $ 7630 Fixed Rate $ 398300 $ 3983 Fixed Rate $ 398100 $ 3981 Arthroscopy Ligament Repair (HOSPITAL ONLY) 29888 Surg $10900 $ 5062 115 Fixed Rate SC 3 $ 3121 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 556900 $ 5569 Fixed Rate $ 770100 $ 7701 of Charge 70 $ 7630 Fixed Rate $ 323900 $ 3239 of Charge 70 $ 7630 Fixed Rate $ 321700 $ 3217 Fixed Rate $ 321400 $ 3214 Comp Metabolic Panel 80053 Lab $132 $ 56 138 RBRVS Fee (100) $ 1437 of Charge 65 $ 86 of Charge 65 $ 86 of Charge 65 $ 86 of Charge 70 $ 92 RBRVS Fee (100) $ 1437 $ 14 of Charge 70 $ 92 RBRVS Fee (100) $ 1437 $ 14 RBRVS Fee (100) $ 1437 $ 14 Surgical Path Tissue Exam 88305 Lab $326 $ 236 38 of Charge 150 $ 51 of Charge 65 $ 212 of Charge 65 $ 212 of Charge 65 $ 212 of Charge 70 $ 228 of charge 100 $ 326 of Charge 70 $ 228 of charge 100 $ 326 of charge 100 $ 326 MRI Abdomen 74183 Radiology $6960 $ 1238 462 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 MRI Brain 70553 Radiology $6804 $ 1238 450 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 MRI Joint Lower Extremity 73721 Radiology $3067 $ 1238 148 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 CT Thorax wo contrast 71250 Radiology $2199 $ 882 149 Fixed Rate $ 771 Fixed Rate $ 47100 $ 471 Fixed Rate $ 81700 $ 817 Fixed Rate $ 116000 $ 1160 of Charge 70 $ 1539 Fixed Rate $ 80100 $ 801 Fixed Rate $ 79200 $ 792 Fixed Rate $ 79300 $ 793 Fixed Rate $ 79500 $ 795 X-ray Chest 71020 Radiology $280 $ 115 142 of Charge 150 $ 25 of Charge 65 $ 182 of Charge 60 $ 168 of Charge 70 $ 196 of Charge 70 $ 196 RBRVS Fee (150) $ 2534 $ 25 of Charge 70 $ 196 RBRVS Fee (150) $ 2534 $ 25 RBRVS Fee (150) $ 2534 $ 25 Screening mammography G0202 Radiology $279 $ 141 98 Fixed Rate $ 128 Fixed Rate $ 13100 $ 131 Fixed Rate $ 14300 $ 143 Fixed Rate $ 16100 $ 161 of Charge 70 $ 195 Fixed Rate $ 13300 $ 133 Fixed Rate $ 13500 $ 135 Fixed Rate $ 13000 $ 130 Fixed Rate $ 11200 $ 112 Mammo Computer Aided 77052 Radiology $75 $ 112 -33 Fixed Rate $ 9 Fixed Rate $ 13100 $ 131 Fixed Rate $ 14300 $ 143 Fixed Rate $ 16100 $ 161 of Charge 70 $ 53 Fixed Rate $ 13300 $ 133 Fixed Rate $ 13500 $ 135 Fixed Rate $ 13000 $ 130 Fixed Rate $ 11200 $ 112 US Abdomen Complete 76700 Radiology $917 $ 397 131 of Charge 150 $ 125 of Charge 65 $ 596 of Charge 60 $ 550 of Charge 70 $ 642 of Charge 70 $ 642 RBRVS Fee (150) $ 12519 $ 125 of Charge 70 $ 642 RBRVS Fee (150) $ 12519 $ 125 RBRVS Fee (150) $ 12519 $ 125 Officeoutpatient visit new pt 30 min (TEC) 99203 EampM $316 $ 248 28 of Charge 70 $ 221 of Charge 65 $ 205 of Charge 60 $ 190 of Charge 70 $ 221 of Charge 70 $ 221 of charge 100 $ 316 of Charge 70 $ 221 of charge 100 $ 316 of charge 100 $ 316 Vaginal delivery 59409 Surg $14484 $ 7290 99 Fixed Rate DRG - 775 $ 5437 2 Day Case Rate + LOC 561700 $ 5617 BaseCMS Weight 584741 $ 5847 BaseCMS Weight 726146 $ 7261 No IP Terms $ - 0 No IP BaseCMS Weight 659343 $ 6593 BaseContract Weight 479451 100 $ 14484 BaseCMS Weight 579110 $ 5791 Lap Sleeve Gastrectomy 43775 Surg $29961 $ 20421 47 Fixed Rate DRG - 621 $ 14872 BaseCMS Weight 1810697 $ 18107 BaseCMS Weight 1835178 $ 18352 BaseCMS Weight 2278911 $ 22789 No IP Terms $ - 0 No IP BaseCMS Weight 2069315 $ 20693 BaseCMS Weight 1730442 100 $ 29961 BaseCMS Weight 1817507 $ 18175 105 Colonoscopy and biopsy (ASC ONLY) Surg $ 219200 $ 2181 Diagnostic colonoscopy (ASC ONLY) Surg $ 267100 $ 2348 Upper gi endoscopy biopsy (ASC ONLY) Surg $ 207500 $ 2758 Knee Arthroscopy (ASC ONLY) Surg $ 417900 $ 3467 Arthroscopy Ligament Repair (ASC ONLY) Surg $ 504800 $ 3386
Cpt Code CPT Description Procedure Category Claims Min 25thNtile 50thNtile Emorys Rates 75thNtile 90thNtile Max 20 Below 50th Ntile 20 Above 50th Ntile 93017 CARDIOVASCULAR STRESS TEST 5 82 $80 $125 $321 $382 $568 $791 $930 $257 $386 71020 CHEST X-RAY 2 2638 $11 $45 $152 $115 $289 $373 $585 $122 $182 71020 CHEST X-RAY 5 8106 $25 $34 $38 $54 $57 $69 $30 $46 45380 COLONOSCOPY AND BIOPSY 6 1256 $541 $560 $572 $2877 $1000 $2024 $3289 $458 $686 77052 COMP SCREEN MAMMOGRAM ADD-ON 2 194 $13 $15 $25 $38 $47 $134 $20 $30 77052 COMP SCREEN MAMMOGRAM ADD-ON 5 2411 $13 $16 $20 $23 $26 $28 $16 $24 80053 COMPREHEN METABOLIC PANEL 8 13019 $9 $19 $23 $55 $24 $25 $69 $19 $28 71250 CT THORAX WO DYE 2 302 $165 $372 $545 $878 $1658 $2067 $436 $654 71250 CT THORAX WO DYE 5 209 $53 $127 $203 $289 $419 $534 $162 $244 45378 DIAGNOSTIC COLONOSCOPY 6 1479 $484 $515 $536 $2914 $831 $1971 $2828 $428 $643 29881 KNEE ARTHROSCOPYSURGERY 6 152 $1650 $1826 $2036 $5235 $3054 $4216 $6461 $1629 $2443 29888 KNEE ARTHROSCOPYSURGERY 6 82 $1682 $3615 $5081 $5145 $7553 $12924 $18532 $4065 $6097 43644 LAP GASTRIC BYPASSROUX-EN-Y 1 21 $11821 $13873 $17050 $18391 $25029 $31079 $13640 $20460 43775 LAP SLEEVE GASTRECTOMY 1 38 $4215 $8250 $13253 $20421 $19197 $21509 $24260 $10602 $15903 74183 MRI ABDOMEN WO amp WDYE 2 120 $919 $987 $1015 $1237 $1252 $2534 $3177 $812 $1218 74183 MRI ABDOMEN WO amp WDYE 5 112 $475 $490 $521 $1154 $1337 $1696 $417 $625 70553 MRI BRAIN WO amp WDYE 2 324 $633 $987 $1142 $1237 $1706 $2805 $3331 $914 $1370 70553 MRI BRAIN WO amp WDYE 5 467 $280 $539 $1023 $1277 $1363 $1726 $818 $1228 73721 MRI JNT OF LWR EXTRE WO DYE 2 304 $804 $859 $967 $1237 $1063 $1598 $2485 $774 $1160 73721 MRI JNT OF LWR EXTRE WO DYE 5 1130 $500 $520 $530 $628 $679 $859 $424 $636 59400 OBSTETRICAL CARE 1 494 $3699 $4402 $4969 $6655 $7307 $8613 $3975 $5963 99203 OFFICEOUTPATIENT VISIT NEW 4 6776 $88 $101 $112 $138 $155 $169 $90 $134 G0202 Screeningmammographydigital 2 7444 $123 $206 $285 $380 $425 $479 $228 $342 G0202 Screeningmammographydigital 5 2754 $117 $165 $195 $230 $247 $252 $156 $234 88305 TISSUE EXAM BY PATHOLOGIST 8 20834 $51 $74 $112 $235 $168 $261 $478 $90 $134 93306 TTE WDOPPLER COMPLETE 2 931 $194 $377 $739 $960 $1267 $1480 $1849 $591 $887 93306 TTE WDOPPLER COMPLETE 5 2299 $151 $296 $373 $538 $573 $834 $298 $448 43239 UPPER GI ENDOSCOPY BIOPSY 6 1264 $424 $514 $550 $800 $1838 $2833 $440 $660 76700 US EXAM ABDOM COMPLETE 2 321 $96 $165 $271 $509 $584 $857 $217 $325 76700 US EXAM ABDOM COMPLETE 5 444 $111 $129 $147 $156 $220 $279 $118 $176 Key 1 Facility - Inpatient 2 Facility - Imaging 3 Physician - Imaging 4 Physician 5 Global - Imaging 6 Facility - Outpatient 8 Lab 41 Physician - Primary Care 42 Physician - Specialist Cardiovascular stress test $ 38279 TTE wDoppler complete $ 96037 Colonoscopy and biopsy $ 287709 Diagnostic colonoscopy $ 291434 Upper gi endoscopy biopsy $ 300526 Knee Arthroscopy $ 523584 Arthroscopy Ligament Repair $ 514501 Comp Metabolic Panel $ 5552 Surgical Path Tissue Exam $ 23570 MRI Abdomen $ 123786 MRI Brain $ 123786 MRI Joint Lower Extremity $ 123786 CT Thorax wo contrast $ 88213 X-ray Chest $ 11548 Screening mammography $ 14098 Mammo Computer Aided $ 11179 US Abdomen Complete $ 39695 Officeoutpatient visit new pt 30 min $ 24753 Vaginal delivery $ 729025 Lap Sleeve Gastrectomy $ 2042124
Page 14
The Member Experience
13
Engagement begins when employee on clear
path to surgery
Patient contacts with COE TPA
TPA team triages and ensures basic criteria
met
Employee put in touch with nurse team
Car pick-up Flight Hotel all arranged by
TPA
Navigators and nurse coordinators help
throughout the stay
Patient visits to hospital to understand
exceptions of procedure and meet treatment
team
Surgery occurs typically next day
Stay length according to procedure typically a
few days
Discharged from facility Travel home COE team updates local
PCP and discuss follow up care
COE provider checks in with local physician
frequently Revert back to standard coverage
Source How Employers Are Fixing Health Care Harvard Business Review March 2019
Case Study 1
Case study 1 ndash Pop Health Approach bull ProblemCircumstance Large multi-employer group needs to
evaluate benefit design disease prevalence health spend and utilization to manage their population
bull ConsiderationsValue Prop Unique industry and geography drive chronic conditions and utilization patterns
bull Solution Provide opportunity assessment comparing this population to other benchmarks to understand where to target intervention and management as well as assess efforts already taken
15
Market Comparison Preference Sensitive Procedures
16
Legend vs
Mt States vs
National gt120 gt110
110-120 105-110 lt80 lt90
Source Multi-payer commercial benchmark Results are weighted by AgeGender Broader market area includes multi-payer data from the mountain regions
Preference Sensitive Procedures Benchmark Comparison
Dartmouth Atlas Preference Sensitive Procedures
IP allowed dollars ALOS Employer vs
Mt States Employer
vs National FY 2017 FY 2018 FY 2017 FY 2018
Hysterectomy for Uterine Fibroids Rate $569354 $436932 45 54 124 140 CABG Rate $1800260 $2400608 53 60 218 130 Cholycystectomy Rate $832675 $755565 68 39 92 120 C-Section Rate 116 110 HighTech Radiology Rate 103 101 PCIPTCA Rate $934486 $1133708 37 55 82 80 Back Surgery Rate $3237613 $4003212 39 57 52 70 Knee Replacement Rate $3086693 $2177334 41 48 50 64 Total Hip Replacement Rate $1023675 $747491 45 64 37 34
Strengths (+)
Employer compares favorably for orthopedic procedures (back hip knee)
Opportunity (-)
Employer has higher than expected rates for CABG and hysterectomy (Note Low PTCA rate combined with high CABG rate may suggest provider practice patterns favoring CABG)
0 50 100 150 200 250
Total Hip Replacement
Knee Replacement
Back Surgery
PCIPTCA
Cholycystectomy
HighTech Radiology
C-Section
CABG
Culinary VsNational
Culinary Vs MtStates
Employer vs Mt States
Employer vs National
Market Comparison Condition Prevalence
17 Source Multi-payer commercial benchmark Results are weighted by AgeGender Broader market area includes multi-payer data from the mountain regions
Condition Prevalence Benchmark Comparison
Condition Employer vs
Mt States Employer vs
National Prevalence Diabetes Rate 229 219 Prevalence Hyperlipidemia Rate 259 207 Prevalence Kidney Disease Rate 143 174 Prevalence Migraine Rate 166 164 Prevalence Low Back Pain Rate 136 139 Prevalence Hypertension Rate 156 134 Prevalence Asthma Rate 146 128 Prevalence CAD Rate 175 115 Prevalence Pregnancy Rate 110 109 Prevalence Adult Preventive Screening Rate 114 91 Prevalence Depression Rate 63 60
Strengths (+)
Rate of depression is low (Note May be due to incomplete behavioral health claims)
Opportunity (-)
Employer has a higher prevalence of most chronic conditions including asthma CAD diabetes hypertension hyperlipidemia Kidney Disease LBP and migraines
0
100
200
300Hyperlipidemia
Diabetes
CAD
Migraine
Hypertension
AsthmaKidney Disease
Low Back Pain
Pregnancy
Depression
Employer vsMt States
Employer vsNational Legend
vs Mt States
vs National
gt120 gt110 110-120 105-110
lt80 lt90
Market Comparison Utilization Rates
18
A higher preventive office visit rate is better Source Multi-payer commercial benchmark Results are weighted by AgeGender Broader market area includes multi-payer data from the mountain regions
Strengths (+)
Lower than average utilization of ED and high dollar patient rate
Opportunity (-)
Higher LOS lengthy admits avoidable admits and readmissions which all drive significantly more spend
Utilization Benchmark Comparison
Condition Employer vs
Mt States Employer vs
National Avoidable Admit Rate 142 144 Lengthy Admit Rate 175 136 Outpatient Problem Focused Office Rate 146 131 Readmission Rate (readmitadmit) 135 126 Average LOS 125 116 One Day Admit Rate 76 103 Office Visit Rate 106 96 Acute Admit Rate 80 95 Avoidable ED Rate 68 86 ED Rate 54 69 Preventive Office Rate 95 68 High Dollar Patient Rate 49 51 Frequent ED User (gt3 times) Rate 24 36
Legend vs
Mt States vs
National gt120 gt110
110-120 105-110 lt80 lt90
0 50 100 150 200
Frequent ED User (gt3 times)
High Dollar Patient
Preventive Office
ED
Avoidable ED
Acute Admit
Office Visit
One Day Admit
Average LOS
Readmissionhellip
Outpt Problem Focusedhellip
Lengthy Admit
Avoidable Admit
Employer vsNational
Employer vsMt States
ED and Avoidable ED
19
Potentially Avoidable ED - Trend View Overall ED
Period Change FY 2017 FY 2018 Count Rate
Measure Mbrs Rate Mbrs Rate Overall ED 16394 12626 13820 10745 -16 -15 FREQUENT ED UTILIZER (mbr1k) 1581 1218 1468 1141 -7 -6 AVOIDABLE ED 6371 4907 5288 4111 -17 -16 Potentially Avoidable ED
Period Change FY 2017 FY 2018 Count Rate
Avoid ED Condition Mbrs Rate Mbrs Rate ABDOMINAL_PAIN 1092 841 895 696 -18 -17 ENT_INFECTION 854 658 742 577 -13 -12 FEVER 715 551 700 544 -2 -1 URINARY 650 501 468 364 -28 -27 HEADACHE 558 430 434 337 -22 -21 BACK_PAIN 414 319 423 329 2 3 NAUSEA 394 303 271 211 -31 -31 ASTHMA 294 226 209 162 -29 -28 CELLULITIS 210 162 198 154 -6 -5 GASTROENTERITIS 254 196 171 133 -33 -32 OTITIS_MEDIA 201 155 160 124 -20 -20 COPD 132 102 108 084 -18 -17 DIABETES 123 095 91 071 -26 -25 BACT_PNEUMONIA 111 085 86 067 -23 -22 DENTAL 93 072 83 065 -11 -10 DEHYDRATION 98 075 81 063 -17 -17 HYPERTENSION 16 012 24 019 50 51 CHF 4 003 3 002 -25 -24 ANGINA 8 006 3 002 -63 -62 IMMUNIZATION_RELATED 2 002 0 000 -100 -100 Grand Total 6371 4907 5288 4111 -17 -16
AHRQ avoidable ED visits are based on the logic for ambulatory care sensitive ED visits from AHRQ and diagnosis code driven
696
577
544 364
337
329
211 162
154 133 ABDOMINAL_PAIN
ENT_INFECTION
FEVER
URINARY
HEADACHE
BACK_PAIN
NAUSEA
- 200 400 600 800
1000 1200
2017 Members 2018 Members
Top Ten 2018 Conditions by Rate
Top Ten Conditions by Member Count
ED Avoidable ED and the impact of new on-site clinic
20
0
1000
2000
3000
4000
5000
6000
0200400600800
10001200140016001800
Clinic Visits ED Visits
Avoidable ED VisitsED Visits (non-avoidable)Clinic EampM Visits
0
500000
1000000
1500000
2000000
2500000
3000000
3500000
$s
Clinic EampM Profess DollarsAvoidable ED Dollars
bull Clinic visits have a clear impact on ED and avoidable ED use and spend
bull Combined ED visits are down on average 157 in FY 18 from FY 17
bull Combined ED spend is down 128 in FY 18 from FY 17
Clinic Live 62017
Pitfalls and Challenges bull Face many of the challenges similar to startup health
plan bull Critical to determine how you will deliver value and
communicate the value to potential customers and brokersconsultants
bull Care management bull Network
21
Considerations in Offering Development bull Care Management Model
bull Traditional care model bull Case management bull Utilization management bull Disease management
bull Longitudinal care model with value based care philosophy bull Primary care driven bull Local care management
bull Predictive analytics and risk stratification model bull Claims history and ongoing data bull EMR data
22
Case Study 2
Case study 2 ndash Large Employer bull Business Problem Large employer wants to contract
directly with 2 major hospital systems developing professional fee schedules
bull ConsiderationsValue Prop Fee schedule should be competitive but also nuanced to minimize gap relative to current reimbursement at physician level
bull Solution Data-driven approach using current market-wide reimbursement distinguished by service level
24
Evaluate Provider Spend Top 25 Service Lines by Allowable Spend
Evaluate Provider Spend Top 20 Professional CPTs by Total Spend
Understand relative market pricing position
27
21
-1
-28
14 10
28
-22
-11 -13
24
3
20 21
8
-20
13
3 9
-39
56
-26
4
-42
60
MRI Colonoscopy Cardiac Cath Lab - OrganPanel
Memorial Hospital Beta Hospital Delta Hospital Charlie Hospital Echo Hospital Alpha Medical Center
ndash25 5 -15 10 0 39
State Charges as a Percent of Peer Average Weighted Averages for MRI Colonoscopy Cardiology and Lab
Total Percent Above Below Market Average2
Memorial Hospital Beta Hospital Delta Hospital Charlie Hospital Echo Hospital Alpha Medical Center
Develop fee schedule relative to market
28
Service Line Procedure CPT CodeDRG
Memorial Hospital
Beta Hosptial
Charlie Hospital
Delta Hospital
Echo Hospital
Alpha Medical Center
Arthroscopy Ligament Repair 29888 $ 5062 $ 9557 $ 5983 $ 10096 $ 7519 $ 2502 Knee Arthroscopy 29881 $ 5069 $ 4185 $ 3837 $ 3022 $ 3729 $ 2266 Upper GI Endoscopy 43239 $ 3075 $ 2539 $ 2012 $ 1132 $ 1565 $ 2240 Lap Sleeve Gastrectomy DRG 621 $ 20421 $ 20815 $ 12105 $ 13230 $ 14600 $ 17800 Colonoscopy and biopsy 45380 $ 3075 $ 3071 $ 2013 $ 1244 $ 1972 $ 859 Diagnostic Colonoscopy 45378 $ 3075 $ 2805 $ 2013 $ 1244 $ 1972 $ 859 MRI Brain w amp wo dye 70553 $ 1238 $ 1468 $ 1117 $ 967 $ 2805 $ 1052 MRI Joint of Lower Extremity wo dye 73721 $ 1238 $ 1398 $ 1042 $ 967 $ 925 $ 557 MRI Abdomen w amp wo dye 74183 $ 1238 $ 1468 $ 1106 $ 967 $ 2805 $ 836 X-ray Chest 71020 $ 115 $ 266 $ 305 $ 279 $ 375 $ 72 CT Thorax wo dye 71250 $ 882 $ 810 $ 505 $ 491 $ 579 $ 319 Ultrasound Abdomen Complete 76700 $ 397 $ 538 $ 545 $ 195 $ 190 $ 168 Mammogram Screening G0202 $ 141 $ 328 $ 431 $ 294 $ 425 $ 168 Computer Detection Add-on 77052 $ 112 $ 99 $ 41 $ 15 $ 45 $ 23 Comp Metabolic Panel 80053 $ 56 $ 15 $ 24 $ 56 $ 51 $ 25 Tissue Exam by Pathologist 88305 $ 236 $ 307 $ 80 $ 152 $ 78 $ 232 Cardiovascular Stress Test 93017 $ 383 $ 432 $ 1299 $ 907 $ 717 $ 797 TTE w Doppler 93306 $ 960 $ 1566 $ 1388 $ 1173 $ 1125 $ 1157
Obstetrics Vaginal Delivery DRG 755 7290$ 5730$ 4654$ 4607$ 5855$ 4688$
GI
Lab
Radiology
Medical Cardiology
Orthopedics
KEY OBSERVA TIONS bull Potential exposure on GI bull Opportunity to align price and acuity in MRI bull Opportunity to raise rates on chest x-ray and mammogram
Percentile Bands Emory Allowables Heatmap TEC ASC Heatmap Allowable Comp Analysis Portal Pricing Sheet1 image1png A few words on Bundled Payments bull Bundled payments are growing as a type of direct contracting bull In some cases third parties match-make between employers
and providers bull Contracts may vary in definitions prepost admission
coverage duration readmission cause (ie all-cause vs medically related) outlier provisions LOS caps andor per diems
bull Providers need to be strategic in pricing to enable profitable growth of market share
29
Considerations in Offering Development bull Network Development
bull Build off existing structure eg health system employee plan network bull How does this fit into your broader value based care strategy bull Employed and independent physicians bull How do you want to approach the buildout of high performance
network bull Quality focus bull Cost efficiency
bull Integrated behavioral health bull Wrap network for other markets
30
Considerations in Offering Development bull Target Market
bull Consideration of employer profile in market bull Fully-insured vs ASO bull Total cost of care vs bundled services
bull Distribution bull Direct marketing bull Brokerconsultant community
bull Plan designs bull Standard designs vs flexible ndash Dependent on target market
bull Claims administration bull Data sharing amp analytics
31
Considerations in Offering Development bull Other components of comprehensive offering
bull Pharmacy bull Preventive health bull Onsite clinics bull Wellness programs bull Technology platform
32
Sample Bundle Analysis
33
Cover page Dotson Hazelrigs Nation Mainly of charge of fixed Cardiovascular stress test TTE wDoppler complete Colonoscopy and biopsy (Combined) Diagnostic colonoscopy (Combined) Upper gi endoscopy biopsy (Combined) Knee Arthroscopy (Combined) Arthroscopy Ligament Repair Comp Metabolic Panel Surgical Path Tissue Exam MRI Abdomen MRI Brain MRI Joint Lower Extremity CT Thorax wo contrast X-ray Chest Screening mammography Mammo Computer Aided US Abdomen Complete Officeoutpatient visit new pt 30 min Vaginal delivery Lap Sleeve Gastrectomy
Piedmont Piedmont Piedmont Piedmont Northside Northside Northside Northside Gwinnett Gwinnett Gwinnett Gwinnett WellStar WellStar WellStar WellStar AMC - Tenet AMC - Tenet AMC - Tenet AMC - Tenet CPT Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing 29881 $11312 $10872 NA NA $7476 $9338 NA $23655 $11856 $3668 NA $17871 $12253 NA NA $15645 $5490 NA NA $23039 29888 NA NA NA NA NA NA NA $23784 NA $8261 NA $18000 NA NA NA $15774 NA NA NA $23168 43239 NA $4408 NA NA NA NA $5997 $8852 NA $3304 NA $7424 $1267 NA NA $9230 NA $2458 NA $8274 43644 $26468 NA NA NA $3382 $12050 NA $1861 NA NA NA $1316 $7841 NA NA $3444 $18892 $27950 NA $979 43775 NA NA NA NA NA NA NA $352 NA NA NA $302 NA NA NA $413 NA NA NA $83 45378 $2705 $2530 NA NA $4381 $3676 $4496 $1022 $2938 $2138 NA $695 $5504 NA NA $2036 NA NA NA $372 45380 $3075 $2600 NA NA $4723 $3527 $3012 $1757 $4215 $2285 NA NA $5298 NA NA $3268 NA NA NA $627 59400 $6160 NA NA NA NA $5100 NA $1851 NA NA NA $1304 $9035 NA NA $3427 $9116 $5150 NA $966 70553 $2985 NA $1153 NA $2182 NA $1192 $492 NA NA $803 $489 $1512 NA $985 $1187 NA NA NA $197 71020 $61 $69 $43 NA $113 $319 $307 NA $183 $59 $32 NA $213 $66 $40 NA $83 $53 NA NA 71250 $1837 $621 $989 NA $1490 $931 $755 NA NA $745 $401 NA $1067 $982 $616 NA NA $304 NA NA 73721 NA $1098 $1153 NA $2042 $1065 $1192 NA NA $998 $803 NA NA $1275 $985 NA NA $644 NA $178 74183 $2971 $1144 NA NA NA $1092 $1192 $6884 NA $1098 $803 NA $2960 $1197 $985 $5454 NA NA NA $7607 76700 $364 $247 $207 NA $427 $708 $614 $13267 $428 $214 $152 NA $747 $263 $189 $9139 NA $235 NA NA 77052 NA NA NA NA NA NA NA $4744 NA NA NA NA NA NA NA $3070 NA NA NA $5611 93306 $1220 $1117 NA NA $1877 $1657 $2100 $4605 $1433 $413 $945 NA $1336 $1434 $1951 $2931 NA $2399 NA $5472 G0202 $262 $187 NA NA $431 NA NA $4605 $292 NA NA NA $530 $281 NA $2931 $327 NA NA $5472
Provider Group 29881_6 29888_6 43239_6 43644_1 43775_1 45378_6 45380_6 59400_1 70553_2 71020_2 71250_2 73721_2 74183_2 76700_2 77052_2 77052_5 80053_8 88305_8 93306_2 99203_4 G0202_2 G0202_5 93017_2 Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Atlanta Gastroenterology Associates $2399 $536 348 $1628 $536 204 $2400 $536 348 Atlanta Medical Center $24889 $2266 999 $25897 $2502 935 $11449 $2240 411 $81927 $15300 435 $75815 $17800 326 $7317 $859 752 $7317 $859 752 $12821 $4688 173 $6581 $1052 526 $645 $72 796 $3265 $319 925 $3450 $557 519 $7398 $836 785 $1576 $133 1084 $73 $23 217 $635 $25 2440 $891 $232 285 $2967 $1157 156 $344 $168 105 $1265 $797 59 Atlanta Womens Health Physicians Group $29 $14 107 $40 $13 208 $396 $188 111 $278 $118 135 $450 $231 95 Gwinnett Hospital $11941 $3022 295 $21654 $10096 114 $3551 $1132 214 $34384 $10800 218 $56472 $13230 327 $3003 $1244 141 $3533 $1244 184 $8984 $4607 95 $3901 $967 303 $417 $279 49 $2247 $491 358 $4000 $967 314 $3755 $967 288 $1593 $195 717 $50 $15 233 $186 $56 233 $505 $152 233 $1750 $1173 49 $418 $294 42 $1396 $907 54 Northside Hospital $15482 $4185 270 $21651 $9557 127 $4885 $2539 92 $35176 $17000 107 $35233 $20815 69 $3883 $2805 38 $5256 $3071 71 $10911 $5730 90 $4856 $1468 231 $443 $266 67 $2379 $810 194 $3776 $1398 170 $5105 $1468 248 $942 $538 75 $167 $99 69 $379 $15 2427 $433 $307 41 $2252 $1566 44 $459 $328 40 $576 $432 33 Piedmont Hospital $14772 $3837 285 $35493 $5983 493 $5069 $2012 152 $38320 $17750 116 $37125 $12105 207 $3485 $2013 73 $4993 $2013 148 $10143 $4654 118 $5939 $1117 432 $542 $305 78 $2983 $505 491 $3410 $1042 227 $6067 $1106 449 $1364 $545 150 $75 $41 85 $231 $24 863 $657 $80 721 $2041 $1388 47 $490 $431 14 $1780 $1299 37 Piedmont Physicians Group $42 $22 87 $318 $179 78 $239 $159 50 Resurgens $8558 $2036 320 $9293 $2258 312 $4638 $2067 124 $4039 $2164 87 $4392 $2164 103 $2252 $1371 64 $459 $330 39 Wellstar Hospital $9330 $3729 150 $17479 $7519 132 $5261 $1565 236 $35794 $18200 97 $46780 $14600 220 $3707 $1972 88 $4928 $1972 150 $13549 $5855 131 $5054 $2805 80 $528 $375 41 $3222 $579 457 $3694 $925 299 $5495 $2805 96 $1355 $190 615 $66 $45 46 $73 $51 43 $133 $78 71 $1785 $1125 59 $599 $425 41 $1010 $717 41 Avg Mark UpProcedure Atlanta Medical Center 634 Gwinnett Hospital 223 Northside Hospital 233 Piedmont Hospital 259 Wellstar Hospital 155 Emory 105
Atlanta Gastroenterology Associates Atlanta Medical Center Atlanta Womens Health Gwinnett Hospital Northside Hospital Piedmont Hospital Piedmont Physicians Group Resurgens Wellstar Hospital CPT Code CPT Proc Cat Comp Avg Allow Allow Allow Allow Allow Allow Allow Allow Allow 29881 KNEE ARTHROSCOPYSURGERY 6 $3179 $2266 $3022 $4185 $3837 $2036 $3729 29888 KNEE ARTHROSCOPYSURGERY 6 $6319 $2502 $10096 $9557 $5983 $2258 $7519 43239 UPPER GI ENDOSCOPY BIOPSY 6 $1727 $536 $2240 $1132 $2539 $2012 $2067 $1565 43644 LAP GASTRIC BYPASSROUX-EN-Y 1 $15810 $15300 $10800 $17000 $17750 $18200 43775 LAP SLEEVE GASTRECTOMY 1 $17800 $13230 $20815 $12105 $14600 45378 DIAGNOSTIC COLONOSCOPY 6 $1656 $536 $859 $1244 $2805 $2013 $2164 $1972 45380 COLONOSCOPY AND BIOPSY 6 $1694 $536 $859 $1244 $3071 $2013 $2164 $1972 59400 OBSTETRICAL CARE 1 $5107 $4688 $4607 $5730 $4654 $5855 70553 MRI BRAIN WO amp WDYE 2 $1482 $1052 $967 $1468 $1117 $2805 71020 CHEST X-RAY 2 $259 $72 $279 $266 $305 $375 71250 CT THORAX WO DYE 2 $541 $319 $491 $810 $505 $579 73721 MRI JNT OF LWR EXTRE WO DYE 2 $978 $557 $967 $1398 $1042 $925 74183 MRI ABDOMEN WO amp WDYE 2 $1436 $836 $967 $1468 $1106 $2805 76700 US EXAM ABDOM COMPLETE 2 $320 $133 $195 $538 $545 $190 77052 COMP SCREEN MAMMOGRAM ADD-ON 2 $45 $23 $15 $99 $41 $45 77052 COMP SCREEN MAMMOGRAM ADD-ON 5 $14 $14 80053 COMPREHEN METABOLIC PANEL 8 $29 $25 $13 $56 $15 $24 $22 $51 88305 TISSUE EXAM BY PATHOLOGIST 8 $174 $232 $188 $152 $307 $80 $179 $78 93306 TTE WDOPPLER COMPLETE 2 $1297 $1157 $1173 $1566 $1388 $1371 $1125 93017 STRESS TEST 5 $830 $797 $907 $432 $1299 $717 99203 OFFICEOUTPATIENT VISIT NEW 4 $139 $118 $159 G0202 Screeningmammographydigital 2 $329 $168 $294 $328 $431 $330 $425 G0202 Screeningmammographydigital 5 $231 $231
Service Line Procedure CPT Code Emory Atlanta Gastroenterology Associates Resurgens Atlanta Womens Health Piedmont Physicians Group Orthopedics (ASC) Knee Arthroscopy 29881 $3467 $2036 Arthroscopy Ligament Repair 29888 $3386 $2258 GI (ASC) Upper GI Endoscopy 43239 $2758 $536 Diagnostic Colonoscopy 45378 $2348 $536 Colonoscopy and biopsy 45380 $2181 $536 Radiology Mammogram Screening G0202 $164 $231 Computer Detection Add-on 77052 $93 $14 Lab Comp Metabolic Panel 80053 $53 $13 $22 Tissue Exam by Pathologist 88305 $277 $188 $179 EampM (TEC) Office Visit new pt 99203 $269 $118 $159
Service Line Procedure CPT CodeDRG Memorial Hospital Beta Hosptial Charlie Hospital Delta Hospital Echo Hospital Alpha Medical Center Atlanta Gastroenterology Associates Resurgens Atlanta Womens Health Piedmont Physicians Group Market Avg Emory abovebelow Orthopedics Arthroscopy Ligament Repair 29888 $ 5062 $ 9557 $ 5983 $ 10096 $ 7519 $ 2502 $ 2258 $ 6319 -20 Knee Arthroscopy 29881 6 $ 5069 $ 4185 $ 3837 $ 3022 $ 3729 $ 2266 $ 2036 $ 3179 59 GI Upper GI Endoscopy 43239 6 $ 3075 $ 2539 $ 2012 $ 1132 $ 1565 $ 2240 $ 536 $ 1671 84 Lap Sleeve Gastrectomy DRG 621 $ 20421 $ 20815 $ 12105 $ 13230 $ 14600 $ 17800 $ 15710 30 Colonoscopy and biopsy 45380 $ 3075 $ 3071 $ 2013 $ 1244 $ 1972 $ 859 $ 536 $ 1616 90 Diagnostic Colonoscopy 45378 6 $ 3075 $ 2805 $ 2013 $ 1244 $ 1972 $ 859 $ 536 $ 1572 96 Radiology MRI Brain w amp wo dye 70553 2 $ 1238 $ 1468 $ 1117 $ 967 $ 2805 $ 1052 $ 1482 -16 MRI Joint of Lower Extremity wo dye 73721 2 $ 1238 $ 1398 $ 1042 $ 967 $ 925 $ 557 $ 978 27 MRI Abdomen w amp wo dye 74183 2 $ 1238 $ 1468 $ 1106 $ 967 $ 2805 $ 836 $ 1436 -14 X-ray Chest 71020 $ 115 $ 266 $ 305 $ 279 $ 375 $ 72 $ 259 -56 CT Thorax wo dye 71250 $ 882 $ 810 $ 505 $ 491 $ 579 $ 319 $ 541 63 Ultrasound Abdomen Complete 76700 $ 397 $ 538 $ 545 $ 195 $ 190 $ 168 $ 327 21 Mammogram Screening G0202 2 $ 141 $ 328 $ 431 $ 294 $ 425 $ 168 $ 231 $ 313 -55 Computer Detection Add-on 77052 2 $ 112 $ 99 $ 41 $ 15 $ 45 $ 23 $ 14 $ 39 183 Lab Comp Metabolic Panel 80053 8 $ 56 $ 15 $ 24 $ 56 $ 51 $ 25 $ 13 $ 22 $ 29 88 Tissue Exam by Pathologist 88305 8 $ 236 $ 307 $ 80 $ 152 $ 78 $ 232 $ 188 $ 179 $ 174 36 Medical Cardiology Cardiovascular Stress Test 93017 $ 383 $ 432 $ 1299 $ 907 $ 717 $ 797 $ 830 -54 TTE w Doppler 93306 2 $ 960 $ 1566 $ 1388 $ 1173 $ 1125 $ 1157 $ 1282 -25 Obstetrics Vaginal Delivery DRG 755 $ 7290 $ 5730 $ 4654 $ 4607 $ 5855 $ 4688 $ 5107 43 EampM Office Visit new pt 99203 4 $ 248 $ 118 $ 159 $ 139 78 Colonoscopy and biopsy (HOSPITAL ONLY) 45380 Surg 2530 $ 307591 Diagnostic colonoscopy (HOSPITAL ONLY) 45378 Surg 2255 $ 307591 Upper gi endoscopy biopsy (HOSPITAL ONLY) 43239 Surg 1787 $ 307591 Knee Arthroscopy (HOSPITAL ONLY) 29881 Surg 10900 $ 506893 Arthroscopy Ligament Repair (HOSPITAL ONLY) 29888 Surg 10900 $ 506200 Key 1 Facility - Inpatient 2 Facility - Imaging 3 Physician - Imaging 4 Physician 5 Global - Imaging 6 Facility - Outpatient 8 Lab 41 Physician - Primary Care 42 Physician - Specialist
Blue Cross United - EJCH EUH EUHM WW United - SJH Non Options United - SJH Options Aetna - ASC TEC (HMO) Cigna - ASC TEC (HMO) Aetna - EJCH ESJH ECHM WW Cigna - EJCH (HMO) Cigna - ESJH EUHM (HMO) List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract Description CPT Code Charge Average Final Price (all plans) Emory Mark Up Reimbursement Method ( of charge or fixed) - 1713 Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Cardiovascular stress test 93017 Cardio $543 $ 425 28 of Charge 70 $ 380 of Charge 65 $ 353 of Charge 60 $ 326 of Charge 70 $ 380 of Charge 70 $ 380 of charge 100 $ 543 of Charge 70 $ 380 of charge 100 $ 543 of charge 100 $ 543 TTE wDoppler complete 93306 Cardio $1226 $ 960 28 of Charge 70 $ 858 of Charge 65 $ 797 of Charge 60 $ 736 of Charge 70 $ 858 of Charge 70 $ 858 of charge 100 $ 1226 of Charge 70 $ 858 of charge 100 $ 1226 of charge 100 $ 1226 Colonoscopy and biopsy (HOSPITAL ONLY) 45380 Surg $2530 $ 3076 -18 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 of Charge 70 $ 1771 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Diagnostic colonoscopy (HOSPITAL ONLY) 45378 Surg $2255 $ 3076 -27 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 of Charge 70 $ 1579 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Upper gi endoscopy biopsy (HOSPITAL ONLY) 43239 Surg $1787 $ 3076 -42 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Knee Arthroscopy (HOSPITAL ONLY) 29881 Surg $10900 $ 5069 115 Fixed Rate SC 4 $ 3865 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 449300 $ 4493 Fixed Rate $ 654700 $ 6547 of Charge 70 $ 7630 Fixed Rate $ 401000 $ 4010 of Charge 70 $ 7630 Fixed Rate $ 398300 $ 3983 Fixed Rate $ 398100 $ 3981 Arthroscopy Ligament Repair (HOSPITAL ONLY) 29888 Surg $10900 $ 5062 115 Fixed Rate SC 3 $ 3121 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 556900 $ 5569 Fixed Rate $ 770100 $ 7701 of Charge 70 $ 7630 Fixed Rate $ 323900 $ 3239 of Charge 70 $ 7630 Fixed Rate $ 321700 $ 3217 Fixed Rate $ 321400 $ 3214 Comp Metabolic Panel 80053 Lab $132 $ 56 138 RBRVS Fee (100) $ 1437 of Charge 65 $ 86 of Charge 65 $ 86 of Charge 65 $ 86 of Charge 70 $ 92 RBRVS Fee (100) $ 1437 $ 14 of Charge 70 $ 92 RBRVS Fee (100) $ 1437 $ 14 RBRVS Fee (100) $ 1437 $ 14 Surgical Path Tissue Exam 88305 Lab $326 $ 236 38 of Charge 150 $ 51 of Charge 65 $ 212 of Charge 65 $ 212 of Charge 65 $ 212 of Charge 70 $ 228 of charge 100 $ 326 of Charge 70 $ 228 of charge 100 $ 326 of charge 100 $ 326 MRI Abdomen 74183 Radiology $6960 $ 1238 462 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 MRI Brain 70553 Radiology $6804 $ 1238 450 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 MRI Joint Lower Extremity 73721 Radiology $3067 $ 1238 148 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 CT Thorax wo contrast 71250 Radiology $2199 $ 882 149 Fixed Rate $ 771 Fixed Rate $ 47100 $ 471 Fixed Rate $ 81700 $ 817 Fixed Rate $ 116000 $ 1160 of Charge 70 $ 1539 Fixed Rate $ 80100 $ 801 Fixed Rate $ 79200 $ 792 Fixed Rate $ 79300 $ 793 Fixed Rate $ 79500 $ 795 X-ray Chest 71020 Radiology $280 $ 115 142 of Charge 150 $ 25 of Charge 65 $ 182 of Charge 60 $ 168 of Charge 70 $ 196 of Charge 70 $ 196 RBRVS Fee (150) $ 2534 $ 25 of Charge 70 $ 196 RBRVS Fee (150) $ 2534 $ 25 RBRVS Fee (150) $ 2534 $ 25 Screening mammography G0202 Radiology $279 $ 141 98 Fixed Rate $ 128 Fixed Rate $ 13100 $ 131 Fixed Rate $ 14300 $ 143 Fixed Rate $ 16100 $ 161 of Charge 70 $ 195 Fixed Rate $ 13300 $ 133 Fixed Rate $ 13500 $ 135 Fixed Rate $ 13000 $ 130 Fixed Rate $ 11200 $ 112 Mammo Computer Aided 77052 Radiology $75 $ 112 -33 Fixed Rate $ 9 Fixed Rate $ 13100 $ 131 Fixed Rate $ 14300 $ 143 Fixed Rate $ 16100 $ 161 of Charge 70 $ 53 Fixed Rate $ 13300 $ 133 Fixed Rate $ 13500 $ 135 Fixed Rate $ 13000 $ 130 Fixed Rate $ 11200 $ 112 US Abdomen Complete 76700 Radiology $917 $ 397 131 of Charge 150 $ 125 of Charge 65 $ 596 of Charge 60 $ 550 of Charge 70 $ 642 of Charge 70 $ 642 RBRVS Fee (150) $ 12519 $ 125 of Charge 70 $ 642 RBRVS Fee (150) $ 12519 $ 125 RBRVS Fee (150) $ 12519 $ 125 Officeoutpatient visit new pt 30 min (TEC) 99203 EampM $316 $ 248 28 of Charge 70 $ 221 of Charge 65 $ 205 of Charge 60 $ 190 of Charge 70 $ 221 of Charge 70 $ 221 of charge 100 $ 316 of Charge 70 $ 221 of charge 100 $ 316 of charge 100 $ 316 Vaginal delivery 59409 Surg $14484 $ 7290 99 Fixed Rate DRG - 775 $ 5437 2 Day Case Rate + LOC 561700 $ 5617 BaseCMS Weight 584741 $ 5847 BaseCMS Weight 726146 $ 7261 No IP Terms $ - 0 No IP BaseCMS Weight 659343 $ 6593 BaseContract Weight 479451 100 $ 14484 BaseCMS Weight 579110 $ 5791 Lap Sleeve Gastrectomy 43775 Surg $29961 $ 20421 47 Fixed Rate DRG - 621 $ 14872 BaseCMS Weight 1810697 $ 18107 BaseCMS Weight 1835178 $ 18352 BaseCMS Weight 2278911 $ 22789 No IP Terms $ - 0 No IP BaseCMS Weight 2069315 $ 20693 BaseCMS Weight 1730442 100 $ 29961 BaseCMS Weight 1817507 $ 18175 105 Colonoscopy and biopsy (ASC ONLY) Surg $ 219200 $ 2181 Diagnostic colonoscopy (ASC ONLY) Surg $ 267100 $ 2348 Upper gi endoscopy biopsy (ASC ONLY) Surg $ 207500 $ 2758 Knee Arthroscopy (ASC ONLY) Surg $ 417900 $ 3467 Arthroscopy Ligament Repair (ASC ONLY) Surg $ 504800 $ 3386
Cpt Code CPT Description Procedure Category Claims Min 25thNtile 50thNtile Emorys Rates 75thNtile 90thNtile Max 20 Below 50th Ntile 20 Above 50th Ntile 93017 CARDIOVASCULAR STRESS TEST 5 82 $80 $125 $321 $382 $568 $791 $930 $257 $386 71020 CHEST X-RAY 2 2638 $11 $45 $152 $115 $289 $373 $585 $122 $182 71020 CHEST X-RAY 5 8106 $25 $34 $38 $54 $57 $69 $30 $46 45380 COLONOSCOPY AND BIOPSY 6 1256 $541 $560 $572 $2877 $1000 $2024 $3289 $458 $686 77052 COMP SCREEN MAMMOGRAM ADD-ON 2 194 $13 $15 $25 $38 $47 $134 $20 $30 77052 COMP SCREEN MAMMOGRAM ADD-ON 5 2411 $13 $16 $20 $23 $26 $28 $16 $24 80053 COMPREHEN METABOLIC PANEL 8 13019 $9 $19 $23 $55 $24 $25 $69 $19 $28 71250 CT THORAX WO DYE 2 302 $165 $372 $545 $878 $1658 $2067 $436 $654 71250 CT THORAX WO DYE 5 209 $53 $127 $203 $289 $419 $534 $162 $244 45378 DIAGNOSTIC COLONOSCOPY 6 1479 $484 $515 $536 $2914 $831 $1971 $2828 $428 $643 29881 KNEE ARTHROSCOPYSURGERY 6 152 $1650 $1826 $2036 $5235 $3054 $4216 $6461 $1629 $2443 29888 KNEE ARTHROSCOPYSURGERY 6 82 $1682 $3615 $5081 $5145 $7553 $12924 $18532 $4065 $6097 43644 LAP GASTRIC BYPASSROUX-EN-Y 1 21 $11821 $13873 $17050 $18391 $25029 $31079 $13640 $20460 43775 LAP SLEEVE GASTRECTOMY 1 38 $4215 $8250 $13253 $20421 $19197 $21509 $24260 $10602 $15903 74183 MRI ABDOMEN WO amp WDYE 2 120 $919 $987 $1015 $1237 $1252 $2534 $3177 $812 $1218 74183 MRI ABDOMEN WO amp WDYE 5 112 $475 $490 $521 $1154 $1337 $1696 $417 $625 70553 MRI BRAIN WO amp WDYE 2 324 $633 $987 $1142 $1237 $1706 $2805 $3331 $914 $1370 70553 MRI BRAIN WO amp WDYE 5 467 $280 $539 $1023 $1277 $1363 $1726 $818 $1228 73721 MRI JNT OF LWR EXTRE WO DYE 2 304 $804 $859 $967 $1237 $1063 $1598 $2485 $774 $1160 73721 MRI JNT OF LWR EXTRE WO DYE 5 1130 $500 $520 $530 $628 $679 $859 $424 $636 59400 OBSTETRICAL CARE 1 494 $3699 $4402 $4969 $6655 $7307 $8613 $3975 $5963 99203 OFFICEOUTPATIENT VISIT NEW 4 6776 $88 $101 $112 $138 $155 $169 $90 $134 G0202 Screeningmammographydigital 2 7444 $123 $206 $285 $380 $425 $479 $228 $342 G0202 Screeningmammographydigital 5 2754 $117 $165 $195 $230 $247 $252 $156 $234 88305 TISSUE EXAM BY PATHOLOGIST 8 20834 $51 $74 $112 $235 $168 $261 $478 $90 $134 93306 TTE WDOPPLER COMPLETE 2 931 $194 $377 $739 $960 $1267 $1480 $1849 $591 $887 93306 TTE WDOPPLER COMPLETE 5 2299 $151 $296 $373 $538 $573 $834 $298 $448 43239 UPPER GI ENDOSCOPY BIOPSY 6 1264 $424 $514 $550 $800 $1838 $2833 $440 $660 76700 US EXAM ABDOM COMPLETE 2 321 $96 $165 $271 $509 $584 $857 $217 $325 76700 US EXAM ABDOM COMPLETE 5 444 $111 $129 $147 $156 $220 $279 $118 $176 Key 1 Facility - Inpatient 2 Facility - Imaging 3 Physician - Imaging 4 Physician 5 Global - Imaging 6 Facility - Outpatient 8 Lab 41 Physician - Primary Care 42 Physician - Specialist Cardiovascular stress test $ 38279 TTE wDoppler complete $ 96037 Colonoscopy and biopsy $ 287709 Diagnostic colonoscopy $ 291434 Upper gi endoscopy biopsy $ 300526 Knee Arthroscopy $ 523584 Arthroscopy Ligament Repair $ 514501 Comp Metabolic Panel $ 5552 Surgical Path Tissue Exam $ 23570 MRI Abdomen $ 123786 MRI Brain $ 123786 MRI Joint Lower Extremity $ 123786 CT Thorax wo contrast $ 88213 X-ray Chest $ 11548 Screening mammography $ 14098 Mammo Computer Aided $ 11179 US Abdomen Complete $ 39695 Officeoutpatient visit new pt 30 min $ 24753 Vaginal delivery $ 729025 Lap Sleeve Gastrectomy $ 2042124
Page 15
Case Study 1
Case study 1 ndash Pop Health Approach bull ProblemCircumstance Large multi-employer group needs to
evaluate benefit design disease prevalence health spend and utilization to manage their population
bull ConsiderationsValue Prop Unique industry and geography drive chronic conditions and utilization patterns
bull Solution Provide opportunity assessment comparing this population to other benchmarks to understand where to target intervention and management as well as assess efforts already taken
15
Market Comparison Preference Sensitive Procedures
16
Legend vs
Mt States vs
National gt120 gt110
110-120 105-110 lt80 lt90
Source Multi-payer commercial benchmark Results are weighted by AgeGender Broader market area includes multi-payer data from the mountain regions
Preference Sensitive Procedures Benchmark Comparison
Dartmouth Atlas Preference Sensitive Procedures
IP allowed dollars ALOS Employer vs
Mt States Employer
vs National FY 2017 FY 2018 FY 2017 FY 2018
Hysterectomy for Uterine Fibroids Rate $569354 $436932 45 54 124 140 CABG Rate $1800260 $2400608 53 60 218 130 Cholycystectomy Rate $832675 $755565 68 39 92 120 C-Section Rate 116 110 HighTech Radiology Rate 103 101 PCIPTCA Rate $934486 $1133708 37 55 82 80 Back Surgery Rate $3237613 $4003212 39 57 52 70 Knee Replacement Rate $3086693 $2177334 41 48 50 64 Total Hip Replacement Rate $1023675 $747491 45 64 37 34
Strengths (+)
Employer compares favorably for orthopedic procedures (back hip knee)
Opportunity (-)
Employer has higher than expected rates for CABG and hysterectomy (Note Low PTCA rate combined with high CABG rate may suggest provider practice patterns favoring CABG)
0 50 100 150 200 250
Total Hip Replacement
Knee Replacement
Back Surgery
PCIPTCA
Cholycystectomy
HighTech Radiology
C-Section
CABG
Culinary VsNational
Culinary Vs MtStates
Employer vs Mt States
Employer vs National
Market Comparison Condition Prevalence
17 Source Multi-payer commercial benchmark Results are weighted by AgeGender Broader market area includes multi-payer data from the mountain regions
Condition Prevalence Benchmark Comparison
Condition Employer vs
Mt States Employer vs
National Prevalence Diabetes Rate 229 219 Prevalence Hyperlipidemia Rate 259 207 Prevalence Kidney Disease Rate 143 174 Prevalence Migraine Rate 166 164 Prevalence Low Back Pain Rate 136 139 Prevalence Hypertension Rate 156 134 Prevalence Asthma Rate 146 128 Prevalence CAD Rate 175 115 Prevalence Pregnancy Rate 110 109 Prevalence Adult Preventive Screening Rate 114 91 Prevalence Depression Rate 63 60
Strengths (+)
Rate of depression is low (Note May be due to incomplete behavioral health claims)
Opportunity (-)
Employer has a higher prevalence of most chronic conditions including asthma CAD diabetes hypertension hyperlipidemia Kidney Disease LBP and migraines
0
100
200
300Hyperlipidemia
Diabetes
CAD
Migraine
Hypertension
AsthmaKidney Disease
Low Back Pain
Pregnancy
Depression
Employer vsMt States
Employer vsNational Legend
vs Mt States
vs National
gt120 gt110 110-120 105-110
lt80 lt90
Market Comparison Utilization Rates
18
A higher preventive office visit rate is better Source Multi-payer commercial benchmark Results are weighted by AgeGender Broader market area includes multi-payer data from the mountain regions
Strengths (+)
Lower than average utilization of ED and high dollar patient rate
Opportunity (-)
Higher LOS lengthy admits avoidable admits and readmissions which all drive significantly more spend
Utilization Benchmark Comparison
Condition Employer vs
Mt States Employer vs
National Avoidable Admit Rate 142 144 Lengthy Admit Rate 175 136 Outpatient Problem Focused Office Rate 146 131 Readmission Rate (readmitadmit) 135 126 Average LOS 125 116 One Day Admit Rate 76 103 Office Visit Rate 106 96 Acute Admit Rate 80 95 Avoidable ED Rate 68 86 ED Rate 54 69 Preventive Office Rate 95 68 High Dollar Patient Rate 49 51 Frequent ED User (gt3 times) Rate 24 36
Legend vs
Mt States vs
National gt120 gt110
110-120 105-110 lt80 lt90
0 50 100 150 200
Frequent ED User (gt3 times)
High Dollar Patient
Preventive Office
ED
Avoidable ED
Acute Admit
Office Visit
One Day Admit
Average LOS
Readmissionhellip
Outpt Problem Focusedhellip
Lengthy Admit
Avoidable Admit
Employer vsNational
Employer vsMt States
ED and Avoidable ED
19
Potentially Avoidable ED - Trend View Overall ED
Period Change FY 2017 FY 2018 Count Rate
Measure Mbrs Rate Mbrs Rate Overall ED 16394 12626 13820 10745 -16 -15 FREQUENT ED UTILIZER (mbr1k) 1581 1218 1468 1141 -7 -6 AVOIDABLE ED 6371 4907 5288 4111 -17 -16 Potentially Avoidable ED
Period Change FY 2017 FY 2018 Count Rate
Avoid ED Condition Mbrs Rate Mbrs Rate ABDOMINAL_PAIN 1092 841 895 696 -18 -17 ENT_INFECTION 854 658 742 577 -13 -12 FEVER 715 551 700 544 -2 -1 URINARY 650 501 468 364 -28 -27 HEADACHE 558 430 434 337 -22 -21 BACK_PAIN 414 319 423 329 2 3 NAUSEA 394 303 271 211 -31 -31 ASTHMA 294 226 209 162 -29 -28 CELLULITIS 210 162 198 154 -6 -5 GASTROENTERITIS 254 196 171 133 -33 -32 OTITIS_MEDIA 201 155 160 124 -20 -20 COPD 132 102 108 084 -18 -17 DIABETES 123 095 91 071 -26 -25 BACT_PNEUMONIA 111 085 86 067 -23 -22 DENTAL 93 072 83 065 -11 -10 DEHYDRATION 98 075 81 063 -17 -17 HYPERTENSION 16 012 24 019 50 51 CHF 4 003 3 002 -25 -24 ANGINA 8 006 3 002 -63 -62 IMMUNIZATION_RELATED 2 002 0 000 -100 -100 Grand Total 6371 4907 5288 4111 -17 -16
AHRQ avoidable ED visits are based on the logic for ambulatory care sensitive ED visits from AHRQ and diagnosis code driven
696
577
544 364
337
329
211 162
154 133 ABDOMINAL_PAIN
ENT_INFECTION
FEVER
URINARY
HEADACHE
BACK_PAIN
NAUSEA
- 200 400 600 800
1000 1200
2017 Members 2018 Members
Top Ten 2018 Conditions by Rate
Top Ten Conditions by Member Count
ED Avoidable ED and the impact of new on-site clinic
20
0
1000
2000
3000
4000
5000
6000
0200400600800
10001200140016001800
Clinic Visits ED Visits
Avoidable ED VisitsED Visits (non-avoidable)Clinic EampM Visits
0
500000
1000000
1500000
2000000
2500000
3000000
3500000
$s
Clinic EampM Profess DollarsAvoidable ED Dollars
bull Clinic visits have a clear impact on ED and avoidable ED use and spend
bull Combined ED visits are down on average 157 in FY 18 from FY 17
bull Combined ED spend is down 128 in FY 18 from FY 17
Clinic Live 62017
Pitfalls and Challenges bull Face many of the challenges similar to startup health
plan bull Critical to determine how you will deliver value and
communicate the value to potential customers and brokersconsultants
bull Care management bull Network
21
Considerations in Offering Development bull Care Management Model
bull Traditional care model bull Case management bull Utilization management bull Disease management
bull Longitudinal care model with value based care philosophy bull Primary care driven bull Local care management
bull Predictive analytics and risk stratification model bull Claims history and ongoing data bull EMR data
22
Case Study 2
Case study 2 ndash Large Employer bull Business Problem Large employer wants to contract
directly with 2 major hospital systems developing professional fee schedules
bull ConsiderationsValue Prop Fee schedule should be competitive but also nuanced to minimize gap relative to current reimbursement at physician level
bull Solution Data-driven approach using current market-wide reimbursement distinguished by service level
24
Evaluate Provider Spend Top 25 Service Lines by Allowable Spend
Evaluate Provider Spend Top 20 Professional CPTs by Total Spend
Understand relative market pricing position
27
21
-1
-28
14 10
28
-22
-11 -13
24
3
20 21
8
-20
13
3 9
-39
56
-26
4
-42
60
MRI Colonoscopy Cardiac Cath Lab - OrganPanel
Memorial Hospital Beta Hospital Delta Hospital Charlie Hospital Echo Hospital Alpha Medical Center
ndash25 5 -15 10 0 39
State Charges as a Percent of Peer Average Weighted Averages for MRI Colonoscopy Cardiology and Lab
Total Percent Above Below Market Average2
Memorial Hospital Beta Hospital Delta Hospital Charlie Hospital Echo Hospital Alpha Medical Center
Develop fee schedule relative to market
28
Service Line Procedure CPT CodeDRG
Memorial Hospital
Beta Hosptial
Charlie Hospital
Delta Hospital
Echo Hospital
Alpha Medical Center
Arthroscopy Ligament Repair 29888 $ 5062 $ 9557 $ 5983 $ 10096 $ 7519 $ 2502 Knee Arthroscopy 29881 $ 5069 $ 4185 $ 3837 $ 3022 $ 3729 $ 2266 Upper GI Endoscopy 43239 $ 3075 $ 2539 $ 2012 $ 1132 $ 1565 $ 2240 Lap Sleeve Gastrectomy DRG 621 $ 20421 $ 20815 $ 12105 $ 13230 $ 14600 $ 17800 Colonoscopy and biopsy 45380 $ 3075 $ 3071 $ 2013 $ 1244 $ 1972 $ 859 Diagnostic Colonoscopy 45378 $ 3075 $ 2805 $ 2013 $ 1244 $ 1972 $ 859 MRI Brain w amp wo dye 70553 $ 1238 $ 1468 $ 1117 $ 967 $ 2805 $ 1052 MRI Joint of Lower Extremity wo dye 73721 $ 1238 $ 1398 $ 1042 $ 967 $ 925 $ 557 MRI Abdomen w amp wo dye 74183 $ 1238 $ 1468 $ 1106 $ 967 $ 2805 $ 836 X-ray Chest 71020 $ 115 $ 266 $ 305 $ 279 $ 375 $ 72 CT Thorax wo dye 71250 $ 882 $ 810 $ 505 $ 491 $ 579 $ 319 Ultrasound Abdomen Complete 76700 $ 397 $ 538 $ 545 $ 195 $ 190 $ 168 Mammogram Screening G0202 $ 141 $ 328 $ 431 $ 294 $ 425 $ 168 Computer Detection Add-on 77052 $ 112 $ 99 $ 41 $ 15 $ 45 $ 23 Comp Metabolic Panel 80053 $ 56 $ 15 $ 24 $ 56 $ 51 $ 25 Tissue Exam by Pathologist 88305 $ 236 $ 307 $ 80 $ 152 $ 78 $ 232 Cardiovascular Stress Test 93017 $ 383 $ 432 $ 1299 $ 907 $ 717 $ 797 TTE w Doppler 93306 $ 960 $ 1566 $ 1388 $ 1173 $ 1125 $ 1157
Obstetrics Vaginal Delivery DRG 755 7290$ 5730$ 4654$ 4607$ 5855$ 4688$
GI
Lab
Radiology
Medical Cardiology
Orthopedics
KEY OBSERVA TIONS bull Potential exposure on GI bull Opportunity to align price and acuity in MRI bull Opportunity to raise rates on chest x-ray and mammogram
Percentile Bands Emory Allowables Heatmap TEC ASC Heatmap Allowable Comp Analysis Portal Pricing Sheet1 image1png A few words on Bundled Payments bull Bundled payments are growing as a type of direct contracting bull In some cases third parties match-make between employers
and providers bull Contracts may vary in definitions prepost admission
coverage duration readmission cause (ie all-cause vs medically related) outlier provisions LOS caps andor per diems
bull Providers need to be strategic in pricing to enable profitable growth of market share
29
Considerations in Offering Development bull Network Development
bull Build off existing structure eg health system employee plan network bull How does this fit into your broader value based care strategy bull Employed and independent physicians bull How do you want to approach the buildout of high performance
network bull Quality focus bull Cost efficiency
bull Integrated behavioral health bull Wrap network for other markets
30
Considerations in Offering Development bull Target Market
bull Consideration of employer profile in market bull Fully-insured vs ASO bull Total cost of care vs bundled services
bull Distribution bull Direct marketing bull Brokerconsultant community
bull Plan designs bull Standard designs vs flexible ndash Dependent on target market
bull Claims administration bull Data sharing amp analytics
31
Considerations in Offering Development bull Other components of comprehensive offering
bull Pharmacy bull Preventive health bull Onsite clinics bull Wellness programs bull Technology platform
32
Sample Bundle Analysis
33
Cover page Dotson Hazelrigs Nation Mainly of charge of fixed Cardiovascular stress test TTE wDoppler complete Colonoscopy and biopsy (Combined) Diagnostic colonoscopy (Combined) Upper gi endoscopy biopsy (Combined) Knee Arthroscopy (Combined) Arthroscopy Ligament Repair Comp Metabolic Panel Surgical Path Tissue Exam MRI Abdomen MRI Brain MRI Joint Lower Extremity CT Thorax wo contrast X-ray Chest Screening mammography Mammo Computer Aided US Abdomen Complete Officeoutpatient visit new pt 30 min Vaginal delivery Lap Sleeve Gastrectomy
Piedmont Piedmont Piedmont Piedmont Northside Northside Northside Northside Gwinnett Gwinnett Gwinnett Gwinnett WellStar WellStar WellStar WellStar AMC - Tenet AMC - Tenet AMC - Tenet AMC - Tenet CPT Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing 29881 $11312 $10872 NA NA $7476 $9338 NA $23655 $11856 $3668 NA $17871 $12253 NA NA $15645 $5490 NA NA $23039 29888 NA NA NA NA NA NA NA $23784 NA $8261 NA $18000 NA NA NA $15774 NA NA NA $23168 43239 NA $4408 NA NA NA NA $5997 $8852 NA $3304 NA $7424 $1267 NA NA $9230 NA $2458 NA $8274 43644 $26468 NA NA NA $3382 $12050 NA $1861 NA NA NA $1316 $7841 NA NA $3444 $18892 $27950 NA $979 43775 NA NA NA NA NA NA NA $352 NA NA NA $302 NA NA NA $413 NA NA NA $83 45378 $2705 $2530 NA NA $4381 $3676 $4496 $1022 $2938 $2138 NA $695 $5504 NA NA $2036 NA NA NA $372 45380 $3075 $2600 NA NA $4723 $3527 $3012 $1757 $4215 $2285 NA NA $5298 NA NA $3268 NA NA NA $627 59400 $6160 NA NA NA NA $5100 NA $1851 NA NA NA $1304 $9035 NA NA $3427 $9116 $5150 NA $966 70553 $2985 NA $1153 NA $2182 NA $1192 $492 NA NA $803 $489 $1512 NA $985 $1187 NA NA NA $197 71020 $61 $69 $43 NA $113 $319 $307 NA $183 $59 $32 NA $213 $66 $40 NA $83 $53 NA NA 71250 $1837 $621 $989 NA $1490 $931 $755 NA NA $745 $401 NA $1067 $982 $616 NA NA $304 NA NA 73721 NA $1098 $1153 NA $2042 $1065 $1192 NA NA $998 $803 NA NA $1275 $985 NA NA $644 NA $178 74183 $2971 $1144 NA NA NA $1092 $1192 $6884 NA $1098 $803 NA $2960 $1197 $985 $5454 NA NA NA $7607 76700 $364 $247 $207 NA $427 $708 $614 $13267 $428 $214 $152 NA $747 $263 $189 $9139 NA $235 NA NA 77052 NA NA NA NA NA NA NA $4744 NA NA NA NA NA NA NA $3070 NA NA NA $5611 93306 $1220 $1117 NA NA $1877 $1657 $2100 $4605 $1433 $413 $945 NA $1336 $1434 $1951 $2931 NA $2399 NA $5472 G0202 $262 $187 NA NA $431 NA NA $4605 $292 NA NA NA $530 $281 NA $2931 $327 NA NA $5472
Provider Group 29881_6 29888_6 43239_6 43644_1 43775_1 45378_6 45380_6 59400_1 70553_2 71020_2 71250_2 73721_2 74183_2 76700_2 77052_2 77052_5 80053_8 88305_8 93306_2 99203_4 G0202_2 G0202_5 93017_2 Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Atlanta Gastroenterology Associates $2399 $536 348 $1628 $536 204 $2400 $536 348 Atlanta Medical Center $24889 $2266 999 $25897 $2502 935 $11449 $2240 411 $81927 $15300 435 $75815 $17800 326 $7317 $859 752 $7317 $859 752 $12821 $4688 173 $6581 $1052 526 $645 $72 796 $3265 $319 925 $3450 $557 519 $7398 $836 785 $1576 $133 1084 $73 $23 217 $635 $25 2440 $891 $232 285 $2967 $1157 156 $344 $168 105 $1265 $797 59 Atlanta Womens Health Physicians Group $29 $14 107 $40 $13 208 $396 $188 111 $278 $118 135 $450 $231 95 Gwinnett Hospital $11941 $3022 295 $21654 $10096 114 $3551 $1132 214 $34384 $10800 218 $56472 $13230 327 $3003 $1244 141 $3533 $1244 184 $8984 $4607 95 $3901 $967 303 $417 $279 49 $2247 $491 358 $4000 $967 314 $3755 $967 288 $1593 $195 717 $50 $15 233 $186 $56 233 $505 $152 233 $1750 $1173 49 $418 $294 42 $1396 $907 54 Northside Hospital $15482 $4185 270 $21651 $9557 127 $4885 $2539 92 $35176 $17000 107 $35233 $20815 69 $3883 $2805 38 $5256 $3071 71 $10911 $5730 90 $4856 $1468 231 $443 $266 67 $2379 $810 194 $3776 $1398 170 $5105 $1468 248 $942 $538 75 $167 $99 69 $379 $15 2427 $433 $307 41 $2252 $1566 44 $459 $328 40 $576 $432 33 Piedmont Hospital $14772 $3837 285 $35493 $5983 493 $5069 $2012 152 $38320 $17750 116 $37125 $12105 207 $3485 $2013 73 $4993 $2013 148 $10143 $4654 118 $5939 $1117 432 $542 $305 78 $2983 $505 491 $3410 $1042 227 $6067 $1106 449 $1364 $545 150 $75 $41 85 $231 $24 863 $657 $80 721 $2041 $1388 47 $490 $431 14 $1780 $1299 37 Piedmont Physicians Group $42 $22 87 $318 $179 78 $239 $159 50 Resurgens $8558 $2036 320 $9293 $2258 312 $4638 $2067 124 $4039 $2164 87 $4392 $2164 103 $2252 $1371 64 $459 $330 39 Wellstar Hospital $9330 $3729 150 $17479 $7519 132 $5261 $1565 236 $35794 $18200 97 $46780 $14600 220 $3707 $1972 88 $4928 $1972 150 $13549 $5855 131 $5054 $2805 80 $528 $375 41 $3222 $579 457 $3694 $925 299 $5495 $2805 96 $1355 $190 615 $66 $45 46 $73 $51 43 $133 $78 71 $1785 $1125 59 $599 $425 41 $1010 $717 41 Avg Mark UpProcedure Atlanta Medical Center 634 Gwinnett Hospital 223 Northside Hospital 233 Piedmont Hospital 259 Wellstar Hospital 155 Emory 105
Atlanta Gastroenterology Associates Atlanta Medical Center Atlanta Womens Health Gwinnett Hospital Northside Hospital Piedmont Hospital Piedmont Physicians Group Resurgens Wellstar Hospital CPT Code CPT Proc Cat Comp Avg Allow Allow Allow Allow Allow Allow Allow Allow Allow 29881 KNEE ARTHROSCOPYSURGERY 6 $3179 $2266 $3022 $4185 $3837 $2036 $3729 29888 KNEE ARTHROSCOPYSURGERY 6 $6319 $2502 $10096 $9557 $5983 $2258 $7519 43239 UPPER GI ENDOSCOPY BIOPSY 6 $1727 $536 $2240 $1132 $2539 $2012 $2067 $1565 43644 LAP GASTRIC BYPASSROUX-EN-Y 1 $15810 $15300 $10800 $17000 $17750 $18200 43775 LAP SLEEVE GASTRECTOMY 1 $17800 $13230 $20815 $12105 $14600 45378 DIAGNOSTIC COLONOSCOPY 6 $1656 $536 $859 $1244 $2805 $2013 $2164 $1972 45380 COLONOSCOPY AND BIOPSY 6 $1694 $536 $859 $1244 $3071 $2013 $2164 $1972 59400 OBSTETRICAL CARE 1 $5107 $4688 $4607 $5730 $4654 $5855 70553 MRI BRAIN WO amp WDYE 2 $1482 $1052 $967 $1468 $1117 $2805 71020 CHEST X-RAY 2 $259 $72 $279 $266 $305 $375 71250 CT THORAX WO DYE 2 $541 $319 $491 $810 $505 $579 73721 MRI JNT OF LWR EXTRE WO DYE 2 $978 $557 $967 $1398 $1042 $925 74183 MRI ABDOMEN WO amp WDYE 2 $1436 $836 $967 $1468 $1106 $2805 76700 US EXAM ABDOM COMPLETE 2 $320 $133 $195 $538 $545 $190 77052 COMP SCREEN MAMMOGRAM ADD-ON 2 $45 $23 $15 $99 $41 $45 77052 COMP SCREEN MAMMOGRAM ADD-ON 5 $14 $14 80053 COMPREHEN METABOLIC PANEL 8 $29 $25 $13 $56 $15 $24 $22 $51 88305 TISSUE EXAM BY PATHOLOGIST 8 $174 $232 $188 $152 $307 $80 $179 $78 93306 TTE WDOPPLER COMPLETE 2 $1297 $1157 $1173 $1566 $1388 $1371 $1125 93017 STRESS TEST 5 $830 $797 $907 $432 $1299 $717 99203 OFFICEOUTPATIENT VISIT NEW 4 $139 $118 $159 G0202 Screeningmammographydigital 2 $329 $168 $294 $328 $431 $330 $425 G0202 Screeningmammographydigital 5 $231 $231
Service Line Procedure CPT Code Emory Atlanta Gastroenterology Associates Resurgens Atlanta Womens Health Piedmont Physicians Group Orthopedics (ASC) Knee Arthroscopy 29881 $3467 $2036 Arthroscopy Ligament Repair 29888 $3386 $2258 GI (ASC) Upper GI Endoscopy 43239 $2758 $536 Diagnostic Colonoscopy 45378 $2348 $536 Colonoscopy and biopsy 45380 $2181 $536 Radiology Mammogram Screening G0202 $164 $231 Computer Detection Add-on 77052 $93 $14 Lab Comp Metabolic Panel 80053 $53 $13 $22 Tissue Exam by Pathologist 88305 $277 $188 $179 EampM (TEC) Office Visit new pt 99203 $269 $118 $159
Service Line Procedure CPT CodeDRG Memorial Hospital Beta Hosptial Charlie Hospital Delta Hospital Echo Hospital Alpha Medical Center Atlanta Gastroenterology Associates Resurgens Atlanta Womens Health Piedmont Physicians Group Market Avg Emory abovebelow Orthopedics Arthroscopy Ligament Repair 29888 $ 5062 $ 9557 $ 5983 $ 10096 $ 7519 $ 2502 $ 2258 $ 6319 -20 Knee Arthroscopy 29881 6 $ 5069 $ 4185 $ 3837 $ 3022 $ 3729 $ 2266 $ 2036 $ 3179 59 GI Upper GI Endoscopy 43239 6 $ 3075 $ 2539 $ 2012 $ 1132 $ 1565 $ 2240 $ 536 $ 1671 84 Lap Sleeve Gastrectomy DRG 621 $ 20421 $ 20815 $ 12105 $ 13230 $ 14600 $ 17800 $ 15710 30 Colonoscopy and biopsy 45380 $ 3075 $ 3071 $ 2013 $ 1244 $ 1972 $ 859 $ 536 $ 1616 90 Diagnostic Colonoscopy 45378 6 $ 3075 $ 2805 $ 2013 $ 1244 $ 1972 $ 859 $ 536 $ 1572 96 Radiology MRI Brain w amp wo dye 70553 2 $ 1238 $ 1468 $ 1117 $ 967 $ 2805 $ 1052 $ 1482 -16 MRI Joint of Lower Extremity wo dye 73721 2 $ 1238 $ 1398 $ 1042 $ 967 $ 925 $ 557 $ 978 27 MRI Abdomen w amp wo dye 74183 2 $ 1238 $ 1468 $ 1106 $ 967 $ 2805 $ 836 $ 1436 -14 X-ray Chest 71020 $ 115 $ 266 $ 305 $ 279 $ 375 $ 72 $ 259 -56 CT Thorax wo dye 71250 $ 882 $ 810 $ 505 $ 491 $ 579 $ 319 $ 541 63 Ultrasound Abdomen Complete 76700 $ 397 $ 538 $ 545 $ 195 $ 190 $ 168 $ 327 21 Mammogram Screening G0202 2 $ 141 $ 328 $ 431 $ 294 $ 425 $ 168 $ 231 $ 313 -55 Computer Detection Add-on 77052 2 $ 112 $ 99 $ 41 $ 15 $ 45 $ 23 $ 14 $ 39 183 Lab Comp Metabolic Panel 80053 8 $ 56 $ 15 $ 24 $ 56 $ 51 $ 25 $ 13 $ 22 $ 29 88 Tissue Exam by Pathologist 88305 8 $ 236 $ 307 $ 80 $ 152 $ 78 $ 232 $ 188 $ 179 $ 174 36 Medical Cardiology Cardiovascular Stress Test 93017 $ 383 $ 432 $ 1299 $ 907 $ 717 $ 797 $ 830 -54 TTE w Doppler 93306 2 $ 960 $ 1566 $ 1388 $ 1173 $ 1125 $ 1157 $ 1282 -25 Obstetrics Vaginal Delivery DRG 755 $ 7290 $ 5730 $ 4654 $ 4607 $ 5855 $ 4688 $ 5107 43 EampM Office Visit new pt 99203 4 $ 248 $ 118 $ 159 $ 139 78 Colonoscopy and biopsy (HOSPITAL ONLY) 45380 Surg 2530 $ 307591 Diagnostic colonoscopy (HOSPITAL ONLY) 45378 Surg 2255 $ 307591 Upper gi endoscopy biopsy (HOSPITAL ONLY) 43239 Surg 1787 $ 307591 Knee Arthroscopy (HOSPITAL ONLY) 29881 Surg 10900 $ 506893 Arthroscopy Ligament Repair (HOSPITAL ONLY) 29888 Surg 10900 $ 506200 Key 1 Facility - Inpatient 2 Facility - Imaging 3 Physician - Imaging 4 Physician 5 Global - Imaging 6 Facility - Outpatient 8 Lab 41 Physician - Primary Care 42 Physician - Specialist
Blue Cross United - EJCH EUH EUHM WW United - SJH Non Options United - SJH Options Aetna - ASC TEC (HMO) Cigna - ASC TEC (HMO) Aetna - EJCH ESJH ECHM WW Cigna - EJCH (HMO) Cigna - ESJH EUHM (HMO) List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract Description CPT Code Charge Average Final Price (all plans) Emory Mark Up Reimbursement Method ( of charge or fixed) - 1713 Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Cardiovascular stress test 93017 Cardio $543 $ 425 28 of Charge 70 $ 380 of Charge 65 $ 353 of Charge 60 $ 326 of Charge 70 $ 380 of Charge 70 $ 380 of charge 100 $ 543 of Charge 70 $ 380 of charge 100 $ 543 of charge 100 $ 543 TTE wDoppler complete 93306 Cardio $1226 $ 960 28 of Charge 70 $ 858 of Charge 65 $ 797 of Charge 60 $ 736 of Charge 70 $ 858 of Charge 70 $ 858 of charge 100 $ 1226 of Charge 70 $ 858 of charge 100 $ 1226 of charge 100 $ 1226 Colonoscopy and biopsy (HOSPITAL ONLY) 45380 Surg $2530 $ 3076 -18 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 of Charge 70 $ 1771 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Diagnostic colonoscopy (HOSPITAL ONLY) 45378 Surg $2255 $ 3076 -27 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 of Charge 70 $ 1579 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Upper gi endoscopy biopsy (HOSPITAL ONLY) 43239 Surg $1787 $ 3076 -42 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Knee Arthroscopy (HOSPITAL ONLY) 29881 Surg $10900 $ 5069 115 Fixed Rate SC 4 $ 3865 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 449300 $ 4493 Fixed Rate $ 654700 $ 6547 of Charge 70 $ 7630 Fixed Rate $ 401000 $ 4010 of Charge 70 $ 7630 Fixed Rate $ 398300 $ 3983 Fixed Rate $ 398100 $ 3981 Arthroscopy Ligament Repair (HOSPITAL ONLY) 29888 Surg $10900 $ 5062 115 Fixed Rate SC 3 $ 3121 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 556900 $ 5569 Fixed Rate $ 770100 $ 7701 of Charge 70 $ 7630 Fixed Rate $ 323900 $ 3239 of Charge 70 $ 7630 Fixed Rate $ 321700 $ 3217 Fixed Rate $ 321400 $ 3214 Comp Metabolic Panel 80053 Lab $132 $ 56 138 RBRVS Fee (100) $ 1437 of Charge 65 $ 86 of Charge 65 $ 86 of Charge 65 $ 86 of Charge 70 $ 92 RBRVS Fee (100) $ 1437 $ 14 of Charge 70 $ 92 RBRVS Fee (100) $ 1437 $ 14 RBRVS Fee (100) $ 1437 $ 14 Surgical Path Tissue Exam 88305 Lab $326 $ 236 38 of Charge 150 $ 51 of Charge 65 $ 212 of Charge 65 $ 212 of Charge 65 $ 212 of Charge 70 $ 228 of charge 100 $ 326 of Charge 70 $ 228 of charge 100 $ 326 of charge 100 $ 326 MRI Abdomen 74183 Radiology $6960 $ 1238 462 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 MRI Brain 70553 Radiology $6804 $ 1238 450 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 MRI Joint Lower Extremity 73721 Radiology $3067 $ 1238 148 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 CT Thorax wo contrast 71250 Radiology $2199 $ 882 149 Fixed Rate $ 771 Fixed Rate $ 47100 $ 471 Fixed Rate $ 81700 $ 817 Fixed Rate $ 116000 $ 1160 of Charge 70 $ 1539 Fixed Rate $ 80100 $ 801 Fixed Rate $ 79200 $ 792 Fixed Rate $ 79300 $ 793 Fixed Rate $ 79500 $ 795 X-ray Chest 71020 Radiology $280 $ 115 142 of Charge 150 $ 25 of Charge 65 $ 182 of Charge 60 $ 168 of Charge 70 $ 196 of Charge 70 $ 196 RBRVS Fee (150) $ 2534 $ 25 of Charge 70 $ 196 RBRVS Fee (150) $ 2534 $ 25 RBRVS Fee (150) $ 2534 $ 25 Screening mammography G0202 Radiology $279 $ 141 98 Fixed Rate $ 128 Fixed Rate $ 13100 $ 131 Fixed Rate $ 14300 $ 143 Fixed Rate $ 16100 $ 161 of Charge 70 $ 195 Fixed Rate $ 13300 $ 133 Fixed Rate $ 13500 $ 135 Fixed Rate $ 13000 $ 130 Fixed Rate $ 11200 $ 112 Mammo Computer Aided 77052 Radiology $75 $ 112 -33 Fixed Rate $ 9 Fixed Rate $ 13100 $ 131 Fixed Rate $ 14300 $ 143 Fixed Rate $ 16100 $ 161 of Charge 70 $ 53 Fixed Rate $ 13300 $ 133 Fixed Rate $ 13500 $ 135 Fixed Rate $ 13000 $ 130 Fixed Rate $ 11200 $ 112 US Abdomen Complete 76700 Radiology $917 $ 397 131 of Charge 150 $ 125 of Charge 65 $ 596 of Charge 60 $ 550 of Charge 70 $ 642 of Charge 70 $ 642 RBRVS Fee (150) $ 12519 $ 125 of Charge 70 $ 642 RBRVS Fee (150) $ 12519 $ 125 RBRVS Fee (150) $ 12519 $ 125 Officeoutpatient visit new pt 30 min (TEC) 99203 EampM $316 $ 248 28 of Charge 70 $ 221 of Charge 65 $ 205 of Charge 60 $ 190 of Charge 70 $ 221 of Charge 70 $ 221 of charge 100 $ 316 of Charge 70 $ 221 of charge 100 $ 316 of charge 100 $ 316 Vaginal delivery 59409 Surg $14484 $ 7290 99 Fixed Rate DRG - 775 $ 5437 2 Day Case Rate + LOC 561700 $ 5617 BaseCMS Weight 584741 $ 5847 BaseCMS Weight 726146 $ 7261 No IP Terms $ - 0 No IP BaseCMS Weight 659343 $ 6593 BaseContract Weight 479451 100 $ 14484 BaseCMS Weight 579110 $ 5791 Lap Sleeve Gastrectomy 43775 Surg $29961 $ 20421 47 Fixed Rate DRG - 621 $ 14872 BaseCMS Weight 1810697 $ 18107 BaseCMS Weight 1835178 $ 18352 BaseCMS Weight 2278911 $ 22789 No IP Terms $ - 0 No IP BaseCMS Weight 2069315 $ 20693 BaseCMS Weight 1730442 100 $ 29961 BaseCMS Weight 1817507 $ 18175 105 Colonoscopy and biopsy (ASC ONLY) Surg $ 219200 $ 2181 Diagnostic colonoscopy (ASC ONLY) Surg $ 267100 $ 2348 Upper gi endoscopy biopsy (ASC ONLY) Surg $ 207500 $ 2758 Knee Arthroscopy (ASC ONLY) Surg $ 417900 $ 3467 Arthroscopy Ligament Repair (ASC ONLY) Surg $ 504800 $ 3386
Cpt Code CPT Description Procedure Category Claims Min 25thNtile 50thNtile Emorys Rates 75thNtile 90thNtile Max 20 Below 50th Ntile 20 Above 50th Ntile 93017 CARDIOVASCULAR STRESS TEST 5 82 $80 $125 $321 $382 $568 $791 $930 $257 $386 71020 CHEST X-RAY 2 2638 $11 $45 $152 $115 $289 $373 $585 $122 $182 71020 CHEST X-RAY 5 8106 $25 $34 $38 $54 $57 $69 $30 $46 45380 COLONOSCOPY AND BIOPSY 6 1256 $541 $560 $572 $2877 $1000 $2024 $3289 $458 $686 77052 COMP SCREEN MAMMOGRAM ADD-ON 2 194 $13 $15 $25 $38 $47 $134 $20 $30 77052 COMP SCREEN MAMMOGRAM ADD-ON 5 2411 $13 $16 $20 $23 $26 $28 $16 $24 80053 COMPREHEN METABOLIC PANEL 8 13019 $9 $19 $23 $55 $24 $25 $69 $19 $28 71250 CT THORAX WO DYE 2 302 $165 $372 $545 $878 $1658 $2067 $436 $654 71250 CT THORAX WO DYE 5 209 $53 $127 $203 $289 $419 $534 $162 $244 45378 DIAGNOSTIC COLONOSCOPY 6 1479 $484 $515 $536 $2914 $831 $1971 $2828 $428 $643 29881 KNEE ARTHROSCOPYSURGERY 6 152 $1650 $1826 $2036 $5235 $3054 $4216 $6461 $1629 $2443 29888 KNEE ARTHROSCOPYSURGERY 6 82 $1682 $3615 $5081 $5145 $7553 $12924 $18532 $4065 $6097 43644 LAP GASTRIC BYPASSROUX-EN-Y 1 21 $11821 $13873 $17050 $18391 $25029 $31079 $13640 $20460 43775 LAP SLEEVE GASTRECTOMY 1 38 $4215 $8250 $13253 $20421 $19197 $21509 $24260 $10602 $15903 74183 MRI ABDOMEN WO amp WDYE 2 120 $919 $987 $1015 $1237 $1252 $2534 $3177 $812 $1218 74183 MRI ABDOMEN WO amp WDYE 5 112 $475 $490 $521 $1154 $1337 $1696 $417 $625 70553 MRI BRAIN WO amp WDYE 2 324 $633 $987 $1142 $1237 $1706 $2805 $3331 $914 $1370 70553 MRI BRAIN WO amp WDYE 5 467 $280 $539 $1023 $1277 $1363 $1726 $818 $1228 73721 MRI JNT OF LWR EXTRE WO DYE 2 304 $804 $859 $967 $1237 $1063 $1598 $2485 $774 $1160 73721 MRI JNT OF LWR EXTRE WO DYE 5 1130 $500 $520 $530 $628 $679 $859 $424 $636 59400 OBSTETRICAL CARE 1 494 $3699 $4402 $4969 $6655 $7307 $8613 $3975 $5963 99203 OFFICEOUTPATIENT VISIT NEW 4 6776 $88 $101 $112 $138 $155 $169 $90 $134 G0202 Screeningmammographydigital 2 7444 $123 $206 $285 $380 $425 $479 $228 $342 G0202 Screeningmammographydigital 5 2754 $117 $165 $195 $230 $247 $252 $156 $234 88305 TISSUE EXAM BY PATHOLOGIST 8 20834 $51 $74 $112 $235 $168 $261 $478 $90 $134 93306 TTE WDOPPLER COMPLETE 2 931 $194 $377 $739 $960 $1267 $1480 $1849 $591 $887 93306 TTE WDOPPLER COMPLETE 5 2299 $151 $296 $373 $538 $573 $834 $298 $448 43239 UPPER GI ENDOSCOPY BIOPSY 6 1264 $424 $514 $550 $800 $1838 $2833 $440 $660 76700 US EXAM ABDOM COMPLETE 2 321 $96 $165 $271 $509 $584 $857 $217 $325 76700 US EXAM ABDOM COMPLETE 5 444 $111 $129 $147 $156 $220 $279 $118 $176 Key 1 Facility - Inpatient 2 Facility - Imaging 3 Physician - Imaging 4 Physician 5 Global - Imaging 6 Facility - Outpatient 8 Lab 41 Physician - Primary Care 42 Physician - Specialist Cardiovascular stress test $ 38279 TTE wDoppler complete $ 96037 Colonoscopy and biopsy $ 287709 Diagnostic colonoscopy $ 291434 Upper gi endoscopy biopsy $ 300526 Knee Arthroscopy $ 523584 Arthroscopy Ligament Repair $ 514501 Comp Metabolic Panel $ 5552 Surgical Path Tissue Exam $ 23570 MRI Abdomen $ 123786 MRI Brain $ 123786 MRI Joint Lower Extremity $ 123786 CT Thorax wo contrast $ 88213 X-ray Chest $ 11548 Screening mammography $ 14098 Mammo Computer Aided $ 11179 US Abdomen Complete $ 39695 Officeoutpatient visit new pt 30 min $ 24753 Vaginal delivery $ 729025 Lap Sleeve Gastrectomy $ 2042124
Page 16
Case study 1 ndash Pop Health Approach bull ProblemCircumstance Large multi-employer group needs to
evaluate benefit design disease prevalence health spend and utilization to manage their population
bull ConsiderationsValue Prop Unique industry and geography drive chronic conditions and utilization patterns
bull Solution Provide opportunity assessment comparing this population to other benchmarks to understand where to target intervention and management as well as assess efforts already taken
15
Market Comparison Preference Sensitive Procedures
16
Legend vs
Mt States vs
National gt120 gt110
110-120 105-110 lt80 lt90
Source Multi-payer commercial benchmark Results are weighted by AgeGender Broader market area includes multi-payer data from the mountain regions
Preference Sensitive Procedures Benchmark Comparison
Dartmouth Atlas Preference Sensitive Procedures
IP allowed dollars ALOS Employer vs
Mt States Employer
vs National FY 2017 FY 2018 FY 2017 FY 2018
Hysterectomy for Uterine Fibroids Rate $569354 $436932 45 54 124 140 CABG Rate $1800260 $2400608 53 60 218 130 Cholycystectomy Rate $832675 $755565 68 39 92 120 C-Section Rate 116 110 HighTech Radiology Rate 103 101 PCIPTCA Rate $934486 $1133708 37 55 82 80 Back Surgery Rate $3237613 $4003212 39 57 52 70 Knee Replacement Rate $3086693 $2177334 41 48 50 64 Total Hip Replacement Rate $1023675 $747491 45 64 37 34
Strengths (+)
Employer compares favorably for orthopedic procedures (back hip knee)
Opportunity (-)
Employer has higher than expected rates for CABG and hysterectomy (Note Low PTCA rate combined with high CABG rate may suggest provider practice patterns favoring CABG)
0 50 100 150 200 250
Total Hip Replacement
Knee Replacement
Back Surgery
PCIPTCA
Cholycystectomy
HighTech Radiology
C-Section
CABG
Culinary VsNational
Culinary Vs MtStates
Employer vs Mt States
Employer vs National
Market Comparison Condition Prevalence
17 Source Multi-payer commercial benchmark Results are weighted by AgeGender Broader market area includes multi-payer data from the mountain regions
Condition Prevalence Benchmark Comparison
Condition Employer vs
Mt States Employer vs
National Prevalence Diabetes Rate 229 219 Prevalence Hyperlipidemia Rate 259 207 Prevalence Kidney Disease Rate 143 174 Prevalence Migraine Rate 166 164 Prevalence Low Back Pain Rate 136 139 Prevalence Hypertension Rate 156 134 Prevalence Asthma Rate 146 128 Prevalence CAD Rate 175 115 Prevalence Pregnancy Rate 110 109 Prevalence Adult Preventive Screening Rate 114 91 Prevalence Depression Rate 63 60
Strengths (+)
Rate of depression is low (Note May be due to incomplete behavioral health claims)
Opportunity (-)
Employer has a higher prevalence of most chronic conditions including asthma CAD diabetes hypertension hyperlipidemia Kidney Disease LBP and migraines
0
100
200
300Hyperlipidemia
Diabetes
CAD
Migraine
Hypertension
AsthmaKidney Disease
Low Back Pain
Pregnancy
Depression
Employer vsMt States
Employer vsNational Legend
vs Mt States
vs National
gt120 gt110 110-120 105-110
lt80 lt90
Market Comparison Utilization Rates
18
A higher preventive office visit rate is better Source Multi-payer commercial benchmark Results are weighted by AgeGender Broader market area includes multi-payer data from the mountain regions
Strengths (+)
Lower than average utilization of ED and high dollar patient rate
Opportunity (-)
Higher LOS lengthy admits avoidable admits and readmissions which all drive significantly more spend
Utilization Benchmark Comparison
Condition Employer vs
Mt States Employer vs
National Avoidable Admit Rate 142 144 Lengthy Admit Rate 175 136 Outpatient Problem Focused Office Rate 146 131 Readmission Rate (readmitadmit) 135 126 Average LOS 125 116 One Day Admit Rate 76 103 Office Visit Rate 106 96 Acute Admit Rate 80 95 Avoidable ED Rate 68 86 ED Rate 54 69 Preventive Office Rate 95 68 High Dollar Patient Rate 49 51 Frequent ED User (gt3 times) Rate 24 36
Legend vs
Mt States vs
National gt120 gt110
110-120 105-110 lt80 lt90
0 50 100 150 200
Frequent ED User (gt3 times)
High Dollar Patient
Preventive Office
ED
Avoidable ED
Acute Admit
Office Visit
One Day Admit
Average LOS
Readmissionhellip
Outpt Problem Focusedhellip
Lengthy Admit
Avoidable Admit
Employer vsNational
Employer vsMt States
ED and Avoidable ED
19
Potentially Avoidable ED - Trend View Overall ED
Period Change FY 2017 FY 2018 Count Rate
Measure Mbrs Rate Mbrs Rate Overall ED 16394 12626 13820 10745 -16 -15 FREQUENT ED UTILIZER (mbr1k) 1581 1218 1468 1141 -7 -6 AVOIDABLE ED 6371 4907 5288 4111 -17 -16 Potentially Avoidable ED
Period Change FY 2017 FY 2018 Count Rate
Avoid ED Condition Mbrs Rate Mbrs Rate ABDOMINAL_PAIN 1092 841 895 696 -18 -17 ENT_INFECTION 854 658 742 577 -13 -12 FEVER 715 551 700 544 -2 -1 URINARY 650 501 468 364 -28 -27 HEADACHE 558 430 434 337 -22 -21 BACK_PAIN 414 319 423 329 2 3 NAUSEA 394 303 271 211 -31 -31 ASTHMA 294 226 209 162 -29 -28 CELLULITIS 210 162 198 154 -6 -5 GASTROENTERITIS 254 196 171 133 -33 -32 OTITIS_MEDIA 201 155 160 124 -20 -20 COPD 132 102 108 084 -18 -17 DIABETES 123 095 91 071 -26 -25 BACT_PNEUMONIA 111 085 86 067 -23 -22 DENTAL 93 072 83 065 -11 -10 DEHYDRATION 98 075 81 063 -17 -17 HYPERTENSION 16 012 24 019 50 51 CHF 4 003 3 002 -25 -24 ANGINA 8 006 3 002 -63 -62 IMMUNIZATION_RELATED 2 002 0 000 -100 -100 Grand Total 6371 4907 5288 4111 -17 -16
AHRQ avoidable ED visits are based on the logic for ambulatory care sensitive ED visits from AHRQ and diagnosis code driven
696
577
544 364
337
329
211 162
154 133 ABDOMINAL_PAIN
ENT_INFECTION
FEVER
URINARY
HEADACHE
BACK_PAIN
NAUSEA
- 200 400 600 800
1000 1200
2017 Members 2018 Members
Top Ten 2018 Conditions by Rate
Top Ten Conditions by Member Count
ED Avoidable ED and the impact of new on-site clinic
20
0
1000
2000
3000
4000
5000
6000
0200400600800
10001200140016001800
Clinic Visits ED Visits
Avoidable ED VisitsED Visits (non-avoidable)Clinic EampM Visits
0
500000
1000000
1500000
2000000
2500000
3000000
3500000
$s
Clinic EampM Profess DollarsAvoidable ED Dollars
bull Clinic visits have a clear impact on ED and avoidable ED use and spend
bull Combined ED visits are down on average 157 in FY 18 from FY 17
bull Combined ED spend is down 128 in FY 18 from FY 17
Clinic Live 62017
Pitfalls and Challenges bull Face many of the challenges similar to startup health
plan bull Critical to determine how you will deliver value and
communicate the value to potential customers and brokersconsultants
bull Care management bull Network
21
Considerations in Offering Development bull Care Management Model
bull Traditional care model bull Case management bull Utilization management bull Disease management
bull Longitudinal care model with value based care philosophy bull Primary care driven bull Local care management
bull Predictive analytics and risk stratification model bull Claims history and ongoing data bull EMR data
22
Case Study 2
Case study 2 ndash Large Employer bull Business Problem Large employer wants to contract
directly with 2 major hospital systems developing professional fee schedules
bull ConsiderationsValue Prop Fee schedule should be competitive but also nuanced to minimize gap relative to current reimbursement at physician level
bull Solution Data-driven approach using current market-wide reimbursement distinguished by service level
24
Evaluate Provider Spend Top 25 Service Lines by Allowable Spend
Evaluate Provider Spend Top 20 Professional CPTs by Total Spend
Understand relative market pricing position
27
21
-1
-28
14 10
28
-22
-11 -13
24
3
20 21
8
-20
13
3 9
-39
56
-26
4
-42
60
MRI Colonoscopy Cardiac Cath Lab - OrganPanel
Memorial Hospital Beta Hospital Delta Hospital Charlie Hospital Echo Hospital Alpha Medical Center
ndash25 5 -15 10 0 39
State Charges as a Percent of Peer Average Weighted Averages for MRI Colonoscopy Cardiology and Lab
Total Percent Above Below Market Average2
Memorial Hospital Beta Hospital Delta Hospital Charlie Hospital Echo Hospital Alpha Medical Center
Develop fee schedule relative to market
28
Service Line Procedure CPT CodeDRG
Memorial Hospital
Beta Hosptial
Charlie Hospital
Delta Hospital
Echo Hospital
Alpha Medical Center
Arthroscopy Ligament Repair 29888 $ 5062 $ 9557 $ 5983 $ 10096 $ 7519 $ 2502 Knee Arthroscopy 29881 $ 5069 $ 4185 $ 3837 $ 3022 $ 3729 $ 2266 Upper GI Endoscopy 43239 $ 3075 $ 2539 $ 2012 $ 1132 $ 1565 $ 2240 Lap Sleeve Gastrectomy DRG 621 $ 20421 $ 20815 $ 12105 $ 13230 $ 14600 $ 17800 Colonoscopy and biopsy 45380 $ 3075 $ 3071 $ 2013 $ 1244 $ 1972 $ 859 Diagnostic Colonoscopy 45378 $ 3075 $ 2805 $ 2013 $ 1244 $ 1972 $ 859 MRI Brain w amp wo dye 70553 $ 1238 $ 1468 $ 1117 $ 967 $ 2805 $ 1052 MRI Joint of Lower Extremity wo dye 73721 $ 1238 $ 1398 $ 1042 $ 967 $ 925 $ 557 MRI Abdomen w amp wo dye 74183 $ 1238 $ 1468 $ 1106 $ 967 $ 2805 $ 836 X-ray Chest 71020 $ 115 $ 266 $ 305 $ 279 $ 375 $ 72 CT Thorax wo dye 71250 $ 882 $ 810 $ 505 $ 491 $ 579 $ 319 Ultrasound Abdomen Complete 76700 $ 397 $ 538 $ 545 $ 195 $ 190 $ 168 Mammogram Screening G0202 $ 141 $ 328 $ 431 $ 294 $ 425 $ 168 Computer Detection Add-on 77052 $ 112 $ 99 $ 41 $ 15 $ 45 $ 23 Comp Metabolic Panel 80053 $ 56 $ 15 $ 24 $ 56 $ 51 $ 25 Tissue Exam by Pathologist 88305 $ 236 $ 307 $ 80 $ 152 $ 78 $ 232 Cardiovascular Stress Test 93017 $ 383 $ 432 $ 1299 $ 907 $ 717 $ 797 TTE w Doppler 93306 $ 960 $ 1566 $ 1388 $ 1173 $ 1125 $ 1157
Obstetrics Vaginal Delivery DRG 755 7290$ 5730$ 4654$ 4607$ 5855$ 4688$
GI
Lab
Radiology
Medical Cardiology
Orthopedics
KEY OBSERVA TIONS bull Potential exposure on GI bull Opportunity to align price and acuity in MRI bull Opportunity to raise rates on chest x-ray and mammogram
Percentile Bands Emory Allowables Heatmap TEC ASC Heatmap Allowable Comp Analysis Portal Pricing Sheet1 image1png A few words on Bundled Payments bull Bundled payments are growing as a type of direct contracting bull In some cases third parties match-make between employers
and providers bull Contracts may vary in definitions prepost admission
coverage duration readmission cause (ie all-cause vs medically related) outlier provisions LOS caps andor per diems
bull Providers need to be strategic in pricing to enable profitable growth of market share
29
Considerations in Offering Development bull Network Development
bull Build off existing structure eg health system employee plan network bull How does this fit into your broader value based care strategy bull Employed and independent physicians bull How do you want to approach the buildout of high performance
network bull Quality focus bull Cost efficiency
bull Integrated behavioral health bull Wrap network for other markets
30
Considerations in Offering Development bull Target Market
bull Consideration of employer profile in market bull Fully-insured vs ASO bull Total cost of care vs bundled services
bull Distribution bull Direct marketing bull Brokerconsultant community
bull Plan designs bull Standard designs vs flexible ndash Dependent on target market
bull Claims administration bull Data sharing amp analytics
31
Considerations in Offering Development bull Other components of comprehensive offering
bull Pharmacy bull Preventive health bull Onsite clinics bull Wellness programs bull Technology platform
32
Sample Bundle Analysis
33
Cover page Dotson Hazelrigs Nation Mainly of charge of fixed Cardiovascular stress test TTE wDoppler complete Colonoscopy and biopsy (Combined) Diagnostic colonoscopy (Combined) Upper gi endoscopy biopsy (Combined) Knee Arthroscopy (Combined) Arthroscopy Ligament Repair Comp Metabolic Panel Surgical Path Tissue Exam MRI Abdomen MRI Brain MRI Joint Lower Extremity CT Thorax wo contrast X-ray Chest Screening mammography Mammo Computer Aided US Abdomen Complete Officeoutpatient visit new pt 30 min Vaginal delivery Lap Sleeve Gastrectomy
Piedmont Piedmont Piedmont Piedmont Northside Northside Northside Northside Gwinnett Gwinnett Gwinnett Gwinnett WellStar WellStar WellStar WellStar AMC - Tenet AMC - Tenet AMC - Tenet AMC - Tenet CPT Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing 29881 $11312 $10872 NA NA $7476 $9338 NA $23655 $11856 $3668 NA $17871 $12253 NA NA $15645 $5490 NA NA $23039 29888 NA NA NA NA NA NA NA $23784 NA $8261 NA $18000 NA NA NA $15774 NA NA NA $23168 43239 NA $4408 NA NA NA NA $5997 $8852 NA $3304 NA $7424 $1267 NA NA $9230 NA $2458 NA $8274 43644 $26468 NA NA NA $3382 $12050 NA $1861 NA NA NA $1316 $7841 NA NA $3444 $18892 $27950 NA $979 43775 NA NA NA NA NA NA NA $352 NA NA NA $302 NA NA NA $413 NA NA NA $83 45378 $2705 $2530 NA NA $4381 $3676 $4496 $1022 $2938 $2138 NA $695 $5504 NA NA $2036 NA NA NA $372 45380 $3075 $2600 NA NA $4723 $3527 $3012 $1757 $4215 $2285 NA NA $5298 NA NA $3268 NA NA NA $627 59400 $6160 NA NA NA NA $5100 NA $1851 NA NA NA $1304 $9035 NA NA $3427 $9116 $5150 NA $966 70553 $2985 NA $1153 NA $2182 NA $1192 $492 NA NA $803 $489 $1512 NA $985 $1187 NA NA NA $197 71020 $61 $69 $43 NA $113 $319 $307 NA $183 $59 $32 NA $213 $66 $40 NA $83 $53 NA NA 71250 $1837 $621 $989 NA $1490 $931 $755 NA NA $745 $401 NA $1067 $982 $616 NA NA $304 NA NA 73721 NA $1098 $1153 NA $2042 $1065 $1192 NA NA $998 $803 NA NA $1275 $985 NA NA $644 NA $178 74183 $2971 $1144 NA NA NA $1092 $1192 $6884 NA $1098 $803 NA $2960 $1197 $985 $5454 NA NA NA $7607 76700 $364 $247 $207 NA $427 $708 $614 $13267 $428 $214 $152 NA $747 $263 $189 $9139 NA $235 NA NA 77052 NA NA NA NA NA NA NA $4744 NA NA NA NA NA NA NA $3070 NA NA NA $5611 93306 $1220 $1117 NA NA $1877 $1657 $2100 $4605 $1433 $413 $945 NA $1336 $1434 $1951 $2931 NA $2399 NA $5472 G0202 $262 $187 NA NA $431 NA NA $4605 $292 NA NA NA $530 $281 NA $2931 $327 NA NA $5472
Provider Group 29881_6 29888_6 43239_6 43644_1 43775_1 45378_6 45380_6 59400_1 70553_2 71020_2 71250_2 73721_2 74183_2 76700_2 77052_2 77052_5 80053_8 88305_8 93306_2 99203_4 G0202_2 G0202_5 93017_2 Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Atlanta Gastroenterology Associates $2399 $536 348 $1628 $536 204 $2400 $536 348 Atlanta Medical Center $24889 $2266 999 $25897 $2502 935 $11449 $2240 411 $81927 $15300 435 $75815 $17800 326 $7317 $859 752 $7317 $859 752 $12821 $4688 173 $6581 $1052 526 $645 $72 796 $3265 $319 925 $3450 $557 519 $7398 $836 785 $1576 $133 1084 $73 $23 217 $635 $25 2440 $891 $232 285 $2967 $1157 156 $344 $168 105 $1265 $797 59 Atlanta Womens Health Physicians Group $29 $14 107 $40 $13 208 $396 $188 111 $278 $118 135 $450 $231 95 Gwinnett Hospital $11941 $3022 295 $21654 $10096 114 $3551 $1132 214 $34384 $10800 218 $56472 $13230 327 $3003 $1244 141 $3533 $1244 184 $8984 $4607 95 $3901 $967 303 $417 $279 49 $2247 $491 358 $4000 $967 314 $3755 $967 288 $1593 $195 717 $50 $15 233 $186 $56 233 $505 $152 233 $1750 $1173 49 $418 $294 42 $1396 $907 54 Northside Hospital $15482 $4185 270 $21651 $9557 127 $4885 $2539 92 $35176 $17000 107 $35233 $20815 69 $3883 $2805 38 $5256 $3071 71 $10911 $5730 90 $4856 $1468 231 $443 $266 67 $2379 $810 194 $3776 $1398 170 $5105 $1468 248 $942 $538 75 $167 $99 69 $379 $15 2427 $433 $307 41 $2252 $1566 44 $459 $328 40 $576 $432 33 Piedmont Hospital $14772 $3837 285 $35493 $5983 493 $5069 $2012 152 $38320 $17750 116 $37125 $12105 207 $3485 $2013 73 $4993 $2013 148 $10143 $4654 118 $5939 $1117 432 $542 $305 78 $2983 $505 491 $3410 $1042 227 $6067 $1106 449 $1364 $545 150 $75 $41 85 $231 $24 863 $657 $80 721 $2041 $1388 47 $490 $431 14 $1780 $1299 37 Piedmont Physicians Group $42 $22 87 $318 $179 78 $239 $159 50 Resurgens $8558 $2036 320 $9293 $2258 312 $4638 $2067 124 $4039 $2164 87 $4392 $2164 103 $2252 $1371 64 $459 $330 39 Wellstar Hospital $9330 $3729 150 $17479 $7519 132 $5261 $1565 236 $35794 $18200 97 $46780 $14600 220 $3707 $1972 88 $4928 $1972 150 $13549 $5855 131 $5054 $2805 80 $528 $375 41 $3222 $579 457 $3694 $925 299 $5495 $2805 96 $1355 $190 615 $66 $45 46 $73 $51 43 $133 $78 71 $1785 $1125 59 $599 $425 41 $1010 $717 41 Avg Mark UpProcedure Atlanta Medical Center 634 Gwinnett Hospital 223 Northside Hospital 233 Piedmont Hospital 259 Wellstar Hospital 155 Emory 105
Atlanta Gastroenterology Associates Atlanta Medical Center Atlanta Womens Health Gwinnett Hospital Northside Hospital Piedmont Hospital Piedmont Physicians Group Resurgens Wellstar Hospital CPT Code CPT Proc Cat Comp Avg Allow Allow Allow Allow Allow Allow Allow Allow Allow 29881 KNEE ARTHROSCOPYSURGERY 6 $3179 $2266 $3022 $4185 $3837 $2036 $3729 29888 KNEE ARTHROSCOPYSURGERY 6 $6319 $2502 $10096 $9557 $5983 $2258 $7519 43239 UPPER GI ENDOSCOPY BIOPSY 6 $1727 $536 $2240 $1132 $2539 $2012 $2067 $1565 43644 LAP GASTRIC BYPASSROUX-EN-Y 1 $15810 $15300 $10800 $17000 $17750 $18200 43775 LAP SLEEVE GASTRECTOMY 1 $17800 $13230 $20815 $12105 $14600 45378 DIAGNOSTIC COLONOSCOPY 6 $1656 $536 $859 $1244 $2805 $2013 $2164 $1972 45380 COLONOSCOPY AND BIOPSY 6 $1694 $536 $859 $1244 $3071 $2013 $2164 $1972 59400 OBSTETRICAL CARE 1 $5107 $4688 $4607 $5730 $4654 $5855 70553 MRI BRAIN WO amp WDYE 2 $1482 $1052 $967 $1468 $1117 $2805 71020 CHEST X-RAY 2 $259 $72 $279 $266 $305 $375 71250 CT THORAX WO DYE 2 $541 $319 $491 $810 $505 $579 73721 MRI JNT OF LWR EXTRE WO DYE 2 $978 $557 $967 $1398 $1042 $925 74183 MRI ABDOMEN WO amp WDYE 2 $1436 $836 $967 $1468 $1106 $2805 76700 US EXAM ABDOM COMPLETE 2 $320 $133 $195 $538 $545 $190 77052 COMP SCREEN MAMMOGRAM ADD-ON 2 $45 $23 $15 $99 $41 $45 77052 COMP SCREEN MAMMOGRAM ADD-ON 5 $14 $14 80053 COMPREHEN METABOLIC PANEL 8 $29 $25 $13 $56 $15 $24 $22 $51 88305 TISSUE EXAM BY PATHOLOGIST 8 $174 $232 $188 $152 $307 $80 $179 $78 93306 TTE WDOPPLER COMPLETE 2 $1297 $1157 $1173 $1566 $1388 $1371 $1125 93017 STRESS TEST 5 $830 $797 $907 $432 $1299 $717 99203 OFFICEOUTPATIENT VISIT NEW 4 $139 $118 $159 G0202 Screeningmammographydigital 2 $329 $168 $294 $328 $431 $330 $425 G0202 Screeningmammographydigital 5 $231 $231
Service Line Procedure CPT Code Emory Atlanta Gastroenterology Associates Resurgens Atlanta Womens Health Piedmont Physicians Group Orthopedics (ASC) Knee Arthroscopy 29881 $3467 $2036 Arthroscopy Ligament Repair 29888 $3386 $2258 GI (ASC) Upper GI Endoscopy 43239 $2758 $536 Diagnostic Colonoscopy 45378 $2348 $536 Colonoscopy and biopsy 45380 $2181 $536 Radiology Mammogram Screening G0202 $164 $231 Computer Detection Add-on 77052 $93 $14 Lab Comp Metabolic Panel 80053 $53 $13 $22 Tissue Exam by Pathologist 88305 $277 $188 $179 EampM (TEC) Office Visit new pt 99203 $269 $118 $159
Service Line Procedure CPT CodeDRG Memorial Hospital Beta Hosptial Charlie Hospital Delta Hospital Echo Hospital Alpha Medical Center Atlanta Gastroenterology Associates Resurgens Atlanta Womens Health Piedmont Physicians Group Market Avg Emory abovebelow Orthopedics Arthroscopy Ligament Repair 29888 $ 5062 $ 9557 $ 5983 $ 10096 $ 7519 $ 2502 $ 2258 $ 6319 -20 Knee Arthroscopy 29881 6 $ 5069 $ 4185 $ 3837 $ 3022 $ 3729 $ 2266 $ 2036 $ 3179 59 GI Upper GI Endoscopy 43239 6 $ 3075 $ 2539 $ 2012 $ 1132 $ 1565 $ 2240 $ 536 $ 1671 84 Lap Sleeve Gastrectomy DRG 621 $ 20421 $ 20815 $ 12105 $ 13230 $ 14600 $ 17800 $ 15710 30 Colonoscopy and biopsy 45380 $ 3075 $ 3071 $ 2013 $ 1244 $ 1972 $ 859 $ 536 $ 1616 90 Diagnostic Colonoscopy 45378 6 $ 3075 $ 2805 $ 2013 $ 1244 $ 1972 $ 859 $ 536 $ 1572 96 Radiology MRI Brain w amp wo dye 70553 2 $ 1238 $ 1468 $ 1117 $ 967 $ 2805 $ 1052 $ 1482 -16 MRI Joint of Lower Extremity wo dye 73721 2 $ 1238 $ 1398 $ 1042 $ 967 $ 925 $ 557 $ 978 27 MRI Abdomen w amp wo dye 74183 2 $ 1238 $ 1468 $ 1106 $ 967 $ 2805 $ 836 $ 1436 -14 X-ray Chest 71020 $ 115 $ 266 $ 305 $ 279 $ 375 $ 72 $ 259 -56 CT Thorax wo dye 71250 $ 882 $ 810 $ 505 $ 491 $ 579 $ 319 $ 541 63 Ultrasound Abdomen Complete 76700 $ 397 $ 538 $ 545 $ 195 $ 190 $ 168 $ 327 21 Mammogram Screening G0202 2 $ 141 $ 328 $ 431 $ 294 $ 425 $ 168 $ 231 $ 313 -55 Computer Detection Add-on 77052 2 $ 112 $ 99 $ 41 $ 15 $ 45 $ 23 $ 14 $ 39 183 Lab Comp Metabolic Panel 80053 8 $ 56 $ 15 $ 24 $ 56 $ 51 $ 25 $ 13 $ 22 $ 29 88 Tissue Exam by Pathologist 88305 8 $ 236 $ 307 $ 80 $ 152 $ 78 $ 232 $ 188 $ 179 $ 174 36 Medical Cardiology Cardiovascular Stress Test 93017 $ 383 $ 432 $ 1299 $ 907 $ 717 $ 797 $ 830 -54 TTE w Doppler 93306 2 $ 960 $ 1566 $ 1388 $ 1173 $ 1125 $ 1157 $ 1282 -25 Obstetrics Vaginal Delivery DRG 755 $ 7290 $ 5730 $ 4654 $ 4607 $ 5855 $ 4688 $ 5107 43 EampM Office Visit new pt 99203 4 $ 248 $ 118 $ 159 $ 139 78 Colonoscopy and biopsy (HOSPITAL ONLY) 45380 Surg 2530 $ 307591 Diagnostic colonoscopy (HOSPITAL ONLY) 45378 Surg 2255 $ 307591 Upper gi endoscopy biopsy (HOSPITAL ONLY) 43239 Surg 1787 $ 307591 Knee Arthroscopy (HOSPITAL ONLY) 29881 Surg 10900 $ 506893 Arthroscopy Ligament Repair (HOSPITAL ONLY) 29888 Surg 10900 $ 506200 Key 1 Facility - Inpatient 2 Facility - Imaging 3 Physician - Imaging 4 Physician 5 Global - Imaging 6 Facility - Outpatient 8 Lab 41 Physician - Primary Care 42 Physician - Specialist
Blue Cross United - EJCH EUH EUHM WW United - SJH Non Options United - SJH Options Aetna - ASC TEC (HMO) Cigna - ASC TEC (HMO) Aetna - EJCH ESJH ECHM WW Cigna - EJCH (HMO) Cigna - ESJH EUHM (HMO) List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract Description CPT Code Charge Average Final Price (all plans) Emory Mark Up Reimbursement Method ( of charge or fixed) - 1713 Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Cardiovascular stress test 93017 Cardio $543 $ 425 28 of Charge 70 $ 380 of Charge 65 $ 353 of Charge 60 $ 326 of Charge 70 $ 380 of Charge 70 $ 380 of charge 100 $ 543 of Charge 70 $ 380 of charge 100 $ 543 of charge 100 $ 543 TTE wDoppler complete 93306 Cardio $1226 $ 960 28 of Charge 70 $ 858 of Charge 65 $ 797 of Charge 60 $ 736 of Charge 70 $ 858 of Charge 70 $ 858 of charge 100 $ 1226 of Charge 70 $ 858 of charge 100 $ 1226 of charge 100 $ 1226 Colonoscopy and biopsy (HOSPITAL ONLY) 45380 Surg $2530 $ 3076 -18 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 of Charge 70 $ 1771 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Diagnostic colonoscopy (HOSPITAL ONLY) 45378 Surg $2255 $ 3076 -27 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 of Charge 70 $ 1579 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Upper gi endoscopy biopsy (HOSPITAL ONLY) 43239 Surg $1787 $ 3076 -42 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Knee Arthroscopy (HOSPITAL ONLY) 29881 Surg $10900 $ 5069 115 Fixed Rate SC 4 $ 3865 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 449300 $ 4493 Fixed Rate $ 654700 $ 6547 of Charge 70 $ 7630 Fixed Rate $ 401000 $ 4010 of Charge 70 $ 7630 Fixed Rate $ 398300 $ 3983 Fixed Rate $ 398100 $ 3981 Arthroscopy Ligament Repair (HOSPITAL ONLY) 29888 Surg $10900 $ 5062 115 Fixed Rate SC 3 $ 3121 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 556900 $ 5569 Fixed Rate $ 770100 $ 7701 of Charge 70 $ 7630 Fixed Rate $ 323900 $ 3239 of Charge 70 $ 7630 Fixed Rate $ 321700 $ 3217 Fixed Rate $ 321400 $ 3214 Comp Metabolic Panel 80053 Lab $132 $ 56 138 RBRVS Fee (100) $ 1437 of Charge 65 $ 86 of Charge 65 $ 86 of Charge 65 $ 86 of Charge 70 $ 92 RBRVS Fee (100) $ 1437 $ 14 of Charge 70 $ 92 RBRVS Fee (100) $ 1437 $ 14 RBRVS Fee (100) $ 1437 $ 14 Surgical Path Tissue Exam 88305 Lab $326 $ 236 38 of Charge 150 $ 51 of Charge 65 $ 212 of Charge 65 $ 212 of Charge 65 $ 212 of Charge 70 $ 228 of charge 100 $ 326 of Charge 70 $ 228 of charge 100 $ 326 of charge 100 $ 326 MRI Abdomen 74183 Radiology $6960 $ 1238 462 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 MRI Brain 70553 Radiology $6804 $ 1238 450 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 MRI Joint Lower Extremity 73721 Radiology $3067 $ 1238 148 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 CT Thorax wo contrast 71250 Radiology $2199 $ 882 149 Fixed Rate $ 771 Fixed Rate $ 47100 $ 471 Fixed Rate $ 81700 $ 817 Fixed Rate $ 116000 $ 1160 of Charge 70 $ 1539 Fixed Rate $ 80100 $ 801 Fixed Rate $ 79200 $ 792 Fixed Rate $ 79300 $ 793 Fixed Rate $ 79500 $ 795 X-ray Chest 71020 Radiology $280 $ 115 142 of Charge 150 $ 25 of Charge 65 $ 182 of Charge 60 $ 168 of Charge 70 $ 196 of Charge 70 $ 196 RBRVS Fee (150) $ 2534 $ 25 of Charge 70 $ 196 RBRVS Fee (150) $ 2534 $ 25 RBRVS Fee (150) $ 2534 $ 25 Screening mammography G0202 Radiology $279 $ 141 98 Fixed Rate $ 128 Fixed Rate $ 13100 $ 131 Fixed Rate $ 14300 $ 143 Fixed Rate $ 16100 $ 161 of Charge 70 $ 195 Fixed Rate $ 13300 $ 133 Fixed Rate $ 13500 $ 135 Fixed Rate $ 13000 $ 130 Fixed Rate $ 11200 $ 112 Mammo Computer Aided 77052 Radiology $75 $ 112 -33 Fixed Rate $ 9 Fixed Rate $ 13100 $ 131 Fixed Rate $ 14300 $ 143 Fixed Rate $ 16100 $ 161 of Charge 70 $ 53 Fixed Rate $ 13300 $ 133 Fixed Rate $ 13500 $ 135 Fixed Rate $ 13000 $ 130 Fixed Rate $ 11200 $ 112 US Abdomen Complete 76700 Radiology $917 $ 397 131 of Charge 150 $ 125 of Charge 65 $ 596 of Charge 60 $ 550 of Charge 70 $ 642 of Charge 70 $ 642 RBRVS Fee (150) $ 12519 $ 125 of Charge 70 $ 642 RBRVS Fee (150) $ 12519 $ 125 RBRVS Fee (150) $ 12519 $ 125 Officeoutpatient visit new pt 30 min (TEC) 99203 EampM $316 $ 248 28 of Charge 70 $ 221 of Charge 65 $ 205 of Charge 60 $ 190 of Charge 70 $ 221 of Charge 70 $ 221 of charge 100 $ 316 of Charge 70 $ 221 of charge 100 $ 316 of charge 100 $ 316 Vaginal delivery 59409 Surg $14484 $ 7290 99 Fixed Rate DRG - 775 $ 5437 2 Day Case Rate + LOC 561700 $ 5617 BaseCMS Weight 584741 $ 5847 BaseCMS Weight 726146 $ 7261 No IP Terms $ - 0 No IP BaseCMS Weight 659343 $ 6593 BaseContract Weight 479451 100 $ 14484 BaseCMS Weight 579110 $ 5791 Lap Sleeve Gastrectomy 43775 Surg $29961 $ 20421 47 Fixed Rate DRG - 621 $ 14872 BaseCMS Weight 1810697 $ 18107 BaseCMS Weight 1835178 $ 18352 BaseCMS Weight 2278911 $ 22789 No IP Terms $ - 0 No IP BaseCMS Weight 2069315 $ 20693 BaseCMS Weight 1730442 100 $ 29961 BaseCMS Weight 1817507 $ 18175 105 Colonoscopy and biopsy (ASC ONLY) Surg $ 219200 $ 2181 Diagnostic colonoscopy (ASC ONLY) Surg $ 267100 $ 2348 Upper gi endoscopy biopsy (ASC ONLY) Surg $ 207500 $ 2758 Knee Arthroscopy (ASC ONLY) Surg $ 417900 $ 3467 Arthroscopy Ligament Repair (ASC ONLY) Surg $ 504800 $ 3386
Cpt Code CPT Description Procedure Category Claims Min 25thNtile 50thNtile Emorys Rates 75thNtile 90thNtile Max 20 Below 50th Ntile 20 Above 50th Ntile 93017 CARDIOVASCULAR STRESS TEST 5 82 $80 $125 $321 $382 $568 $791 $930 $257 $386 71020 CHEST X-RAY 2 2638 $11 $45 $152 $115 $289 $373 $585 $122 $182 71020 CHEST X-RAY 5 8106 $25 $34 $38 $54 $57 $69 $30 $46 45380 COLONOSCOPY AND BIOPSY 6 1256 $541 $560 $572 $2877 $1000 $2024 $3289 $458 $686 77052 COMP SCREEN MAMMOGRAM ADD-ON 2 194 $13 $15 $25 $38 $47 $134 $20 $30 77052 COMP SCREEN MAMMOGRAM ADD-ON 5 2411 $13 $16 $20 $23 $26 $28 $16 $24 80053 COMPREHEN METABOLIC PANEL 8 13019 $9 $19 $23 $55 $24 $25 $69 $19 $28 71250 CT THORAX WO DYE 2 302 $165 $372 $545 $878 $1658 $2067 $436 $654 71250 CT THORAX WO DYE 5 209 $53 $127 $203 $289 $419 $534 $162 $244 45378 DIAGNOSTIC COLONOSCOPY 6 1479 $484 $515 $536 $2914 $831 $1971 $2828 $428 $643 29881 KNEE ARTHROSCOPYSURGERY 6 152 $1650 $1826 $2036 $5235 $3054 $4216 $6461 $1629 $2443 29888 KNEE ARTHROSCOPYSURGERY 6 82 $1682 $3615 $5081 $5145 $7553 $12924 $18532 $4065 $6097 43644 LAP GASTRIC BYPASSROUX-EN-Y 1 21 $11821 $13873 $17050 $18391 $25029 $31079 $13640 $20460 43775 LAP SLEEVE GASTRECTOMY 1 38 $4215 $8250 $13253 $20421 $19197 $21509 $24260 $10602 $15903 74183 MRI ABDOMEN WO amp WDYE 2 120 $919 $987 $1015 $1237 $1252 $2534 $3177 $812 $1218 74183 MRI ABDOMEN WO amp WDYE 5 112 $475 $490 $521 $1154 $1337 $1696 $417 $625 70553 MRI BRAIN WO amp WDYE 2 324 $633 $987 $1142 $1237 $1706 $2805 $3331 $914 $1370 70553 MRI BRAIN WO amp WDYE 5 467 $280 $539 $1023 $1277 $1363 $1726 $818 $1228 73721 MRI JNT OF LWR EXTRE WO DYE 2 304 $804 $859 $967 $1237 $1063 $1598 $2485 $774 $1160 73721 MRI JNT OF LWR EXTRE WO DYE 5 1130 $500 $520 $530 $628 $679 $859 $424 $636 59400 OBSTETRICAL CARE 1 494 $3699 $4402 $4969 $6655 $7307 $8613 $3975 $5963 99203 OFFICEOUTPATIENT VISIT NEW 4 6776 $88 $101 $112 $138 $155 $169 $90 $134 G0202 Screeningmammographydigital 2 7444 $123 $206 $285 $380 $425 $479 $228 $342 G0202 Screeningmammographydigital 5 2754 $117 $165 $195 $230 $247 $252 $156 $234 88305 TISSUE EXAM BY PATHOLOGIST 8 20834 $51 $74 $112 $235 $168 $261 $478 $90 $134 93306 TTE WDOPPLER COMPLETE 2 931 $194 $377 $739 $960 $1267 $1480 $1849 $591 $887 93306 TTE WDOPPLER COMPLETE 5 2299 $151 $296 $373 $538 $573 $834 $298 $448 43239 UPPER GI ENDOSCOPY BIOPSY 6 1264 $424 $514 $550 $800 $1838 $2833 $440 $660 76700 US EXAM ABDOM COMPLETE 2 321 $96 $165 $271 $509 $584 $857 $217 $325 76700 US EXAM ABDOM COMPLETE 5 444 $111 $129 $147 $156 $220 $279 $118 $176 Key 1 Facility - Inpatient 2 Facility - Imaging 3 Physician - Imaging 4 Physician 5 Global - Imaging 6 Facility - Outpatient 8 Lab 41 Physician - Primary Care 42 Physician - Specialist Cardiovascular stress test $ 38279 TTE wDoppler complete $ 96037 Colonoscopy and biopsy $ 287709 Diagnostic colonoscopy $ 291434 Upper gi endoscopy biopsy $ 300526 Knee Arthroscopy $ 523584 Arthroscopy Ligament Repair $ 514501 Comp Metabolic Panel $ 5552 Surgical Path Tissue Exam $ 23570 MRI Abdomen $ 123786 MRI Brain $ 123786 MRI Joint Lower Extremity $ 123786 CT Thorax wo contrast $ 88213 X-ray Chest $ 11548 Screening mammography $ 14098 Mammo Computer Aided $ 11179 US Abdomen Complete $ 39695 Officeoutpatient visit new pt 30 min $ 24753 Vaginal delivery $ 729025 Lap Sleeve Gastrectomy $ 2042124
Page 17
Market Comparison Preference Sensitive Procedures
16
Legend vs
Mt States vs
National gt120 gt110
110-120 105-110 lt80 lt90
Source Multi-payer commercial benchmark Results are weighted by AgeGender Broader market area includes multi-payer data from the mountain regions
Preference Sensitive Procedures Benchmark Comparison
Dartmouth Atlas Preference Sensitive Procedures
IP allowed dollars ALOS Employer vs
Mt States Employer
vs National FY 2017 FY 2018 FY 2017 FY 2018
Hysterectomy for Uterine Fibroids Rate $569354 $436932 45 54 124 140 CABG Rate $1800260 $2400608 53 60 218 130 Cholycystectomy Rate $832675 $755565 68 39 92 120 C-Section Rate 116 110 HighTech Radiology Rate 103 101 PCIPTCA Rate $934486 $1133708 37 55 82 80 Back Surgery Rate $3237613 $4003212 39 57 52 70 Knee Replacement Rate $3086693 $2177334 41 48 50 64 Total Hip Replacement Rate $1023675 $747491 45 64 37 34
Strengths (+)
Employer compares favorably for orthopedic procedures (back hip knee)
Opportunity (-)
Employer has higher than expected rates for CABG and hysterectomy (Note Low PTCA rate combined with high CABG rate may suggest provider practice patterns favoring CABG)
0 50 100 150 200 250
Total Hip Replacement
Knee Replacement
Back Surgery
PCIPTCA
Cholycystectomy
HighTech Radiology
C-Section
CABG
Culinary VsNational
Culinary Vs MtStates
Employer vs Mt States
Employer vs National
Market Comparison Condition Prevalence
17 Source Multi-payer commercial benchmark Results are weighted by AgeGender Broader market area includes multi-payer data from the mountain regions
Condition Prevalence Benchmark Comparison
Condition Employer vs
Mt States Employer vs
National Prevalence Diabetes Rate 229 219 Prevalence Hyperlipidemia Rate 259 207 Prevalence Kidney Disease Rate 143 174 Prevalence Migraine Rate 166 164 Prevalence Low Back Pain Rate 136 139 Prevalence Hypertension Rate 156 134 Prevalence Asthma Rate 146 128 Prevalence CAD Rate 175 115 Prevalence Pregnancy Rate 110 109 Prevalence Adult Preventive Screening Rate 114 91 Prevalence Depression Rate 63 60
Strengths (+)
Rate of depression is low (Note May be due to incomplete behavioral health claims)
Opportunity (-)
Employer has a higher prevalence of most chronic conditions including asthma CAD diabetes hypertension hyperlipidemia Kidney Disease LBP and migraines
0
100
200
300Hyperlipidemia
Diabetes
CAD
Migraine
Hypertension
AsthmaKidney Disease
Low Back Pain
Pregnancy
Depression
Employer vsMt States
Employer vsNational Legend
vs Mt States
vs National
gt120 gt110 110-120 105-110
lt80 lt90
Market Comparison Utilization Rates
18
A higher preventive office visit rate is better Source Multi-payer commercial benchmark Results are weighted by AgeGender Broader market area includes multi-payer data from the mountain regions
Strengths (+)
Lower than average utilization of ED and high dollar patient rate
Opportunity (-)
Higher LOS lengthy admits avoidable admits and readmissions which all drive significantly more spend
Utilization Benchmark Comparison
Condition Employer vs
Mt States Employer vs
National Avoidable Admit Rate 142 144 Lengthy Admit Rate 175 136 Outpatient Problem Focused Office Rate 146 131 Readmission Rate (readmitadmit) 135 126 Average LOS 125 116 One Day Admit Rate 76 103 Office Visit Rate 106 96 Acute Admit Rate 80 95 Avoidable ED Rate 68 86 ED Rate 54 69 Preventive Office Rate 95 68 High Dollar Patient Rate 49 51 Frequent ED User (gt3 times) Rate 24 36
Legend vs
Mt States vs
National gt120 gt110
110-120 105-110 lt80 lt90
0 50 100 150 200
Frequent ED User (gt3 times)
High Dollar Patient
Preventive Office
ED
Avoidable ED
Acute Admit
Office Visit
One Day Admit
Average LOS
Readmissionhellip
Outpt Problem Focusedhellip
Lengthy Admit
Avoidable Admit
Employer vsNational
Employer vsMt States
ED and Avoidable ED
19
Potentially Avoidable ED - Trend View Overall ED
Period Change FY 2017 FY 2018 Count Rate
Measure Mbrs Rate Mbrs Rate Overall ED 16394 12626 13820 10745 -16 -15 FREQUENT ED UTILIZER (mbr1k) 1581 1218 1468 1141 -7 -6 AVOIDABLE ED 6371 4907 5288 4111 -17 -16 Potentially Avoidable ED
Period Change FY 2017 FY 2018 Count Rate
Avoid ED Condition Mbrs Rate Mbrs Rate ABDOMINAL_PAIN 1092 841 895 696 -18 -17 ENT_INFECTION 854 658 742 577 -13 -12 FEVER 715 551 700 544 -2 -1 URINARY 650 501 468 364 -28 -27 HEADACHE 558 430 434 337 -22 -21 BACK_PAIN 414 319 423 329 2 3 NAUSEA 394 303 271 211 -31 -31 ASTHMA 294 226 209 162 -29 -28 CELLULITIS 210 162 198 154 -6 -5 GASTROENTERITIS 254 196 171 133 -33 -32 OTITIS_MEDIA 201 155 160 124 -20 -20 COPD 132 102 108 084 -18 -17 DIABETES 123 095 91 071 -26 -25 BACT_PNEUMONIA 111 085 86 067 -23 -22 DENTAL 93 072 83 065 -11 -10 DEHYDRATION 98 075 81 063 -17 -17 HYPERTENSION 16 012 24 019 50 51 CHF 4 003 3 002 -25 -24 ANGINA 8 006 3 002 -63 -62 IMMUNIZATION_RELATED 2 002 0 000 -100 -100 Grand Total 6371 4907 5288 4111 -17 -16
AHRQ avoidable ED visits are based on the logic for ambulatory care sensitive ED visits from AHRQ and diagnosis code driven
696
577
544 364
337
329
211 162
154 133 ABDOMINAL_PAIN
ENT_INFECTION
FEVER
URINARY
HEADACHE
BACK_PAIN
NAUSEA
- 200 400 600 800
1000 1200
2017 Members 2018 Members
Top Ten 2018 Conditions by Rate
Top Ten Conditions by Member Count
ED Avoidable ED and the impact of new on-site clinic
20
0
1000
2000
3000
4000
5000
6000
0200400600800
10001200140016001800
Clinic Visits ED Visits
Avoidable ED VisitsED Visits (non-avoidable)Clinic EampM Visits
0
500000
1000000
1500000
2000000
2500000
3000000
3500000
$s
Clinic EampM Profess DollarsAvoidable ED Dollars
bull Clinic visits have a clear impact on ED and avoidable ED use and spend
bull Combined ED visits are down on average 157 in FY 18 from FY 17
bull Combined ED spend is down 128 in FY 18 from FY 17
Clinic Live 62017
Pitfalls and Challenges bull Face many of the challenges similar to startup health
plan bull Critical to determine how you will deliver value and
communicate the value to potential customers and brokersconsultants
bull Care management bull Network
21
Considerations in Offering Development bull Care Management Model
bull Traditional care model bull Case management bull Utilization management bull Disease management
bull Longitudinal care model with value based care philosophy bull Primary care driven bull Local care management
bull Predictive analytics and risk stratification model bull Claims history and ongoing data bull EMR data
22
Case Study 2
Case study 2 ndash Large Employer bull Business Problem Large employer wants to contract
directly with 2 major hospital systems developing professional fee schedules
bull ConsiderationsValue Prop Fee schedule should be competitive but also nuanced to minimize gap relative to current reimbursement at physician level
bull Solution Data-driven approach using current market-wide reimbursement distinguished by service level
24
Evaluate Provider Spend Top 25 Service Lines by Allowable Spend
Evaluate Provider Spend Top 20 Professional CPTs by Total Spend
Understand relative market pricing position
27
21
-1
-28
14 10
28
-22
-11 -13
24
3
20 21
8
-20
13
3 9
-39
56
-26
4
-42
60
MRI Colonoscopy Cardiac Cath Lab - OrganPanel
Memorial Hospital Beta Hospital Delta Hospital Charlie Hospital Echo Hospital Alpha Medical Center
ndash25 5 -15 10 0 39
State Charges as a Percent of Peer Average Weighted Averages for MRI Colonoscopy Cardiology and Lab
Total Percent Above Below Market Average2
Memorial Hospital Beta Hospital Delta Hospital Charlie Hospital Echo Hospital Alpha Medical Center
Develop fee schedule relative to market
28
Service Line Procedure CPT CodeDRG
Memorial Hospital
Beta Hosptial
Charlie Hospital
Delta Hospital
Echo Hospital
Alpha Medical Center
Arthroscopy Ligament Repair 29888 $ 5062 $ 9557 $ 5983 $ 10096 $ 7519 $ 2502 Knee Arthroscopy 29881 $ 5069 $ 4185 $ 3837 $ 3022 $ 3729 $ 2266 Upper GI Endoscopy 43239 $ 3075 $ 2539 $ 2012 $ 1132 $ 1565 $ 2240 Lap Sleeve Gastrectomy DRG 621 $ 20421 $ 20815 $ 12105 $ 13230 $ 14600 $ 17800 Colonoscopy and biopsy 45380 $ 3075 $ 3071 $ 2013 $ 1244 $ 1972 $ 859 Diagnostic Colonoscopy 45378 $ 3075 $ 2805 $ 2013 $ 1244 $ 1972 $ 859 MRI Brain w amp wo dye 70553 $ 1238 $ 1468 $ 1117 $ 967 $ 2805 $ 1052 MRI Joint of Lower Extremity wo dye 73721 $ 1238 $ 1398 $ 1042 $ 967 $ 925 $ 557 MRI Abdomen w amp wo dye 74183 $ 1238 $ 1468 $ 1106 $ 967 $ 2805 $ 836 X-ray Chest 71020 $ 115 $ 266 $ 305 $ 279 $ 375 $ 72 CT Thorax wo dye 71250 $ 882 $ 810 $ 505 $ 491 $ 579 $ 319 Ultrasound Abdomen Complete 76700 $ 397 $ 538 $ 545 $ 195 $ 190 $ 168 Mammogram Screening G0202 $ 141 $ 328 $ 431 $ 294 $ 425 $ 168 Computer Detection Add-on 77052 $ 112 $ 99 $ 41 $ 15 $ 45 $ 23 Comp Metabolic Panel 80053 $ 56 $ 15 $ 24 $ 56 $ 51 $ 25 Tissue Exam by Pathologist 88305 $ 236 $ 307 $ 80 $ 152 $ 78 $ 232 Cardiovascular Stress Test 93017 $ 383 $ 432 $ 1299 $ 907 $ 717 $ 797 TTE w Doppler 93306 $ 960 $ 1566 $ 1388 $ 1173 $ 1125 $ 1157
Obstetrics Vaginal Delivery DRG 755 7290$ 5730$ 4654$ 4607$ 5855$ 4688$
GI
Lab
Radiology
Medical Cardiology
Orthopedics
KEY OBSERVA TIONS bull Potential exposure on GI bull Opportunity to align price and acuity in MRI bull Opportunity to raise rates on chest x-ray and mammogram
Percentile Bands Emory Allowables Heatmap TEC ASC Heatmap Allowable Comp Analysis Portal Pricing Sheet1 image1png A few words on Bundled Payments bull Bundled payments are growing as a type of direct contracting bull In some cases third parties match-make between employers
and providers bull Contracts may vary in definitions prepost admission
coverage duration readmission cause (ie all-cause vs medically related) outlier provisions LOS caps andor per diems
bull Providers need to be strategic in pricing to enable profitable growth of market share
29
Considerations in Offering Development bull Network Development
bull Build off existing structure eg health system employee plan network bull How does this fit into your broader value based care strategy bull Employed and independent physicians bull How do you want to approach the buildout of high performance
network bull Quality focus bull Cost efficiency
bull Integrated behavioral health bull Wrap network for other markets
30
Considerations in Offering Development bull Target Market
bull Consideration of employer profile in market bull Fully-insured vs ASO bull Total cost of care vs bundled services
bull Distribution bull Direct marketing bull Brokerconsultant community
bull Plan designs bull Standard designs vs flexible ndash Dependent on target market
bull Claims administration bull Data sharing amp analytics
31
Considerations in Offering Development bull Other components of comprehensive offering
bull Pharmacy bull Preventive health bull Onsite clinics bull Wellness programs bull Technology platform
32
Sample Bundle Analysis
33
Cover page Dotson Hazelrigs Nation Mainly of charge of fixed Cardiovascular stress test TTE wDoppler complete Colonoscopy and biopsy (Combined) Diagnostic colonoscopy (Combined) Upper gi endoscopy biopsy (Combined) Knee Arthroscopy (Combined) Arthroscopy Ligament Repair Comp Metabolic Panel Surgical Path Tissue Exam MRI Abdomen MRI Brain MRI Joint Lower Extremity CT Thorax wo contrast X-ray Chest Screening mammography Mammo Computer Aided US Abdomen Complete Officeoutpatient visit new pt 30 min Vaginal delivery Lap Sleeve Gastrectomy
Piedmont Piedmont Piedmont Piedmont Northside Northside Northside Northside Gwinnett Gwinnett Gwinnett Gwinnett WellStar WellStar WellStar WellStar AMC - Tenet AMC - Tenet AMC - Tenet AMC - Tenet CPT Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing 29881 $11312 $10872 NA NA $7476 $9338 NA $23655 $11856 $3668 NA $17871 $12253 NA NA $15645 $5490 NA NA $23039 29888 NA NA NA NA NA NA NA $23784 NA $8261 NA $18000 NA NA NA $15774 NA NA NA $23168 43239 NA $4408 NA NA NA NA $5997 $8852 NA $3304 NA $7424 $1267 NA NA $9230 NA $2458 NA $8274 43644 $26468 NA NA NA $3382 $12050 NA $1861 NA NA NA $1316 $7841 NA NA $3444 $18892 $27950 NA $979 43775 NA NA NA NA NA NA NA $352 NA NA NA $302 NA NA NA $413 NA NA NA $83 45378 $2705 $2530 NA NA $4381 $3676 $4496 $1022 $2938 $2138 NA $695 $5504 NA NA $2036 NA NA NA $372 45380 $3075 $2600 NA NA $4723 $3527 $3012 $1757 $4215 $2285 NA NA $5298 NA NA $3268 NA NA NA $627 59400 $6160 NA NA NA NA $5100 NA $1851 NA NA NA $1304 $9035 NA NA $3427 $9116 $5150 NA $966 70553 $2985 NA $1153 NA $2182 NA $1192 $492 NA NA $803 $489 $1512 NA $985 $1187 NA NA NA $197 71020 $61 $69 $43 NA $113 $319 $307 NA $183 $59 $32 NA $213 $66 $40 NA $83 $53 NA NA 71250 $1837 $621 $989 NA $1490 $931 $755 NA NA $745 $401 NA $1067 $982 $616 NA NA $304 NA NA 73721 NA $1098 $1153 NA $2042 $1065 $1192 NA NA $998 $803 NA NA $1275 $985 NA NA $644 NA $178 74183 $2971 $1144 NA NA NA $1092 $1192 $6884 NA $1098 $803 NA $2960 $1197 $985 $5454 NA NA NA $7607 76700 $364 $247 $207 NA $427 $708 $614 $13267 $428 $214 $152 NA $747 $263 $189 $9139 NA $235 NA NA 77052 NA NA NA NA NA NA NA $4744 NA NA NA NA NA NA NA $3070 NA NA NA $5611 93306 $1220 $1117 NA NA $1877 $1657 $2100 $4605 $1433 $413 $945 NA $1336 $1434 $1951 $2931 NA $2399 NA $5472 G0202 $262 $187 NA NA $431 NA NA $4605 $292 NA NA NA $530 $281 NA $2931 $327 NA NA $5472
Provider Group 29881_6 29888_6 43239_6 43644_1 43775_1 45378_6 45380_6 59400_1 70553_2 71020_2 71250_2 73721_2 74183_2 76700_2 77052_2 77052_5 80053_8 88305_8 93306_2 99203_4 G0202_2 G0202_5 93017_2 Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Atlanta Gastroenterology Associates $2399 $536 348 $1628 $536 204 $2400 $536 348 Atlanta Medical Center $24889 $2266 999 $25897 $2502 935 $11449 $2240 411 $81927 $15300 435 $75815 $17800 326 $7317 $859 752 $7317 $859 752 $12821 $4688 173 $6581 $1052 526 $645 $72 796 $3265 $319 925 $3450 $557 519 $7398 $836 785 $1576 $133 1084 $73 $23 217 $635 $25 2440 $891 $232 285 $2967 $1157 156 $344 $168 105 $1265 $797 59 Atlanta Womens Health Physicians Group $29 $14 107 $40 $13 208 $396 $188 111 $278 $118 135 $450 $231 95 Gwinnett Hospital $11941 $3022 295 $21654 $10096 114 $3551 $1132 214 $34384 $10800 218 $56472 $13230 327 $3003 $1244 141 $3533 $1244 184 $8984 $4607 95 $3901 $967 303 $417 $279 49 $2247 $491 358 $4000 $967 314 $3755 $967 288 $1593 $195 717 $50 $15 233 $186 $56 233 $505 $152 233 $1750 $1173 49 $418 $294 42 $1396 $907 54 Northside Hospital $15482 $4185 270 $21651 $9557 127 $4885 $2539 92 $35176 $17000 107 $35233 $20815 69 $3883 $2805 38 $5256 $3071 71 $10911 $5730 90 $4856 $1468 231 $443 $266 67 $2379 $810 194 $3776 $1398 170 $5105 $1468 248 $942 $538 75 $167 $99 69 $379 $15 2427 $433 $307 41 $2252 $1566 44 $459 $328 40 $576 $432 33 Piedmont Hospital $14772 $3837 285 $35493 $5983 493 $5069 $2012 152 $38320 $17750 116 $37125 $12105 207 $3485 $2013 73 $4993 $2013 148 $10143 $4654 118 $5939 $1117 432 $542 $305 78 $2983 $505 491 $3410 $1042 227 $6067 $1106 449 $1364 $545 150 $75 $41 85 $231 $24 863 $657 $80 721 $2041 $1388 47 $490 $431 14 $1780 $1299 37 Piedmont Physicians Group $42 $22 87 $318 $179 78 $239 $159 50 Resurgens $8558 $2036 320 $9293 $2258 312 $4638 $2067 124 $4039 $2164 87 $4392 $2164 103 $2252 $1371 64 $459 $330 39 Wellstar Hospital $9330 $3729 150 $17479 $7519 132 $5261 $1565 236 $35794 $18200 97 $46780 $14600 220 $3707 $1972 88 $4928 $1972 150 $13549 $5855 131 $5054 $2805 80 $528 $375 41 $3222 $579 457 $3694 $925 299 $5495 $2805 96 $1355 $190 615 $66 $45 46 $73 $51 43 $133 $78 71 $1785 $1125 59 $599 $425 41 $1010 $717 41 Avg Mark UpProcedure Atlanta Medical Center 634 Gwinnett Hospital 223 Northside Hospital 233 Piedmont Hospital 259 Wellstar Hospital 155 Emory 105
Atlanta Gastroenterology Associates Atlanta Medical Center Atlanta Womens Health Gwinnett Hospital Northside Hospital Piedmont Hospital Piedmont Physicians Group Resurgens Wellstar Hospital CPT Code CPT Proc Cat Comp Avg Allow Allow Allow Allow Allow Allow Allow Allow Allow 29881 KNEE ARTHROSCOPYSURGERY 6 $3179 $2266 $3022 $4185 $3837 $2036 $3729 29888 KNEE ARTHROSCOPYSURGERY 6 $6319 $2502 $10096 $9557 $5983 $2258 $7519 43239 UPPER GI ENDOSCOPY BIOPSY 6 $1727 $536 $2240 $1132 $2539 $2012 $2067 $1565 43644 LAP GASTRIC BYPASSROUX-EN-Y 1 $15810 $15300 $10800 $17000 $17750 $18200 43775 LAP SLEEVE GASTRECTOMY 1 $17800 $13230 $20815 $12105 $14600 45378 DIAGNOSTIC COLONOSCOPY 6 $1656 $536 $859 $1244 $2805 $2013 $2164 $1972 45380 COLONOSCOPY AND BIOPSY 6 $1694 $536 $859 $1244 $3071 $2013 $2164 $1972 59400 OBSTETRICAL CARE 1 $5107 $4688 $4607 $5730 $4654 $5855 70553 MRI BRAIN WO amp WDYE 2 $1482 $1052 $967 $1468 $1117 $2805 71020 CHEST X-RAY 2 $259 $72 $279 $266 $305 $375 71250 CT THORAX WO DYE 2 $541 $319 $491 $810 $505 $579 73721 MRI JNT OF LWR EXTRE WO DYE 2 $978 $557 $967 $1398 $1042 $925 74183 MRI ABDOMEN WO amp WDYE 2 $1436 $836 $967 $1468 $1106 $2805 76700 US EXAM ABDOM COMPLETE 2 $320 $133 $195 $538 $545 $190 77052 COMP SCREEN MAMMOGRAM ADD-ON 2 $45 $23 $15 $99 $41 $45 77052 COMP SCREEN MAMMOGRAM ADD-ON 5 $14 $14 80053 COMPREHEN METABOLIC PANEL 8 $29 $25 $13 $56 $15 $24 $22 $51 88305 TISSUE EXAM BY PATHOLOGIST 8 $174 $232 $188 $152 $307 $80 $179 $78 93306 TTE WDOPPLER COMPLETE 2 $1297 $1157 $1173 $1566 $1388 $1371 $1125 93017 STRESS TEST 5 $830 $797 $907 $432 $1299 $717 99203 OFFICEOUTPATIENT VISIT NEW 4 $139 $118 $159 G0202 Screeningmammographydigital 2 $329 $168 $294 $328 $431 $330 $425 G0202 Screeningmammographydigital 5 $231 $231
Service Line Procedure CPT Code Emory Atlanta Gastroenterology Associates Resurgens Atlanta Womens Health Piedmont Physicians Group Orthopedics (ASC) Knee Arthroscopy 29881 $3467 $2036 Arthroscopy Ligament Repair 29888 $3386 $2258 GI (ASC) Upper GI Endoscopy 43239 $2758 $536 Diagnostic Colonoscopy 45378 $2348 $536 Colonoscopy and biopsy 45380 $2181 $536 Radiology Mammogram Screening G0202 $164 $231 Computer Detection Add-on 77052 $93 $14 Lab Comp Metabolic Panel 80053 $53 $13 $22 Tissue Exam by Pathologist 88305 $277 $188 $179 EampM (TEC) Office Visit new pt 99203 $269 $118 $159
Service Line Procedure CPT CodeDRG Memorial Hospital Beta Hosptial Charlie Hospital Delta Hospital Echo Hospital Alpha Medical Center Atlanta Gastroenterology Associates Resurgens Atlanta Womens Health Piedmont Physicians Group Market Avg Emory abovebelow Orthopedics Arthroscopy Ligament Repair 29888 $ 5062 $ 9557 $ 5983 $ 10096 $ 7519 $ 2502 $ 2258 $ 6319 -20 Knee Arthroscopy 29881 6 $ 5069 $ 4185 $ 3837 $ 3022 $ 3729 $ 2266 $ 2036 $ 3179 59 GI Upper GI Endoscopy 43239 6 $ 3075 $ 2539 $ 2012 $ 1132 $ 1565 $ 2240 $ 536 $ 1671 84 Lap Sleeve Gastrectomy DRG 621 $ 20421 $ 20815 $ 12105 $ 13230 $ 14600 $ 17800 $ 15710 30 Colonoscopy and biopsy 45380 $ 3075 $ 3071 $ 2013 $ 1244 $ 1972 $ 859 $ 536 $ 1616 90 Diagnostic Colonoscopy 45378 6 $ 3075 $ 2805 $ 2013 $ 1244 $ 1972 $ 859 $ 536 $ 1572 96 Radiology MRI Brain w amp wo dye 70553 2 $ 1238 $ 1468 $ 1117 $ 967 $ 2805 $ 1052 $ 1482 -16 MRI Joint of Lower Extremity wo dye 73721 2 $ 1238 $ 1398 $ 1042 $ 967 $ 925 $ 557 $ 978 27 MRI Abdomen w amp wo dye 74183 2 $ 1238 $ 1468 $ 1106 $ 967 $ 2805 $ 836 $ 1436 -14 X-ray Chest 71020 $ 115 $ 266 $ 305 $ 279 $ 375 $ 72 $ 259 -56 CT Thorax wo dye 71250 $ 882 $ 810 $ 505 $ 491 $ 579 $ 319 $ 541 63 Ultrasound Abdomen Complete 76700 $ 397 $ 538 $ 545 $ 195 $ 190 $ 168 $ 327 21 Mammogram Screening G0202 2 $ 141 $ 328 $ 431 $ 294 $ 425 $ 168 $ 231 $ 313 -55 Computer Detection Add-on 77052 2 $ 112 $ 99 $ 41 $ 15 $ 45 $ 23 $ 14 $ 39 183 Lab Comp Metabolic Panel 80053 8 $ 56 $ 15 $ 24 $ 56 $ 51 $ 25 $ 13 $ 22 $ 29 88 Tissue Exam by Pathologist 88305 8 $ 236 $ 307 $ 80 $ 152 $ 78 $ 232 $ 188 $ 179 $ 174 36 Medical Cardiology Cardiovascular Stress Test 93017 $ 383 $ 432 $ 1299 $ 907 $ 717 $ 797 $ 830 -54 TTE w Doppler 93306 2 $ 960 $ 1566 $ 1388 $ 1173 $ 1125 $ 1157 $ 1282 -25 Obstetrics Vaginal Delivery DRG 755 $ 7290 $ 5730 $ 4654 $ 4607 $ 5855 $ 4688 $ 5107 43 EampM Office Visit new pt 99203 4 $ 248 $ 118 $ 159 $ 139 78 Colonoscopy and biopsy (HOSPITAL ONLY) 45380 Surg 2530 $ 307591 Diagnostic colonoscopy (HOSPITAL ONLY) 45378 Surg 2255 $ 307591 Upper gi endoscopy biopsy (HOSPITAL ONLY) 43239 Surg 1787 $ 307591 Knee Arthroscopy (HOSPITAL ONLY) 29881 Surg 10900 $ 506893 Arthroscopy Ligament Repair (HOSPITAL ONLY) 29888 Surg 10900 $ 506200 Key 1 Facility - Inpatient 2 Facility - Imaging 3 Physician - Imaging 4 Physician 5 Global - Imaging 6 Facility - Outpatient 8 Lab 41 Physician - Primary Care 42 Physician - Specialist
Blue Cross United - EJCH EUH EUHM WW United - SJH Non Options United - SJH Options Aetna - ASC TEC (HMO) Cigna - ASC TEC (HMO) Aetna - EJCH ESJH ECHM WW Cigna - EJCH (HMO) Cigna - ESJH EUHM (HMO) List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract Description CPT Code Charge Average Final Price (all plans) Emory Mark Up Reimbursement Method ( of charge or fixed) - 1713 Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Cardiovascular stress test 93017 Cardio $543 $ 425 28 of Charge 70 $ 380 of Charge 65 $ 353 of Charge 60 $ 326 of Charge 70 $ 380 of Charge 70 $ 380 of charge 100 $ 543 of Charge 70 $ 380 of charge 100 $ 543 of charge 100 $ 543 TTE wDoppler complete 93306 Cardio $1226 $ 960 28 of Charge 70 $ 858 of Charge 65 $ 797 of Charge 60 $ 736 of Charge 70 $ 858 of Charge 70 $ 858 of charge 100 $ 1226 of Charge 70 $ 858 of charge 100 $ 1226 of charge 100 $ 1226 Colonoscopy and biopsy (HOSPITAL ONLY) 45380 Surg $2530 $ 3076 -18 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 of Charge 70 $ 1771 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Diagnostic colonoscopy (HOSPITAL ONLY) 45378 Surg $2255 $ 3076 -27 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 of Charge 70 $ 1579 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Upper gi endoscopy biopsy (HOSPITAL ONLY) 43239 Surg $1787 $ 3076 -42 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Knee Arthroscopy (HOSPITAL ONLY) 29881 Surg $10900 $ 5069 115 Fixed Rate SC 4 $ 3865 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 449300 $ 4493 Fixed Rate $ 654700 $ 6547 of Charge 70 $ 7630 Fixed Rate $ 401000 $ 4010 of Charge 70 $ 7630 Fixed Rate $ 398300 $ 3983 Fixed Rate $ 398100 $ 3981 Arthroscopy Ligament Repair (HOSPITAL ONLY) 29888 Surg $10900 $ 5062 115 Fixed Rate SC 3 $ 3121 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 556900 $ 5569 Fixed Rate $ 770100 $ 7701 of Charge 70 $ 7630 Fixed Rate $ 323900 $ 3239 of Charge 70 $ 7630 Fixed Rate $ 321700 $ 3217 Fixed Rate $ 321400 $ 3214 Comp Metabolic Panel 80053 Lab $132 $ 56 138 RBRVS Fee (100) $ 1437 of Charge 65 $ 86 of Charge 65 $ 86 of Charge 65 $ 86 of Charge 70 $ 92 RBRVS Fee (100) $ 1437 $ 14 of Charge 70 $ 92 RBRVS Fee (100) $ 1437 $ 14 RBRVS Fee (100) $ 1437 $ 14 Surgical Path Tissue Exam 88305 Lab $326 $ 236 38 of Charge 150 $ 51 of Charge 65 $ 212 of Charge 65 $ 212 of Charge 65 $ 212 of Charge 70 $ 228 of charge 100 $ 326 of Charge 70 $ 228 of charge 100 $ 326 of charge 100 $ 326 MRI Abdomen 74183 Radiology $6960 $ 1238 462 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 MRI Brain 70553 Radiology $6804 $ 1238 450 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 MRI Joint Lower Extremity 73721 Radiology $3067 $ 1238 148 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 CT Thorax wo contrast 71250 Radiology $2199 $ 882 149 Fixed Rate $ 771 Fixed Rate $ 47100 $ 471 Fixed Rate $ 81700 $ 817 Fixed Rate $ 116000 $ 1160 of Charge 70 $ 1539 Fixed Rate $ 80100 $ 801 Fixed Rate $ 79200 $ 792 Fixed Rate $ 79300 $ 793 Fixed Rate $ 79500 $ 795 X-ray Chest 71020 Radiology $280 $ 115 142 of Charge 150 $ 25 of Charge 65 $ 182 of Charge 60 $ 168 of Charge 70 $ 196 of Charge 70 $ 196 RBRVS Fee (150) $ 2534 $ 25 of Charge 70 $ 196 RBRVS Fee (150) $ 2534 $ 25 RBRVS Fee (150) $ 2534 $ 25 Screening mammography G0202 Radiology $279 $ 141 98 Fixed Rate $ 128 Fixed Rate $ 13100 $ 131 Fixed Rate $ 14300 $ 143 Fixed Rate $ 16100 $ 161 of Charge 70 $ 195 Fixed Rate $ 13300 $ 133 Fixed Rate $ 13500 $ 135 Fixed Rate $ 13000 $ 130 Fixed Rate $ 11200 $ 112 Mammo Computer Aided 77052 Radiology $75 $ 112 -33 Fixed Rate $ 9 Fixed Rate $ 13100 $ 131 Fixed Rate $ 14300 $ 143 Fixed Rate $ 16100 $ 161 of Charge 70 $ 53 Fixed Rate $ 13300 $ 133 Fixed Rate $ 13500 $ 135 Fixed Rate $ 13000 $ 130 Fixed Rate $ 11200 $ 112 US Abdomen Complete 76700 Radiology $917 $ 397 131 of Charge 150 $ 125 of Charge 65 $ 596 of Charge 60 $ 550 of Charge 70 $ 642 of Charge 70 $ 642 RBRVS Fee (150) $ 12519 $ 125 of Charge 70 $ 642 RBRVS Fee (150) $ 12519 $ 125 RBRVS Fee (150) $ 12519 $ 125 Officeoutpatient visit new pt 30 min (TEC) 99203 EampM $316 $ 248 28 of Charge 70 $ 221 of Charge 65 $ 205 of Charge 60 $ 190 of Charge 70 $ 221 of Charge 70 $ 221 of charge 100 $ 316 of Charge 70 $ 221 of charge 100 $ 316 of charge 100 $ 316 Vaginal delivery 59409 Surg $14484 $ 7290 99 Fixed Rate DRG - 775 $ 5437 2 Day Case Rate + LOC 561700 $ 5617 BaseCMS Weight 584741 $ 5847 BaseCMS Weight 726146 $ 7261 No IP Terms $ - 0 No IP BaseCMS Weight 659343 $ 6593 BaseContract Weight 479451 100 $ 14484 BaseCMS Weight 579110 $ 5791 Lap Sleeve Gastrectomy 43775 Surg $29961 $ 20421 47 Fixed Rate DRG - 621 $ 14872 BaseCMS Weight 1810697 $ 18107 BaseCMS Weight 1835178 $ 18352 BaseCMS Weight 2278911 $ 22789 No IP Terms $ - 0 No IP BaseCMS Weight 2069315 $ 20693 BaseCMS Weight 1730442 100 $ 29961 BaseCMS Weight 1817507 $ 18175 105 Colonoscopy and biopsy (ASC ONLY) Surg $ 219200 $ 2181 Diagnostic colonoscopy (ASC ONLY) Surg $ 267100 $ 2348 Upper gi endoscopy biopsy (ASC ONLY) Surg $ 207500 $ 2758 Knee Arthroscopy (ASC ONLY) Surg $ 417900 $ 3467 Arthroscopy Ligament Repair (ASC ONLY) Surg $ 504800 $ 3386
Cpt Code CPT Description Procedure Category Claims Min 25thNtile 50thNtile Emorys Rates 75thNtile 90thNtile Max 20 Below 50th Ntile 20 Above 50th Ntile 93017 CARDIOVASCULAR STRESS TEST 5 82 $80 $125 $321 $382 $568 $791 $930 $257 $386 71020 CHEST X-RAY 2 2638 $11 $45 $152 $115 $289 $373 $585 $122 $182 71020 CHEST X-RAY 5 8106 $25 $34 $38 $54 $57 $69 $30 $46 45380 COLONOSCOPY AND BIOPSY 6 1256 $541 $560 $572 $2877 $1000 $2024 $3289 $458 $686 77052 COMP SCREEN MAMMOGRAM ADD-ON 2 194 $13 $15 $25 $38 $47 $134 $20 $30 77052 COMP SCREEN MAMMOGRAM ADD-ON 5 2411 $13 $16 $20 $23 $26 $28 $16 $24 80053 COMPREHEN METABOLIC PANEL 8 13019 $9 $19 $23 $55 $24 $25 $69 $19 $28 71250 CT THORAX WO DYE 2 302 $165 $372 $545 $878 $1658 $2067 $436 $654 71250 CT THORAX WO DYE 5 209 $53 $127 $203 $289 $419 $534 $162 $244 45378 DIAGNOSTIC COLONOSCOPY 6 1479 $484 $515 $536 $2914 $831 $1971 $2828 $428 $643 29881 KNEE ARTHROSCOPYSURGERY 6 152 $1650 $1826 $2036 $5235 $3054 $4216 $6461 $1629 $2443 29888 KNEE ARTHROSCOPYSURGERY 6 82 $1682 $3615 $5081 $5145 $7553 $12924 $18532 $4065 $6097 43644 LAP GASTRIC BYPASSROUX-EN-Y 1 21 $11821 $13873 $17050 $18391 $25029 $31079 $13640 $20460 43775 LAP SLEEVE GASTRECTOMY 1 38 $4215 $8250 $13253 $20421 $19197 $21509 $24260 $10602 $15903 74183 MRI ABDOMEN WO amp WDYE 2 120 $919 $987 $1015 $1237 $1252 $2534 $3177 $812 $1218 74183 MRI ABDOMEN WO amp WDYE 5 112 $475 $490 $521 $1154 $1337 $1696 $417 $625 70553 MRI BRAIN WO amp WDYE 2 324 $633 $987 $1142 $1237 $1706 $2805 $3331 $914 $1370 70553 MRI BRAIN WO amp WDYE 5 467 $280 $539 $1023 $1277 $1363 $1726 $818 $1228 73721 MRI JNT OF LWR EXTRE WO DYE 2 304 $804 $859 $967 $1237 $1063 $1598 $2485 $774 $1160 73721 MRI JNT OF LWR EXTRE WO DYE 5 1130 $500 $520 $530 $628 $679 $859 $424 $636 59400 OBSTETRICAL CARE 1 494 $3699 $4402 $4969 $6655 $7307 $8613 $3975 $5963 99203 OFFICEOUTPATIENT VISIT NEW 4 6776 $88 $101 $112 $138 $155 $169 $90 $134 G0202 Screeningmammographydigital 2 7444 $123 $206 $285 $380 $425 $479 $228 $342 G0202 Screeningmammographydigital 5 2754 $117 $165 $195 $230 $247 $252 $156 $234 88305 TISSUE EXAM BY PATHOLOGIST 8 20834 $51 $74 $112 $235 $168 $261 $478 $90 $134 93306 TTE WDOPPLER COMPLETE 2 931 $194 $377 $739 $960 $1267 $1480 $1849 $591 $887 93306 TTE WDOPPLER COMPLETE 5 2299 $151 $296 $373 $538 $573 $834 $298 $448 43239 UPPER GI ENDOSCOPY BIOPSY 6 1264 $424 $514 $550 $800 $1838 $2833 $440 $660 76700 US EXAM ABDOM COMPLETE 2 321 $96 $165 $271 $509 $584 $857 $217 $325 76700 US EXAM ABDOM COMPLETE 5 444 $111 $129 $147 $156 $220 $279 $118 $176 Key 1 Facility - Inpatient 2 Facility - Imaging 3 Physician - Imaging 4 Physician 5 Global - Imaging 6 Facility - Outpatient 8 Lab 41 Physician - Primary Care 42 Physician - Specialist Cardiovascular stress test $ 38279 TTE wDoppler complete $ 96037 Colonoscopy and biopsy $ 287709 Diagnostic colonoscopy $ 291434 Upper gi endoscopy biopsy $ 300526 Knee Arthroscopy $ 523584 Arthroscopy Ligament Repair $ 514501 Comp Metabolic Panel $ 5552 Surgical Path Tissue Exam $ 23570 MRI Abdomen $ 123786 MRI Brain $ 123786 MRI Joint Lower Extremity $ 123786 CT Thorax wo contrast $ 88213 X-ray Chest $ 11548 Screening mammography $ 14098 Mammo Computer Aided $ 11179 US Abdomen Complete $ 39695 Officeoutpatient visit new pt 30 min $ 24753 Vaginal delivery $ 729025 Lap Sleeve Gastrectomy $ 2042124
Page 18
Market Comparison Condition Prevalence
17 Source Multi-payer commercial benchmark Results are weighted by AgeGender Broader market area includes multi-payer data from the mountain regions
Condition Prevalence Benchmark Comparison
Condition Employer vs
Mt States Employer vs
National Prevalence Diabetes Rate 229 219 Prevalence Hyperlipidemia Rate 259 207 Prevalence Kidney Disease Rate 143 174 Prevalence Migraine Rate 166 164 Prevalence Low Back Pain Rate 136 139 Prevalence Hypertension Rate 156 134 Prevalence Asthma Rate 146 128 Prevalence CAD Rate 175 115 Prevalence Pregnancy Rate 110 109 Prevalence Adult Preventive Screening Rate 114 91 Prevalence Depression Rate 63 60
Strengths (+)
Rate of depression is low (Note May be due to incomplete behavioral health claims)
Opportunity (-)
Employer has a higher prevalence of most chronic conditions including asthma CAD diabetes hypertension hyperlipidemia Kidney Disease LBP and migraines
0
100
200
300Hyperlipidemia
Diabetes
CAD
Migraine
Hypertension
AsthmaKidney Disease
Low Back Pain
Pregnancy
Depression
Employer vsMt States
Employer vsNational Legend
vs Mt States
vs National
gt120 gt110 110-120 105-110
lt80 lt90
Market Comparison Utilization Rates
18
A higher preventive office visit rate is better Source Multi-payer commercial benchmark Results are weighted by AgeGender Broader market area includes multi-payer data from the mountain regions
Strengths (+)
Lower than average utilization of ED and high dollar patient rate
Opportunity (-)
Higher LOS lengthy admits avoidable admits and readmissions which all drive significantly more spend
Utilization Benchmark Comparison
Condition Employer vs
Mt States Employer vs
National Avoidable Admit Rate 142 144 Lengthy Admit Rate 175 136 Outpatient Problem Focused Office Rate 146 131 Readmission Rate (readmitadmit) 135 126 Average LOS 125 116 One Day Admit Rate 76 103 Office Visit Rate 106 96 Acute Admit Rate 80 95 Avoidable ED Rate 68 86 ED Rate 54 69 Preventive Office Rate 95 68 High Dollar Patient Rate 49 51 Frequent ED User (gt3 times) Rate 24 36
Legend vs
Mt States vs
National gt120 gt110
110-120 105-110 lt80 lt90
0 50 100 150 200
Frequent ED User (gt3 times)
High Dollar Patient
Preventive Office
ED
Avoidable ED
Acute Admit
Office Visit
One Day Admit
Average LOS
Readmissionhellip
Outpt Problem Focusedhellip
Lengthy Admit
Avoidable Admit
Employer vsNational
Employer vsMt States
ED and Avoidable ED
19
Potentially Avoidable ED - Trend View Overall ED
Period Change FY 2017 FY 2018 Count Rate
Measure Mbrs Rate Mbrs Rate Overall ED 16394 12626 13820 10745 -16 -15 FREQUENT ED UTILIZER (mbr1k) 1581 1218 1468 1141 -7 -6 AVOIDABLE ED 6371 4907 5288 4111 -17 -16 Potentially Avoidable ED
Period Change FY 2017 FY 2018 Count Rate
Avoid ED Condition Mbrs Rate Mbrs Rate ABDOMINAL_PAIN 1092 841 895 696 -18 -17 ENT_INFECTION 854 658 742 577 -13 -12 FEVER 715 551 700 544 -2 -1 URINARY 650 501 468 364 -28 -27 HEADACHE 558 430 434 337 -22 -21 BACK_PAIN 414 319 423 329 2 3 NAUSEA 394 303 271 211 -31 -31 ASTHMA 294 226 209 162 -29 -28 CELLULITIS 210 162 198 154 -6 -5 GASTROENTERITIS 254 196 171 133 -33 -32 OTITIS_MEDIA 201 155 160 124 -20 -20 COPD 132 102 108 084 -18 -17 DIABETES 123 095 91 071 -26 -25 BACT_PNEUMONIA 111 085 86 067 -23 -22 DENTAL 93 072 83 065 -11 -10 DEHYDRATION 98 075 81 063 -17 -17 HYPERTENSION 16 012 24 019 50 51 CHF 4 003 3 002 -25 -24 ANGINA 8 006 3 002 -63 -62 IMMUNIZATION_RELATED 2 002 0 000 -100 -100 Grand Total 6371 4907 5288 4111 -17 -16
AHRQ avoidable ED visits are based on the logic for ambulatory care sensitive ED visits from AHRQ and diagnosis code driven
696
577
544 364
337
329
211 162
154 133 ABDOMINAL_PAIN
ENT_INFECTION
FEVER
URINARY
HEADACHE
BACK_PAIN
NAUSEA
- 200 400 600 800
1000 1200
2017 Members 2018 Members
Top Ten 2018 Conditions by Rate
Top Ten Conditions by Member Count
ED Avoidable ED and the impact of new on-site clinic
20
0
1000
2000
3000
4000
5000
6000
0200400600800
10001200140016001800
Clinic Visits ED Visits
Avoidable ED VisitsED Visits (non-avoidable)Clinic EampM Visits
0
500000
1000000
1500000
2000000
2500000
3000000
3500000
$s
Clinic EampM Profess DollarsAvoidable ED Dollars
bull Clinic visits have a clear impact on ED and avoidable ED use and spend
bull Combined ED visits are down on average 157 in FY 18 from FY 17
bull Combined ED spend is down 128 in FY 18 from FY 17
Clinic Live 62017
Pitfalls and Challenges bull Face many of the challenges similar to startup health
plan bull Critical to determine how you will deliver value and
communicate the value to potential customers and brokersconsultants
bull Care management bull Network
21
Considerations in Offering Development bull Care Management Model
bull Traditional care model bull Case management bull Utilization management bull Disease management
bull Longitudinal care model with value based care philosophy bull Primary care driven bull Local care management
bull Predictive analytics and risk stratification model bull Claims history and ongoing data bull EMR data
22
Case Study 2
Case study 2 ndash Large Employer bull Business Problem Large employer wants to contract
directly with 2 major hospital systems developing professional fee schedules
bull ConsiderationsValue Prop Fee schedule should be competitive but also nuanced to minimize gap relative to current reimbursement at physician level
bull Solution Data-driven approach using current market-wide reimbursement distinguished by service level
24
Evaluate Provider Spend Top 25 Service Lines by Allowable Spend
Evaluate Provider Spend Top 20 Professional CPTs by Total Spend
Understand relative market pricing position
27
21
-1
-28
14 10
28
-22
-11 -13
24
3
20 21
8
-20
13
3 9
-39
56
-26
4
-42
60
MRI Colonoscopy Cardiac Cath Lab - OrganPanel
Memorial Hospital Beta Hospital Delta Hospital Charlie Hospital Echo Hospital Alpha Medical Center
ndash25 5 -15 10 0 39
State Charges as a Percent of Peer Average Weighted Averages for MRI Colonoscopy Cardiology and Lab
Total Percent Above Below Market Average2
Memorial Hospital Beta Hospital Delta Hospital Charlie Hospital Echo Hospital Alpha Medical Center
Develop fee schedule relative to market
28
Service Line Procedure CPT CodeDRG
Memorial Hospital
Beta Hosptial
Charlie Hospital
Delta Hospital
Echo Hospital
Alpha Medical Center
Arthroscopy Ligament Repair 29888 $ 5062 $ 9557 $ 5983 $ 10096 $ 7519 $ 2502 Knee Arthroscopy 29881 $ 5069 $ 4185 $ 3837 $ 3022 $ 3729 $ 2266 Upper GI Endoscopy 43239 $ 3075 $ 2539 $ 2012 $ 1132 $ 1565 $ 2240 Lap Sleeve Gastrectomy DRG 621 $ 20421 $ 20815 $ 12105 $ 13230 $ 14600 $ 17800 Colonoscopy and biopsy 45380 $ 3075 $ 3071 $ 2013 $ 1244 $ 1972 $ 859 Diagnostic Colonoscopy 45378 $ 3075 $ 2805 $ 2013 $ 1244 $ 1972 $ 859 MRI Brain w amp wo dye 70553 $ 1238 $ 1468 $ 1117 $ 967 $ 2805 $ 1052 MRI Joint of Lower Extremity wo dye 73721 $ 1238 $ 1398 $ 1042 $ 967 $ 925 $ 557 MRI Abdomen w amp wo dye 74183 $ 1238 $ 1468 $ 1106 $ 967 $ 2805 $ 836 X-ray Chest 71020 $ 115 $ 266 $ 305 $ 279 $ 375 $ 72 CT Thorax wo dye 71250 $ 882 $ 810 $ 505 $ 491 $ 579 $ 319 Ultrasound Abdomen Complete 76700 $ 397 $ 538 $ 545 $ 195 $ 190 $ 168 Mammogram Screening G0202 $ 141 $ 328 $ 431 $ 294 $ 425 $ 168 Computer Detection Add-on 77052 $ 112 $ 99 $ 41 $ 15 $ 45 $ 23 Comp Metabolic Panel 80053 $ 56 $ 15 $ 24 $ 56 $ 51 $ 25 Tissue Exam by Pathologist 88305 $ 236 $ 307 $ 80 $ 152 $ 78 $ 232 Cardiovascular Stress Test 93017 $ 383 $ 432 $ 1299 $ 907 $ 717 $ 797 TTE w Doppler 93306 $ 960 $ 1566 $ 1388 $ 1173 $ 1125 $ 1157
Obstetrics Vaginal Delivery DRG 755 7290$ 5730$ 4654$ 4607$ 5855$ 4688$
GI
Lab
Radiology
Medical Cardiology
Orthopedics
KEY OBSERVA TIONS bull Potential exposure on GI bull Opportunity to align price and acuity in MRI bull Opportunity to raise rates on chest x-ray and mammogram
Percentile Bands Emory Allowables Heatmap TEC ASC Heatmap Allowable Comp Analysis Portal Pricing Sheet1 image1png A few words on Bundled Payments bull Bundled payments are growing as a type of direct contracting bull In some cases third parties match-make between employers
and providers bull Contracts may vary in definitions prepost admission
coverage duration readmission cause (ie all-cause vs medically related) outlier provisions LOS caps andor per diems
bull Providers need to be strategic in pricing to enable profitable growth of market share
29
Considerations in Offering Development bull Network Development
bull Build off existing structure eg health system employee plan network bull How does this fit into your broader value based care strategy bull Employed and independent physicians bull How do you want to approach the buildout of high performance
network bull Quality focus bull Cost efficiency
bull Integrated behavioral health bull Wrap network for other markets
30
Considerations in Offering Development bull Target Market
bull Consideration of employer profile in market bull Fully-insured vs ASO bull Total cost of care vs bundled services
bull Distribution bull Direct marketing bull Brokerconsultant community
bull Plan designs bull Standard designs vs flexible ndash Dependent on target market
bull Claims administration bull Data sharing amp analytics
31
Considerations in Offering Development bull Other components of comprehensive offering
bull Pharmacy bull Preventive health bull Onsite clinics bull Wellness programs bull Technology platform
32
Sample Bundle Analysis
33
Cover page Dotson Hazelrigs Nation Mainly of charge of fixed Cardiovascular stress test TTE wDoppler complete Colonoscopy and biopsy (Combined) Diagnostic colonoscopy (Combined) Upper gi endoscopy biopsy (Combined) Knee Arthroscopy (Combined) Arthroscopy Ligament Repair Comp Metabolic Panel Surgical Path Tissue Exam MRI Abdomen MRI Brain MRI Joint Lower Extremity CT Thorax wo contrast X-ray Chest Screening mammography Mammo Computer Aided US Abdomen Complete Officeoutpatient visit new pt 30 min Vaginal delivery Lap Sleeve Gastrectomy
Piedmont Piedmont Piedmont Piedmont Northside Northside Northside Northside Gwinnett Gwinnett Gwinnett Gwinnett WellStar WellStar WellStar WellStar AMC - Tenet AMC - Tenet AMC - Tenet AMC - Tenet CPT Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing 29881 $11312 $10872 NA NA $7476 $9338 NA $23655 $11856 $3668 NA $17871 $12253 NA NA $15645 $5490 NA NA $23039 29888 NA NA NA NA NA NA NA $23784 NA $8261 NA $18000 NA NA NA $15774 NA NA NA $23168 43239 NA $4408 NA NA NA NA $5997 $8852 NA $3304 NA $7424 $1267 NA NA $9230 NA $2458 NA $8274 43644 $26468 NA NA NA $3382 $12050 NA $1861 NA NA NA $1316 $7841 NA NA $3444 $18892 $27950 NA $979 43775 NA NA NA NA NA NA NA $352 NA NA NA $302 NA NA NA $413 NA NA NA $83 45378 $2705 $2530 NA NA $4381 $3676 $4496 $1022 $2938 $2138 NA $695 $5504 NA NA $2036 NA NA NA $372 45380 $3075 $2600 NA NA $4723 $3527 $3012 $1757 $4215 $2285 NA NA $5298 NA NA $3268 NA NA NA $627 59400 $6160 NA NA NA NA $5100 NA $1851 NA NA NA $1304 $9035 NA NA $3427 $9116 $5150 NA $966 70553 $2985 NA $1153 NA $2182 NA $1192 $492 NA NA $803 $489 $1512 NA $985 $1187 NA NA NA $197 71020 $61 $69 $43 NA $113 $319 $307 NA $183 $59 $32 NA $213 $66 $40 NA $83 $53 NA NA 71250 $1837 $621 $989 NA $1490 $931 $755 NA NA $745 $401 NA $1067 $982 $616 NA NA $304 NA NA 73721 NA $1098 $1153 NA $2042 $1065 $1192 NA NA $998 $803 NA NA $1275 $985 NA NA $644 NA $178 74183 $2971 $1144 NA NA NA $1092 $1192 $6884 NA $1098 $803 NA $2960 $1197 $985 $5454 NA NA NA $7607 76700 $364 $247 $207 NA $427 $708 $614 $13267 $428 $214 $152 NA $747 $263 $189 $9139 NA $235 NA NA 77052 NA NA NA NA NA NA NA $4744 NA NA NA NA NA NA NA $3070 NA NA NA $5611 93306 $1220 $1117 NA NA $1877 $1657 $2100 $4605 $1433 $413 $945 NA $1336 $1434 $1951 $2931 NA $2399 NA $5472 G0202 $262 $187 NA NA $431 NA NA $4605 $292 NA NA NA $530 $281 NA $2931 $327 NA NA $5472
Provider Group 29881_6 29888_6 43239_6 43644_1 43775_1 45378_6 45380_6 59400_1 70553_2 71020_2 71250_2 73721_2 74183_2 76700_2 77052_2 77052_5 80053_8 88305_8 93306_2 99203_4 G0202_2 G0202_5 93017_2 Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Atlanta Gastroenterology Associates $2399 $536 348 $1628 $536 204 $2400 $536 348 Atlanta Medical Center $24889 $2266 999 $25897 $2502 935 $11449 $2240 411 $81927 $15300 435 $75815 $17800 326 $7317 $859 752 $7317 $859 752 $12821 $4688 173 $6581 $1052 526 $645 $72 796 $3265 $319 925 $3450 $557 519 $7398 $836 785 $1576 $133 1084 $73 $23 217 $635 $25 2440 $891 $232 285 $2967 $1157 156 $344 $168 105 $1265 $797 59 Atlanta Womens Health Physicians Group $29 $14 107 $40 $13 208 $396 $188 111 $278 $118 135 $450 $231 95 Gwinnett Hospital $11941 $3022 295 $21654 $10096 114 $3551 $1132 214 $34384 $10800 218 $56472 $13230 327 $3003 $1244 141 $3533 $1244 184 $8984 $4607 95 $3901 $967 303 $417 $279 49 $2247 $491 358 $4000 $967 314 $3755 $967 288 $1593 $195 717 $50 $15 233 $186 $56 233 $505 $152 233 $1750 $1173 49 $418 $294 42 $1396 $907 54 Northside Hospital $15482 $4185 270 $21651 $9557 127 $4885 $2539 92 $35176 $17000 107 $35233 $20815 69 $3883 $2805 38 $5256 $3071 71 $10911 $5730 90 $4856 $1468 231 $443 $266 67 $2379 $810 194 $3776 $1398 170 $5105 $1468 248 $942 $538 75 $167 $99 69 $379 $15 2427 $433 $307 41 $2252 $1566 44 $459 $328 40 $576 $432 33 Piedmont Hospital $14772 $3837 285 $35493 $5983 493 $5069 $2012 152 $38320 $17750 116 $37125 $12105 207 $3485 $2013 73 $4993 $2013 148 $10143 $4654 118 $5939 $1117 432 $542 $305 78 $2983 $505 491 $3410 $1042 227 $6067 $1106 449 $1364 $545 150 $75 $41 85 $231 $24 863 $657 $80 721 $2041 $1388 47 $490 $431 14 $1780 $1299 37 Piedmont Physicians Group $42 $22 87 $318 $179 78 $239 $159 50 Resurgens $8558 $2036 320 $9293 $2258 312 $4638 $2067 124 $4039 $2164 87 $4392 $2164 103 $2252 $1371 64 $459 $330 39 Wellstar Hospital $9330 $3729 150 $17479 $7519 132 $5261 $1565 236 $35794 $18200 97 $46780 $14600 220 $3707 $1972 88 $4928 $1972 150 $13549 $5855 131 $5054 $2805 80 $528 $375 41 $3222 $579 457 $3694 $925 299 $5495 $2805 96 $1355 $190 615 $66 $45 46 $73 $51 43 $133 $78 71 $1785 $1125 59 $599 $425 41 $1010 $717 41 Avg Mark UpProcedure Atlanta Medical Center 634 Gwinnett Hospital 223 Northside Hospital 233 Piedmont Hospital 259 Wellstar Hospital 155 Emory 105
Atlanta Gastroenterology Associates Atlanta Medical Center Atlanta Womens Health Gwinnett Hospital Northside Hospital Piedmont Hospital Piedmont Physicians Group Resurgens Wellstar Hospital CPT Code CPT Proc Cat Comp Avg Allow Allow Allow Allow Allow Allow Allow Allow Allow 29881 KNEE ARTHROSCOPYSURGERY 6 $3179 $2266 $3022 $4185 $3837 $2036 $3729 29888 KNEE ARTHROSCOPYSURGERY 6 $6319 $2502 $10096 $9557 $5983 $2258 $7519 43239 UPPER GI ENDOSCOPY BIOPSY 6 $1727 $536 $2240 $1132 $2539 $2012 $2067 $1565 43644 LAP GASTRIC BYPASSROUX-EN-Y 1 $15810 $15300 $10800 $17000 $17750 $18200 43775 LAP SLEEVE GASTRECTOMY 1 $17800 $13230 $20815 $12105 $14600 45378 DIAGNOSTIC COLONOSCOPY 6 $1656 $536 $859 $1244 $2805 $2013 $2164 $1972 45380 COLONOSCOPY AND BIOPSY 6 $1694 $536 $859 $1244 $3071 $2013 $2164 $1972 59400 OBSTETRICAL CARE 1 $5107 $4688 $4607 $5730 $4654 $5855 70553 MRI BRAIN WO amp WDYE 2 $1482 $1052 $967 $1468 $1117 $2805 71020 CHEST X-RAY 2 $259 $72 $279 $266 $305 $375 71250 CT THORAX WO DYE 2 $541 $319 $491 $810 $505 $579 73721 MRI JNT OF LWR EXTRE WO DYE 2 $978 $557 $967 $1398 $1042 $925 74183 MRI ABDOMEN WO amp WDYE 2 $1436 $836 $967 $1468 $1106 $2805 76700 US EXAM ABDOM COMPLETE 2 $320 $133 $195 $538 $545 $190 77052 COMP SCREEN MAMMOGRAM ADD-ON 2 $45 $23 $15 $99 $41 $45 77052 COMP SCREEN MAMMOGRAM ADD-ON 5 $14 $14 80053 COMPREHEN METABOLIC PANEL 8 $29 $25 $13 $56 $15 $24 $22 $51 88305 TISSUE EXAM BY PATHOLOGIST 8 $174 $232 $188 $152 $307 $80 $179 $78 93306 TTE WDOPPLER COMPLETE 2 $1297 $1157 $1173 $1566 $1388 $1371 $1125 93017 STRESS TEST 5 $830 $797 $907 $432 $1299 $717 99203 OFFICEOUTPATIENT VISIT NEW 4 $139 $118 $159 G0202 Screeningmammographydigital 2 $329 $168 $294 $328 $431 $330 $425 G0202 Screeningmammographydigital 5 $231 $231
Service Line Procedure CPT Code Emory Atlanta Gastroenterology Associates Resurgens Atlanta Womens Health Piedmont Physicians Group Orthopedics (ASC) Knee Arthroscopy 29881 $3467 $2036 Arthroscopy Ligament Repair 29888 $3386 $2258 GI (ASC) Upper GI Endoscopy 43239 $2758 $536 Diagnostic Colonoscopy 45378 $2348 $536 Colonoscopy and biopsy 45380 $2181 $536 Radiology Mammogram Screening G0202 $164 $231 Computer Detection Add-on 77052 $93 $14 Lab Comp Metabolic Panel 80053 $53 $13 $22 Tissue Exam by Pathologist 88305 $277 $188 $179 EampM (TEC) Office Visit new pt 99203 $269 $118 $159
Service Line Procedure CPT CodeDRG Memorial Hospital Beta Hosptial Charlie Hospital Delta Hospital Echo Hospital Alpha Medical Center Atlanta Gastroenterology Associates Resurgens Atlanta Womens Health Piedmont Physicians Group Market Avg Emory abovebelow Orthopedics Arthroscopy Ligament Repair 29888 $ 5062 $ 9557 $ 5983 $ 10096 $ 7519 $ 2502 $ 2258 $ 6319 -20 Knee Arthroscopy 29881 6 $ 5069 $ 4185 $ 3837 $ 3022 $ 3729 $ 2266 $ 2036 $ 3179 59 GI Upper GI Endoscopy 43239 6 $ 3075 $ 2539 $ 2012 $ 1132 $ 1565 $ 2240 $ 536 $ 1671 84 Lap Sleeve Gastrectomy DRG 621 $ 20421 $ 20815 $ 12105 $ 13230 $ 14600 $ 17800 $ 15710 30 Colonoscopy and biopsy 45380 $ 3075 $ 3071 $ 2013 $ 1244 $ 1972 $ 859 $ 536 $ 1616 90 Diagnostic Colonoscopy 45378 6 $ 3075 $ 2805 $ 2013 $ 1244 $ 1972 $ 859 $ 536 $ 1572 96 Radiology MRI Brain w amp wo dye 70553 2 $ 1238 $ 1468 $ 1117 $ 967 $ 2805 $ 1052 $ 1482 -16 MRI Joint of Lower Extremity wo dye 73721 2 $ 1238 $ 1398 $ 1042 $ 967 $ 925 $ 557 $ 978 27 MRI Abdomen w amp wo dye 74183 2 $ 1238 $ 1468 $ 1106 $ 967 $ 2805 $ 836 $ 1436 -14 X-ray Chest 71020 $ 115 $ 266 $ 305 $ 279 $ 375 $ 72 $ 259 -56 CT Thorax wo dye 71250 $ 882 $ 810 $ 505 $ 491 $ 579 $ 319 $ 541 63 Ultrasound Abdomen Complete 76700 $ 397 $ 538 $ 545 $ 195 $ 190 $ 168 $ 327 21 Mammogram Screening G0202 2 $ 141 $ 328 $ 431 $ 294 $ 425 $ 168 $ 231 $ 313 -55 Computer Detection Add-on 77052 2 $ 112 $ 99 $ 41 $ 15 $ 45 $ 23 $ 14 $ 39 183 Lab Comp Metabolic Panel 80053 8 $ 56 $ 15 $ 24 $ 56 $ 51 $ 25 $ 13 $ 22 $ 29 88 Tissue Exam by Pathologist 88305 8 $ 236 $ 307 $ 80 $ 152 $ 78 $ 232 $ 188 $ 179 $ 174 36 Medical Cardiology Cardiovascular Stress Test 93017 $ 383 $ 432 $ 1299 $ 907 $ 717 $ 797 $ 830 -54 TTE w Doppler 93306 2 $ 960 $ 1566 $ 1388 $ 1173 $ 1125 $ 1157 $ 1282 -25 Obstetrics Vaginal Delivery DRG 755 $ 7290 $ 5730 $ 4654 $ 4607 $ 5855 $ 4688 $ 5107 43 EampM Office Visit new pt 99203 4 $ 248 $ 118 $ 159 $ 139 78 Colonoscopy and biopsy (HOSPITAL ONLY) 45380 Surg 2530 $ 307591 Diagnostic colonoscopy (HOSPITAL ONLY) 45378 Surg 2255 $ 307591 Upper gi endoscopy biopsy (HOSPITAL ONLY) 43239 Surg 1787 $ 307591 Knee Arthroscopy (HOSPITAL ONLY) 29881 Surg 10900 $ 506893 Arthroscopy Ligament Repair (HOSPITAL ONLY) 29888 Surg 10900 $ 506200 Key 1 Facility - Inpatient 2 Facility - Imaging 3 Physician - Imaging 4 Physician 5 Global - Imaging 6 Facility - Outpatient 8 Lab 41 Physician - Primary Care 42 Physician - Specialist
Blue Cross United - EJCH EUH EUHM WW United - SJH Non Options United - SJH Options Aetna - ASC TEC (HMO) Cigna - ASC TEC (HMO) Aetna - EJCH ESJH ECHM WW Cigna - EJCH (HMO) Cigna - ESJH EUHM (HMO) List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract Description CPT Code Charge Average Final Price (all plans) Emory Mark Up Reimbursement Method ( of charge or fixed) - 1713 Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Cardiovascular stress test 93017 Cardio $543 $ 425 28 of Charge 70 $ 380 of Charge 65 $ 353 of Charge 60 $ 326 of Charge 70 $ 380 of Charge 70 $ 380 of charge 100 $ 543 of Charge 70 $ 380 of charge 100 $ 543 of charge 100 $ 543 TTE wDoppler complete 93306 Cardio $1226 $ 960 28 of Charge 70 $ 858 of Charge 65 $ 797 of Charge 60 $ 736 of Charge 70 $ 858 of Charge 70 $ 858 of charge 100 $ 1226 of Charge 70 $ 858 of charge 100 $ 1226 of charge 100 $ 1226 Colonoscopy and biopsy (HOSPITAL ONLY) 45380 Surg $2530 $ 3076 -18 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 of Charge 70 $ 1771 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Diagnostic colonoscopy (HOSPITAL ONLY) 45378 Surg $2255 $ 3076 -27 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 of Charge 70 $ 1579 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Upper gi endoscopy biopsy (HOSPITAL ONLY) 43239 Surg $1787 $ 3076 -42 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Knee Arthroscopy (HOSPITAL ONLY) 29881 Surg $10900 $ 5069 115 Fixed Rate SC 4 $ 3865 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 449300 $ 4493 Fixed Rate $ 654700 $ 6547 of Charge 70 $ 7630 Fixed Rate $ 401000 $ 4010 of Charge 70 $ 7630 Fixed Rate $ 398300 $ 3983 Fixed Rate $ 398100 $ 3981 Arthroscopy Ligament Repair (HOSPITAL ONLY) 29888 Surg $10900 $ 5062 115 Fixed Rate SC 3 $ 3121 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 556900 $ 5569 Fixed Rate $ 770100 $ 7701 of Charge 70 $ 7630 Fixed Rate $ 323900 $ 3239 of Charge 70 $ 7630 Fixed Rate $ 321700 $ 3217 Fixed Rate $ 321400 $ 3214 Comp Metabolic Panel 80053 Lab $132 $ 56 138 RBRVS Fee (100) $ 1437 of Charge 65 $ 86 of Charge 65 $ 86 of Charge 65 $ 86 of Charge 70 $ 92 RBRVS Fee (100) $ 1437 $ 14 of Charge 70 $ 92 RBRVS Fee (100) $ 1437 $ 14 RBRVS Fee (100) $ 1437 $ 14 Surgical Path Tissue Exam 88305 Lab $326 $ 236 38 of Charge 150 $ 51 of Charge 65 $ 212 of Charge 65 $ 212 of Charge 65 $ 212 of Charge 70 $ 228 of charge 100 $ 326 of Charge 70 $ 228 of charge 100 $ 326 of charge 100 $ 326 MRI Abdomen 74183 Radiology $6960 $ 1238 462 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 MRI Brain 70553 Radiology $6804 $ 1238 450 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 MRI Joint Lower Extremity 73721 Radiology $3067 $ 1238 148 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 CT Thorax wo contrast 71250 Radiology $2199 $ 882 149 Fixed Rate $ 771 Fixed Rate $ 47100 $ 471 Fixed Rate $ 81700 $ 817 Fixed Rate $ 116000 $ 1160 of Charge 70 $ 1539 Fixed Rate $ 80100 $ 801 Fixed Rate $ 79200 $ 792 Fixed Rate $ 79300 $ 793 Fixed Rate $ 79500 $ 795 X-ray Chest 71020 Radiology $280 $ 115 142 of Charge 150 $ 25 of Charge 65 $ 182 of Charge 60 $ 168 of Charge 70 $ 196 of Charge 70 $ 196 RBRVS Fee (150) $ 2534 $ 25 of Charge 70 $ 196 RBRVS Fee (150) $ 2534 $ 25 RBRVS Fee (150) $ 2534 $ 25 Screening mammography G0202 Radiology $279 $ 141 98 Fixed Rate $ 128 Fixed Rate $ 13100 $ 131 Fixed Rate $ 14300 $ 143 Fixed Rate $ 16100 $ 161 of Charge 70 $ 195 Fixed Rate $ 13300 $ 133 Fixed Rate $ 13500 $ 135 Fixed Rate $ 13000 $ 130 Fixed Rate $ 11200 $ 112 Mammo Computer Aided 77052 Radiology $75 $ 112 -33 Fixed Rate $ 9 Fixed Rate $ 13100 $ 131 Fixed Rate $ 14300 $ 143 Fixed Rate $ 16100 $ 161 of Charge 70 $ 53 Fixed Rate $ 13300 $ 133 Fixed Rate $ 13500 $ 135 Fixed Rate $ 13000 $ 130 Fixed Rate $ 11200 $ 112 US Abdomen Complete 76700 Radiology $917 $ 397 131 of Charge 150 $ 125 of Charge 65 $ 596 of Charge 60 $ 550 of Charge 70 $ 642 of Charge 70 $ 642 RBRVS Fee (150) $ 12519 $ 125 of Charge 70 $ 642 RBRVS Fee (150) $ 12519 $ 125 RBRVS Fee (150) $ 12519 $ 125 Officeoutpatient visit new pt 30 min (TEC) 99203 EampM $316 $ 248 28 of Charge 70 $ 221 of Charge 65 $ 205 of Charge 60 $ 190 of Charge 70 $ 221 of Charge 70 $ 221 of charge 100 $ 316 of Charge 70 $ 221 of charge 100 $ 316 of charge 100 $ 316 Vaginal delivery 59409 Surg $14484 $ 7290 99 Fixed Rate DRG - 775 $ 5437 2 Day Case Rate + LOC 561700 $ 5617 BaseCMS Weight 584741 $ 5847 BaseCMS Weight 726146 $ 7261 No IP Terms $ - 0 No IP BaseCMS Weight 659343 $ 6593 BaseContract Weight 479451 100 $ 14484 BaseCMS Weight 579110 $ 5791 Lap Sleeve Gastrectomy 43775 Surg $29961 $ 20421 47 Fixed Rate DRG - 621 $ 14872 BaseCMS Weight 1810697 $ 18107 BaseCMS Weight 1835178 $ 18352 BaseCMS Weight 2278911 $ 22789 No IP Terms $ - 0 No IP BaseCMS Weight 2069315 $ 20693 BaseCMS Weight 1730442 100 $ 29961 BaseCMS Weight 1817507 $ 18175 105 Colonoscopy and biopsy (ASC ONLY) Surg $ 219200 $ 2181 Diagnostic colonoscopy (ASC ONLY) Surg $ 267100 $ 2348 Upper gi endoscopy biopsy (ASC ONLY) Surg $ 207500 $ 2758 Knee Arthroscopy (ASC ONLY) Surg $ 417900 $ 3467 Arthroscopy Ligament Repair (ASC ONLY) Surg $ 504800 $ 3386
Cpt Code CPT Description Procedure Category Claims Min 25thNtile 50thNtile Emorys Rates 75thNtile 90thNtile Max 20 Below 50th Ntile 20 Above 50th Ntile 93017 CARDIOVASCULAR STRESS TEST 5 82 $80 $125 $321 $382 $568 $791 $930 $257 $386 71020 CHEST X-RAY 2 2638 $11 $45 $152 $115 $289 $373 $585 $122 $182 71020 CHEST X-RAY 5 8106 $25 $34 $38 $54 $57 $69 $30 $46 45380 COLONOSCOPY AND BIOPSY 6 1256 $541 $560 $572 $2877 $1000 $2024 $3289 $458 $686 77052 COMP SCREEN MAMMOGRAM ADD-ON 2 194 $13 $15 $25 $38 $47 $134 $20 $30 77052 COMP SCREEN MAMMOGRAM ADD-ON 5 2411 $13 $16 $20 $23 $26 $28 $16 $24 80053 COMPREHEN METABOLIC PANEL 8 13019 $9 $19 $23 $55 $24 $25 $69 $19 $28 71250 CT THORAX WO DYE 2 302 $165 $372 $545 $878 $1658 $2067 $436 $654 71250 CT THORAX WO DYE 5 209 $53 $127 $203 $289 $419 $534 $162 $244 45378 DIAGNOSTIC COLONOSCOPY 6 1479 $484 $515 $536 $2914 $831 $1971 $2828 $428 $643 29881 KNEE ARTHROSCOPYSURGERY 6 152 $1650 $1826 $2036 $5235 $3054 $4216 $6461 $1629 $2443 29888 KNEE ARTHROSCOPYSURGERY 6 82 $1682 $3615 $5081 $5145 $7553 $12924 $18532 $4065 $6097 43644 LAP GASTRIC BYPASSROUX-EN-Y 1 21 $11821 $13873 $17050 $18391 $25029 $31079 $13640 $20460 43775 LAP SLEEVE GASTRECTOMY 1 38 $4215 $8250 $13253 $20421 $19197 $21509 $24260 $10602 $15903 74183 MRI ABDOMEN WO amp WDYE 2 120 $919 $987 $1015 $1237 $1252 $2534 $3177 $812 $1218 74183 MRI ABDOMEN WO amp WDYE 5 112 $475 $490 $521 $1154 $1337 $1696 $417 $625 70553 MRI BRAIN WO amp WDYE 2 324 $633 $987 $1142 $1237 $1706 $2805 $3331 $914 $1370 70553 MRI BRAIN WO amp WDYE 5 467 $280 $539 $1023 $1277 $1363 $1726 $818 $1228 73721 MRI JNT OF LWR EXTRE WO DYE 2 304 $804 $859 $967 $1237 $1063 $1598 $2485 $774 $1160 73721 MRI JNT OF LWR EXTRE WO DYE 5 1130 $500 $520 $530 $628 $679 $859 $424 $636 59400 OBSTETRICAL CARE 1 494 $3699 $4402 $4969 $6655 $7307 $8613 $3975 $5963 99203 OFFICEOUTPATIENT VISIT NEW 4 6776 $88 $101 $112 $138 $155 $169 $90 $134 G0202 Screeningmammographydigital 2 7444 $123 $206 $285 $380 $425 $479 $228 $342 G0202 Screeningmammographydigital 5 2754 $117 $165 $195 $230 $247 $252 $156 $234 88305 TISSUE EXAM BY PATHOLOGIST 8 20834 $51 $74 $112 $235 $168 $261 $478 $90 $134 93306 TTE WDOPPLER COMPLETE 2 931 $194 $377 $739 $960 $1267 $1480 $1849 $591 $887 93306 TTE WDOPPLER COMPLETE 5 2299 $151 $296 $373 $538 $573 $834 $298 $448 43239 UPPER GI ENDOSCOPY BIOPSY 6 1264 $424 $514 $550 $800 $1838 $2833 $440 $660 76700 US EXAM ABDOM COMPLETE 2 321 $96 $165 $271 $509 $584 $857 $217 $325 76700 US EXAM ABDOM COMPLETE 5 444 $111 $129 $147 $156 $220 $279 $118 $176 Key 1 Facility - Inpatient 2 Facility - Imaging 3 Physician - Imaging 4 Physician 5 Global - Imaging 6 Facility - Outpatient 8 Lab 41 Physician - Primary Care 42 Physician - Specialist Cardiovascular stress test $ 38279 TTE wDoppler complete $ 96037 Colonoscopy and biopsy $ 287709 Diagnostic colonoscopy $ 291434 Upper gi endoscopy biopsy $ 300526 Knee Arthroscopy $ 523584 Arthroscopy Ligament Repair $ 514501 Comp Metabolic Panel $ 5552 Surgical Path Tissue Exam $ 23570 MRI Abdomen $ 123786 MRI Brain $ 123786 MRI Joint Lower Extremity $ 123786 CT Thorax wo contrast $ 88213 X-ray Chest $ 11548 Screening mammography $ 14098 Mammo Computer Aided $ 11179 US Abdomen Complete $ 39695 Officeoutpatient visit new pt 30 min $ 24753 Vaginal delivery $ 729025 Lap Sleeve Gastrectomy $ 2042124
Page 19
Market Comparison Utilization Rates
18
A higher preventive office visit rate is better Source Multi-payer commercial benchmark Results are weighted by AgeGender Broader market area includes multi-payer data from the mountain regions
Strengths (+)
Lower than average utilization of ED and high dollar patient rate
Opportunity (-)
Higher LOS lengthy admits avoidable admits and readmissions which all drive significantly more spend
Utilization Benchmark Comparison
Condition Employer vs
Mt States Employer vs
National Avoidable Admit Rate 142 144 Lengthy Admit Rate 175 136 Outpatient Problem Focused Office Rate 146 131 Readmission Rate (readmitadmit) 135 126 Average LOS 125 116 One Day Admit Rate 76 103 Office Visit Rate 106 96 Acute Admit Rate 80 95 Avoidable ED Rate 68 86 ED Rate 54 69 Preventive Office Rate 95 68 High Dollar Patient Rate 49 51 Frequent ED User (gt3 times) Rate 24 36
Legend vs
Mt States vs
National gt120 gt110
110-120 105-110 lt80 lt90
0 50 100 150 200
Frequent ED User (gt3 times)
High Dollar Patient
Preventive Office
ED
Avoidable ED
Acute Admit
Office Visit
One Day Admit
Average LOS
Readmissionhellip
Outpt Problem Focusedhellip
Lengthy Admit
Avoidable Admit
Employer vsNational
Employer vsMt States
ED and Avoidable ED
19
Potentially Avoidable ED - Trend View Overall ED
Period Change FY 2017 FY 2018 Count Rate
Measure Mbrs Rate Mbrs Rate Overall ED 16394 12626 13820 10745 -16 -15 FREQUENT ED UTILIZER (mbr1k) 1581 1218 1468 1141 -7 -6 AVOIDABLE ED 6371 4907 5288 4111 -17 -16 Potentially Avoidable ED
Period Change FY 2017 FY 2018 Count Rate
Avoid ED Condition Mbrs Rate Mbrs Rate ABDOMINAL_PAIN 1092 841 895 696 -18 -17 ENT_INFECTION 854 658 742 577 -13 -12 FEVER 715 551 700 544 -2 -1 URINARY 650 501 468 364 -28 -27 HEADACHE 558 430 434 337 -22 -21 BACK_PAIN 414 319 423 329 2 3 NAUSEA 394 303 271 211 -31 -31 ASTHMA 294 226 209 162 -29 -28 CELLULITIS 210 162 198 154 -6 -5 GASTROENTERITIS 254 196 171 133 -33 -32 OTITIS_MEDIA 201 155 160 124 -20 -20 COPD 132 102 108 084 -18 -17 DIABETES 123 095 91 071 -26 -25 BACT_PNEUMONIA 111 085 86 067 -23 -22 DENTAL 93 072 83 065 -11 -10 DEHYDRATION 98 075 81 063 -17 -17 HYPERTENSION 16 012 24 019 50 51 CHF 4 003 3 002 -25 -24 ANGINA 8 006 3 002 -63 -62 IMMUNIZATION_RELATED 2 002 0 000 -100 -100 Grand Total 6371 4907 5288 4111 -17 -16
AHRQ avoidable ED visits are based on the logic for ambulatory care sensitive ED visits from AHRQ and diagnosis code driven
696
577
544 364
337
329
211 162
154 133 ABDOMINAL_PAIN
ENT_INFECTION
FEVER
URINARY
HEADACHE
BACK_PAIN
NAUSEA
- 200 400 600 800
1000 1200
2017 Members 2018 Members
Top Ten 2018 Conditions by Rate
Top Ten Conditions by Member Count
ED Avoidable ED and the impact of new on-site clinic
20
0
1000
2000
3000
4000
5000
6000
0200400600800
10001200140016001800
Clinic Visits ED Visits
Avoidable ED VisitsED Visits (non-avoidable)Clinic EampM Visits
0
500000
1000000
1500000
2000000
2500000
3000000
3500000
$s
Clinic EampM Profess DollarsAvoidable ED Dollars
bull Clinic visits have a clear impact on ED and avoidable ED use and spend
bull Combined ED visits are down on average 157 in FY 18 from FY 17
bull Combined ED spend is down 128 in FY 18 from FY 17
Clinic Live 62017
Pitfalls and Challenges bull Face many of the challenges similar to startup health
plan bull Critical to determine how you will deliver value and
communicate the value to potential customers and brokersconsultants
bull Care management bull Network
21
Considerations in Offering Development bull Care Management Model
bull Traditional care model bull Case management bull Utilization management bull Disease management
bull Longitudinal care model with value based care philosophy bull Primary care driven bull Local care management
bull Predictive analytics and risk stratification model bull Claims history and ongoing data bull EMR data
22
Case Study 2
Case study 2 ndash Large Employer bull Business Problem Large employer wants to contract
directly with 2 major hospital systems developing professional fee schedules
bull ConsiderationsValue Prop Fee schedule should be competitive but also nuanced to minimize gap relative to current reimbursement at physician level
bull Solution Data-driven approach using current market-wide reimbursement distinguished by service level
24
Evaluate Provider Spend Top 25 Service Lines by Allowable Spend
Evaluate Provider Spend Top 20 Professional CPTs by Total Spend
Understand relative market pricing position
27
21
-1
-28
14 10
28
-22
-11 -13
24
3
20 21
8
-20
13
3 9
-39
56
-26
4
-42
60
MRI Colonoscopy Cardiac Cath Lab - OrganPanel
Memorial Hospital Beta Hospital Delta Hospital Charlie Hospital Echo Hospital Alpha Medical Center
ndash25 5 -15 10 0 39
State Charges as a Percent of Peer Average Weighted Averages for MRI Colonoscopy Cardiology and Lab
Total Percent Above Below Market Average2
Memorial Hospital Beta Hospital Delta Hospital Charlie Hospital Echo Hospital Alpha Medical Center
Develop fee schedule relative to market
28
Service Line Procedure CPT CodeDRG
Memorial Hospital
Beta Hosptial
Charlie Hospital
Delta Hospital
Echo Hospital
Alpha Medical Center
Arthroscopy Ligament Repair 29888 $ 5062 $ 9557 $ 5983 $ 10096 $ 7519 $ 2502 Knee Arthroscopy 29881 $ 5069 $ 4185 $ 3837 $ 3022 $ 3729 $ 2266 Upper GI Endoscopy 43239 $ 3075 $ 2539 $ 2012 $ 1132 $ 1565 $ 2240 Lap Sleeve Gastrectomy DRG 621 $ 20421 $ 20815 $ 12105 $ 13230 $ 14600 $ 17800 Colonoscopy and biopsy 45380 $ 3075 $ 3071 $ 2013 $ 1244 $ 1972 $ 859 Diagnostic Colonoscopy 45378 $ 3075 $ 2805 $ 2013 $ 1244 $ 1972 $ 859 MRI Brain w amp wo dye 70553 $ 1238 $ 1468 $ 1117 $ 967 $ 2805 $ 1052 MRI Joint of Lower Extremity wo dye 73721 $ 1238 $ 1398 $ 1042 $ 967 $ 925 $ 557 MRI Abdomen w amp wo dye 74183 $ 1238 $ 1468 $ 1106 $ 967 $ 2805 $ 836 X-ray Chest 71020 $ 115 $ 266 $ 305 $ 279 $ 375 $ 72 CT Thorax wo dye 71250 $ 882 $ 810 $ 505 $ 491 $ 579 $ 319 Ultrasound Abdomen Complete 76700 $ 397 $ 538 $ 545 $ 195 $ 190 $ 168 Mammogram Screening G0202 $ 141 $ 328 $ 431 $ 294 $ 425 $ 168 Computer Detection Add-on 77052 $ 112 $ 99 $ 41 $ 15 $ 45 $ 23 Comp Metabolic Panel 80053 $ 56 $ 15 $ 24 $ 56 $ 51 $ 25 Tissue Exam by Pathologist 88305 $ 236 $ 307 $ 80 $ 152 $ 78 $ 232 Cardiovascular Stress Test 93017 $ 383 $ 432 $ 1299 $ 907 $ 717 $ 797 TTE w Doppler 93306 $ 960 $ 1566 $ 1388 $ 1173 $ 1125 $ 1157
Obstetrics Vaginal Delivery DRG 755 7290$ 5730$ 4654$ 4607$ 5855$ 4688$
GI
Lab
Radiology
Medical Cardiology
Orthopedics
KEY OBSERVA TIONS bull Potential exposure on GI bull Opportunity to align price and acuity in MRI bull Opportunity to raise rates on chest x-ray and mammogram
Percentile Bands Emory Allowables Heatmap TEC ASC Heatmap Allowable Comp Analysis Portal Pricing Sheet1 image1png A few words on Bundled Payments bull Bundled payments are growing as a type of direct contracting bull In some cases third parties match-make between employers
and providers bull Contracts may vary in definitions prepost admission
coverage duration readmission cause (ie all-cause vs medically related) outlier provisions LOS caps andor per diems
bull Providers need to be strategic in pricing to enable profitable growth of market share
29
Considerations in Offering Development bull Network Development
bull Build off existing structure eg health system employee plan network bull How does this fit into your broader value based care strategy bull Employed and independent physicians bull How do you want to approach the buildout of high performance
network bull Quality focus bull Cost efficiency
bull Integrated behavioral health bull Wrap network for other markets
30
Considerations in Offering Development bull Target Market
bull Consideration of employer profile in market bull Fully-insured vs ASO bull Total cost of care vs bundled services
bull Distribution bull Direct marketing bull Brokerconsultant community
bull Plan designs bull Standard designs vs flexible ndash Dependent on target market
bull Claims administration bull Data sharing amp analytics
31
Considerations in Offering Development bull Other components of comprehensive offering
bull Pharmacy bull Preventive health bull Onsite clinics bull Wellness programs bull Technology platform
32
Sample Bundle Analysis
33
Cover page Dotson Hazelrigs Nation Mainly of charge of fixed Cardiovascular stress test TTE wDoppler complete Colonoscopy and biopsy (Combined) Diagnostic colonoscopy (Combined) Upper gi endoscopy biopsy (Combined) Knee Arthroscopy (Combined) Arthroscopy Ligament Repair Comp Metabolic Panel Surgical Path Tissue Exam MRI Abdomen MRI Brain MRI Joint Lower Extremity CT Thorax wo contrast X-ray Chest Screening mammography Mammo Computer Aided US Abdomen Complete Officeoutpatient visit new pt 30 min Vaginal delivery Lap Sleeve Gastrectomy
Piedmont Piedmont Piedmont Piedmont Northside Northside Northside Northside Gwinnett Gwinnett Gwinnett Gwinnett WellStar WellStar WellStar WellStar AMC - Tenet AMC - Tenet AMC - Tenet AMC - Tenet CPT Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing 29881 $11312 $10872 NA NA $7476 $9338 NA $23655 $11856 $3668 NA $17871 $12253 NA NA $15645 $5490 NA NA $23039 29888 NA NA NA NA NA NA NA $23784 NA $8261 NA $18000 NA NA NA $15774 NA NA NA $23168 43239 NA $4408 NA NA NA NA $5997 $8852 NA $3304 NA $7424 $1267 NA NA $9230 NA $2458 NA $8274 43644 $26468 NA NA NA $3382 $12050 NA $1861 NA NA NA $1316 $7841 NA NA $3444 $18892 $27950 NA $979 43775 NA NA NA NA NA NA NA $352 NA NA NA $302 NA NA NA $413 NA NA NA $83 45378 $2705 $2530 NA NA $4381 $3676 $4496 $1022 $2938 $2138 NA $695 $5504 NA NA $2036 NA NA NA $372 45380 $3075 $2600 NA NA $4723 $3527 $3012 $1757 $4215 $2285 NA NA $5298 NA NA $3268 NA NA NA $627 59400 $6160 NA NA NA NA $5100 NA $1851 NA NA NA $1304 $9035 NA NA $3427 $9116 $5150 NA $966 70553 $2985 NA $1153 NA $2182 NA $1192 $492 NA NA $803 $489 $1512 NA $985 $1187 NA NA NA $197 71020 $61 $69 $43 NA $113 $319 $307 NA $183 $59 $32 NA $213 $66 $40 NA $83 $53 NA NA 71250 $1837 $621 $989 NA $1490 $931 $755 NA NA $745 $401 NA $1067 $982 $616 NA NA $304 NA NA 73721 NA $1098 $1153 NA $2042 $1065 $1192 NA NA $998 $803 NA NA $1275 $985 NA NA $644 NA $178 74183 $2971 $1144 NA NA NA $1092 $1192 $6884 NA $1098 $803 NA $2960 $1197 $985 $5454 NA NA NA $7607 76700 $364 $247 $207 NA $427 $708 $614 $13267 $428 $214 $152 NA $747 $263 $189 $9139 NA $235 NA NA 77052 NA NA NA NA NA NA NA $4744 NA NA NA NA NA NA NA $3070 NA NA NA $5611 93306 $1220 $1117 NA NA $1877 $1657 $2100 $4605 $1433 $413 $945 NA $1336 $1434 $1951 $2931 NA $2399 NA $5472 G0202 $262 $187 NA NA $431 NA NA $4605 $292 NA NA NA $530 $281 NA $2931 $327 NA NA $5472
Provider Group 29881_6 29888_6 43239_6 43644_1 43775_1 45378_6 45380_6 59400_1 70553_2 71020_2 71250_2 73721_2 74183_2 76700_2 77052_2 77052_5 80053_8 88305_8 93306_2 99203_4 G0202_2 G0202_5 93017_2 Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Atlanta Gastroenterology Associates $2399 $536 348 $1628 $536 204 $2400 $536 348 Atlanta Medical Center $24889 $2266 999 $25897 $2502 935 $11449 $2240 411 $81927 $15300 435 $75815 $17800 326 $7317 $859 752 $7317 $859 752 $12821 $4688 173 $6581 $1052 526 $645 $72 796 $3265 $319 925 $3450 $557 519 $7398 $836 785 $1576 $133 1084 $73 $23 217 $635 $25 2440 $891 $232 285 $2967 $1157 156 $344 $168 105 $1265 $797 59 Atlanta Womens Health Physicians Group $29 $14 107 $40 $13 208 $396 $188 111 $278 $118 135 $450 $231 95 Gwinnett Hospital $11941 $3022 295 $21654 $10096 114 $3551 $1132 214 $34384 $10800 218 $56472 $13230 327 $3003 $1244 141 $3533 $1244 184 $8984 $4607 95 $3901 $967 303 $417 $279 49 $2247 $491 358 $4000 $967 314 $3755 $967 288 $1593 $195 717 $50 $15 233 $186 $56 233 $505 $152 233 $1750 $1173 49 $418 $294 42 $1396 $907 54 Northside Hospital $15482 $4185 270 $21651 $9557 127 $4885 $2539 92 $35176 $17000 107 $35233 $20815 69 $3883 $2805 38 $5256 $3071 71 $10911 $5730 90 $4856 $1468 231 $443 $266 67 $2379 $810 194 $3776 $1398 170 $5105 $1468 248 $942 $538 75 $167 $99 69 $379 $15 2427 $433 $307 41 $2252 $1566 44 $459 $328 40 $576 $432 33 Piedmont Hospital $14772 $3837 285 $35493 $5983 493 $5069 $2012 152 $38320 $17750 116 $37125 $12105 207 $3485 $2013 73 $4993 $2013 148 $10143 $4654 118 $5939 $1117 432 $542 $305 78 $2983 $505 491 $3410 $1042 227 $6067 $1106 449 $1364 $545 150 $75 $41 85 $231 $24 863 $657 $80 721 $2041 $1388 47 $490 $431 14 $1780 $1299 37 Piedmont Physicians Group $42 $22 87 $318 $179 78 $239 $159 50 Resurgens $8558 $2036 320 $9293 $2258 312 $4638 $2067 124 $4039 $2164 87 $4392 $2164 103 $2252 $1371 64 $459 $330 39 Wellstar Hospital $9330 $3729 150 $17479 $7519 132 $5261 $1565 236 $35794 $18200 97 $46780 $14600 220 $3707 $1972 88 $4928 $1972 150 $13549 $5855 131 $5054 $2805 80 $528 $375 41 $3222 $579 457 $3694 $925 299 $5495 $2805 96 $1355 $190 615 $66 $45 46 $73 $51 43 $133 $78 71 $1785 $1125 59 $599 $425 41 $1010 $717 41 Avg Mark UpProcedure Atlanta Medical Center 634 Gwinnett Hospital 223 Northside Hospital 233 Piedmont Hospital 259 Wellstar Hospital 155 Emory 105
Atlanta Gastroenterology Associates Atlanta Medical Center Atlanta Womens Health Gwinnett Hospital Northside Hospital Piedmont Hospital Piedmont Physicians Group Resurgens Wellstar Hospital CPT Code CPT Proc Cat Comp Avg Allow Allow Allow Allow Allow Allow Allow Allow Allow 29881 KNEE ARTHROSCOPYSURGERY 6 $3179 $2266 $3022 $4185 $3837 $2036 $3729 29888 KNEE ARTHROSCOPYSURGERY 6 $6319 $2502 $10096 $9557 $5983 $2258 $7519 43239 UPPER GI ENDOSCOPY BIOPSY 6 $1727 $536 $2240 $1132 $2539 $2012 $2067 $1565 43644 LAP GASTRIC BYPASSROUX-EN-Y 1 $15810 $15300 $10800 $17000 $17750 $18200 43775 LAP SLEEVE GASTRECTOMY 1 $17800 $13230 $20815 $12105 $14600 45378 DIAGNOSTIC COLONOSCOPY 6 $1656 $536 $859 $1244 $2805 $2013 $2164 $1972 45380 COLONOSCOPY AND BIOPSY 6 $1694 $536 $859 $1244 $3071 $2013 $2164 $1972 59400 OBSTETRICAL CARE 1 $5107 $4688 $4607 $5730 $4654 $5855 70553 MRI BRAIN WO amp WDYE 2 $1482 $1052 $967 $1468 $1117 $2805 71020 CHEST X-RAY 2 $259 $72 $279 $266 $305 $375 71250 CT THORAX WO DYE 2 $541 $319 $491 $810 $505 $579 73721 MRI JNT OF LWR EXTRE WO DYE 2 $978 $557 $967 $1398 $1042 $925 74183 MRI ABDOMEN WO amp WDYE 2 $1436 $836 $967 $1468 $1106 $2805 76700 US EXAM ABDOM COMPLETE 2 $320 $133 $195 $538 $545 $190 77052 COMP SCREEN MAMMOGRAM ADD-ON 2 $45 $23 $15 $99 $41 $45 77052 COMP SCREEN MAMMOGRAM ADD-ON 5 $14 $14 80053 COMPREHEN METABOLIC PANEL 8 $29 $25 $13 $56 $15 $24 $22 $51 88305 TISSUE EXAM BY PATHOLOGIST 8 $174 $232 $188 $152 $307 $80 $179 $78 93306 TTE WDOPPLER COMPLETE 2 $1297 $1157 $1173 $1566 $1388 $1371 $1125 93017 STRESS TEST 5 $830 $797 $907 $432 $1299 $717 99203 OFFICEOUTPATIENT VISIT NEW 4 $139 $118 $159 G0202 Screeningmammographydigital 2 $329 $168 $294 $328 $431 $330 $425 G0202 Screeningmammographydigital 5 $231 $231
Service Line Procedure CPT Code Emory Atlanta Gastroenterology Associates Resurgens Atlanta Womens Health Piedmont Physicians Group Orthopedics (ASC) Knee Arthroscopy 29881 $3467 $2036 Arthroscopy Ligament Repair 29888 $3386 $2258 GI (ASC) Upper GI Endoscopy 43239 $2758 $536 Diagnostic Colonoscopy 45378 $2348 $536 Colonoscopy and biopsy 45380 $2181 $536 Radiology Mammogram Screening G0202 $164 $231 Computer Detection Add-on 77052 $93 $14 Lab Comp Metabolic Panel 80053 $53 $13 $22 Tissue Exam by Pathologist 88305 $277 $188 $179 EampM (TEC) Office Visit new pt 99203 $269 $118 $159
Service Line Procedure CPT CodeDRG Memorial Hospital Beta Hosptial Charlie Hospital Delta Hospital Echo Hospital Alpha Medical Center Atlanta Gastroenterology Associates Resurgens Atlanta Womens Health Piedmont Physicians Group Market Avg Emory abovebelow Orthopedics Arthroscopy Ligament Repair 29888 $ 5062 $ 9557 $ 5983 $ 10096 $ 7519 $ 2502 $ 2258 $ 6319 -20 Knee Arthroscopy 29881 6 $ 5069 $ 4185 $ 3837 $ 3022 $ 3729 $ 2266 $ 2036 $ 3179 59 GI Upper GI Endoscopy 43239 6 $ 3075 $ 2539 $ 2012 $ 1132 $ 1565 $ 2240 $ 536 $ 1671 84 Lap Sleeve Gastrectomy DRG 621 $ 20421 $ 20815 $ 12105 $ 13230 $ 14600 $ 17800 $ 15710 30 Colonoscopy and biopsy 45380 $ 3075 $ 3071 $ 2013 $ 1244 $ 1972 $ 859 $ 536 $ 1616 90 Diagnostic Colonoscopy 45378 6 $ 3075 $ 2805 $ 2013 $ 1244 $ 1972 $ 859 $ 536 $ 1572 96 Radiology MRI Brain w amp wo dye 70553 2 $ 1238 $ 1468 $ 1117 $ 967 $ 2805 $ 1052 $ 1482 -16 MRI Joint of Lower Extremity wo dye 73721 2 $ 1238 $ 1398 $ 1042 $ 967 $ 925 $ 557 $ 978 27 MRI Abdomen w amp wo dye 74183 2 $ 1238 $ 1468 $ 1106 $ 967 $ 2805 $ 836 $ 1436 -14 X-ray Chest 71020 $ 115 $ 266 $ 305 $ 279 $ 375 $ 72 $ 259 -56 CT Thorax wo dye 71250 $ 882 $ 810 $ 505 $ 491 $ 579 $ 319 $ 541 63 Ultrasound Abdomen Complete 76700 $ 397 $ 538 $ 545 $ 195 $ 190 $ 168 $ 327 21 Mammogram Screening G0202 2 $ 141 $ 328 $ 431 $ 294 $ 425 $ 168 $ 231 $ 313 -55 Computer Detection Add-on 77052 2 $ 112 $ 99 $ 41 $ 15 $ 45 $ 23 $ 14 $ 39 183 Lab Comp Metabolic Panel 80053 8 $ 56 $ 15 $ 24 $ 56 $ 51 $ 25 $ 13 $ 22 $ 29 88 Tissue Exam by Pathologist 88305 8 $ 236 $ 307 $ 80 $ 152 $ 78 $ 232 $ 188 $ 179 $ 174 36 Medical Cardiology Cardiovascular Stress Test 93017 $ 383 $ 432 $ 1299 $ 907 $ 717 $ 797 $ 830 -54 TTE w Doppler 93306 2 $ 960 $ 1566 $ 1388 $ 1173 $ 1125 $ 1157 $ 1282 -25 Obstetrics Vaginal Delivery DRG 755 $ 7290 $ 5730 $ 4654 $ 4607 $ 5855 $ 4688 $ 5107 43 EampM Office Visit new pt 99203 4 $ 248 $ 118 $ 159 $ 139 78 Colonoscopy and biopsy (HOSPITAL ONLY) 45380 Surg 2530 $ 307591 Diagnostic colonoscopy (HOSPITAL ONLY) 45378 Surg 2255 $ 307591 Upper gi endoscopy biopsy (HOSPITAL ONLY) 43239 Surg 1787 $ 307591 Knee Arthroscopy (HOSPITAL ONLY) 29881 Surg 10900 $ 506893 Arthroscopy Ligament Repair (HOSPITAL ONLY) 29888 Surg 10900 $ 506200 Key 1 Facility - Inpatient 2 Facility - Imaging 3 Physician - Imaging 4 Physician 5 Global - Imaging 6 Facility - Outpatient 8 Lab 41 Physician - Primary Care 42 Physician - Specialist
Blue Cross United - EJCH EUH EUHM WW United - SJH Non Options United - SJH Options Aetna - ASC TEC (HMO) Cigna - ASC TEC (HMO) Aetna - EJCH ESJH ECHM WW Cigna - EJCH (HMO) Cigna - ESJH EUHM (HMO) List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract Description CPT Code Charge Average Final Price (all plans) Emory Mark Up Reimbursement Method ( of charge or fixed) - 1713 Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Cardiovascular stress test 93017 Cardio $543 $ 425 28 of Charge 70 $ 380 of Charge 65 $ 353 of Charge 60 $ 326 of Charge 70 $ 380 of Charge 70 $ 380 of charge 100 $ 543 of Charge 70 $ 380 of charge 100 $ 543 of charge 100 $ 543 TTE wDoppler complete 93306 Cardio $1226 $ 960 28 of Charge 70 $ 858 of Charge 65 $ 797 of Charge 60 $ 736 of Charge 70 $ 858 of Charge 70 $ 858 of charge 100 $ 1226 of Charge 70 $ 858 of charge 100 $ 1226 of charge 100 $ 1226 Colonoscopy and biopsy (HOSPITAL ONLY) 45380 Surg $2530 $ 3076 -18 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 of Charge 70 $ 1771 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Diagnostic colonoscopy (HOSPITAL ONLY) 45378 Surg $2255 $ 3076 -27 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 of Charge 70 $ 1579 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Upper gi endoscopy biopsy (HOSPITAL ONLY) 43239 Surg $1787 $ 3076 -42 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Knee Arthroscopy (HOSPITAL ONLY) 29881 Surg $10900 $ 5069 115 Fixed Rate SC 4 $ 3865 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 449300 $ 4493 Fixed Rate $ 654700 $ 6547 of Charge 70 $ 7630 Fixed Rate $ 401000 $ 4010 of Charge 70 $ 7630 Fixed Rate $ 398300 $ 3983 Fixed Rate $ 398100 $ 3981 Arthroscopy Ligament Repair (HOSPITAL ONLY) 29888 Surg $10900 $ 5062 115 Fixed Rate SC 3 $ 3121 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 556900 $ 5569 Fixed Rate $ 770100 $ 7701 of Charge 70 $ 7630 Fixed Rate $ 323900 $ 3239 of Charge 70 $ 7630 Fixed Rate $ 321700 $ 3217 Fixed Rate $ 321400 $ 3214 Comp Metabolic Panel 80053 Lab $132 $ 56 138 RBRVS Fee (100) $ 1437 of Charge 65 $ 86 of Charge 65 $ 86 of Charge 65 $ 86 of Charge 70 $ 92 RBRVS Fee (100) $ 1437 $ 14 of Charge 70 $ 92 RBRVS Fee (100) $ 1437 $ 14 RBRVS Fee (100) $ 1437 $ 14 Surgical Path Tissue Exam 88305 Lab $326 $ 236 38 of Charge 150 $ 51 of Charge 65 $ 212 of Charge 65 $ 212 of Charge 65 $ 212 of Charge 70 $ 228 of charge 100 $ 326 of Charge 70 $ 228 of charge 100 $ 326 of charge 100 $ 326 MRI Abdomen 74183 Radiology $6960 $ 1238 462 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 MRI Brain 70553 Radiology $6804 $ 1238 450 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 MRI Joint Lower Extremity 73721 Radiology $3067 $ 1238 148 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 CT Thorax wo contrast 71250 Radiology $2199 $ 882 149 Fixed Rate $ 771 Fixed Rate $ 47100 $ 471 Fixed Rate $ 81700 $ 817 Fixed Rate $ 116000 $ 1160 of Charge 70 $ 1539 Fixed Rate $ 80100 $ 801 Fixed Rate $ 79200 $ 792 Fixed Rate $ 79300 $ 793 Fixed Rate $ 79500 $ 795 X-ray Chest 71020 Radiology $280 $ 115 142 of Charge 150 $ 25 of Charge 65 $ 182 of Charge 60 $ 168 of Charge 70 $ 196 of Charge 70 $ 196 RBRVS Fee (150) $ 2534 $ 25 of Charge 70 $ 196 RBRVS Fee (150) $ 2534 $ 25 RBRVS Fee (150) $ 2534 $ 25 Screening mammography G0202 Radiology $279 $ 141 98 Fixed Rate $ 128 Fixed Rate $ 13100 $ 131 Fixed Rate $ 14300 $ 143 Fixed Rate $ 16100 $ 161 of Charge 70 $ 195 Fixed Rate $ 13300 $ 133 Fixed Rate $ 13500 $ 135 Fixed Rate $ 13000 $ 130 Fixed Rate $ 11200 $ 112 Mammo Computer Aided 77052 Radiology $75 $ 112 -33 Fixed Rate $ 9 Fixed Rate $ 13100 $ 131 Fixed Rate $ 14300 $ 143 Fixed Rate $ 16100 $ 161 of Charge 70 $ 53 Fixed Rate $ 13300 $ 133 Fixed Rate $ 13500 $ 135 Fixed Rate $ 13000 $ 130 Fixed Rate $ 11200 $ 112 US Abdomen Complete 76700 Radiology $917 $ 397 131 of Charge 150 $ 125 of Charge 65 $ 596 of Charge 60 $ 550 of Charge 70 $ 642 of Charge 70 $ 642 RBRVS Fee (150) $ 12519 $ 125 of Charge 70 $ 642 RBRVS Fee (150) $ 12519 $ 125 RBRVS Fee (150) $ 12519 $ 125 Officeoutpatient visit new pt 30 min (TEC) 99203 EampM $316 $ 248 28 of Charge 70 $ 221 of Charge 65 $ 205 of Charge 60 $ 190 of Charge 70 $ 221 of Charge 70 $ 221 of charge 100 $ 316 of Charge 70 $ 221 of charge 100 $ 316 of charge 100 $ 316 Vaginal delivery 59409 Surg $14484 $ 7290 99 Fixed Rate DRG - 775 $ 5437 2 Day Case Rate + LOC 561700 $ 5617 BaseCMS Weight 584741 $ 5847 BaseCMS Weight 726146 $ 7261 No IP Terms $ - 0 No IP BaseCMS Weight 659343 $ 6593 BaseContract Weight 479451 100 $ 14484 BaseCMS Weight 579110 $ 5791 Lap Sleeve Gastrectomy 43775 Surg $29961 $ 20421 47 Fixed Rate DRG - 621 $ 14872 BaseCMS Weight 1810697 $ 18107 BaseCMS Weight 1835178 $ 18352 BaseCMS Weight 2278911 $ 22789 No IP Terms $ - 0 No IP BaseCMS Weight 2069315 $ 20693 BaseCMS Weight 1730442 100 $ 29961 BaseCMS Weight 1817507 $ 18175 105 Colonoscopy and biopsy (ASC ONLY) Surg $ 219200 $ 2181 Diagnostic colonoscopy (ASC ONLY) Surg $ 267100 $ 2348 Upper gi endoscopy biopsy (ASC ONLY) Surg $ 207500 $ 2758 Knee Arthroscopy (ASC ONLY) Surg $ 417900 $ 3467 Arthroscopy Ligament Repair (ASC ONLY) Surg $ 504800 $ 3386
Cpt Code CPT Description Procedure Category Claims Min 25thNtile 50thNtile Emorys Rates 75thNtile 90thNtile Max 20 Below 50th Ntile 20 Above 50th Ntile 93017 CARDIOVASCULAR STRESS TEST 5 82 $80 $125 $321 $382 $568 $791 $930 $257 $386 71020 CHEST X-RAY 2 2638 $11 $45 $152 $115 $289 $373 $585 $122 $182 71020 CHEST X-RAY 5 8106 $25 $34 $38 $54 $57 $69 $30 $46 45380 COLONOSCOPY AND BIOPSY 6 1256 $541 $560 $572 $2877 $1000 $2024 $3289 $458 $686 77052 COMP SCREEN MAMMOGRAM ADD-ON 2 194 $13 $15 $25 $38 $47 $134 $20 $30 77052 COMP SCREEN MAMMOGRAM ADD-ON 5 2411 $13 $16 $20 $23 $26 $28 $16 $24 80053 COMPREHEN METABOLIC PANEL 8 13019 $9 $19 $23 $55 $24 $25 $69 $19 $28 71250 CT THORAX WO DYE 2 302 $165 $372 $545 $878 $1658 $2067 $436 $654 71250 CT THORAX WO DYE 5 209 $53 $127 $203 $289 $419 $534 $162 $244 45378 DIAGNOSTIC COLONOSCOPY 6 1479 $484 $515 $536 $2914 $831 $1971 $2828 $428 $643 29881 KNEE ARTHROSCOPYSURGERY 6 152 $1650 $1826 $2036 $5235 $3054 $4216 $6461 $1629 $2443 29888 KNEE ARTHROSCOPYSURGERY 6 82 $1682 $3615 $5081 $5145 $7553 $12924 $18532 $4065 $6097 43644 LAP GASTRIC BYPASSROUX-EN-Y 1 21 $11821 $13873 $17050 $18391 $25029 $31079 $13640 $20460 43775 LAP SLEEVE GASTRECTOMY 1 38 $4215 $8250 $13253 $20421 $19197 $21509 $24260 $10602 $15903 74183 MRI ABDOMEN WO amp WDYE 2 120 $919 $987 $1015 $1237 $1252 $2534 $3177 $812 $1218 74183 MRI ABDOMEN WO amp WDYE 5 112 $475 $490 $521 $1154 $1337 $1696 $417 $625 70553 MRI BRAIN WO amp WDYE 2 324 $633 $987 $1142 $1237 $1706 $2805 $3331 $914 $1370 70553 MRI BRAIN WO amp WDYE 5 467 $280 $539 $1023 $1277 $1363 $1726 $818 $1228 73721 MRI JNT OF LWR EXTRE WO DYE 2 304 $804 $859 $967 $1237 $1063 $1598 $2485 $774 $1160 73721 MRI JNT OF LWR EXTRE WO DYE 5 1130 $500 $520 $530 $628 $679 $859 $424 $636 59400 OBSTETRICAL CARE 1 494 $3699 $4402 $4969 $6655 $7307 $8613 $3975 $5963 99203 OFFICEOUTPATIENT VISIT NEW 4 6776 $88 $101 $112 $138 $155 $169 $90 $134 G0202 Screeningmammographydigital 2 7444 $123 $206 $285 $380 $425 $479 $228 $342 G0202 Screeningmammographydigital 5 2754 $117 $165 $195 $230 $247 $252 $156 $234 88305 TISSUE EXAM BY PATHOLOGIST 8 20834 $51 $74 $112 $235 $168 $261 $478 $90 $134 93306 TTE WDOPPLER COMPLETE 2 931 $194 $377 $739 $960 $1267 $1480 $1849 $591 $887 93306 TTE WDOPPLER COMPLETE 5 2299 $151 $296 $373 $538 $573 $834 $298 $448 43239 UPPER GI ENDOSCOPY BIOPSY 6 1264 $424 $514 $550 $800 $1838 $2833 $440 $660 76700 US EXAM ABDOM COMPLETE 2 321 $96 $165 $271 $509 $584 $857 $217 $325 76700 US EXAM ABDOM COMPLETE 5 444 $111 $129 $147 $156 $220 $279 $118 $176 Key 1 Facility - Inpatient 2 Facility - Imaging 3 Physician - Imaging 4 Physician 5 Global - Imaging 6 Facility - Outpatient 8 Lab 41 Physician - Primary Care 42 Physician - Specialist Cardiovascular stress test $ 38279 TTE wDoppler complete $ 96037 Colonoscopy and biopsy $ 287709 Diagnostic colonoscopy $ 291434 Upper gi endoscopy biopsy $ 300526 Knee Arthroscopy $ 523584 Arthroscopy Ligament Repair $ 514501 Comp Metabolic Panel $ 5552 Surgical Path Tissue Exam $ 23570 MRI Abdomen $ 123786 MRI Brain $ 123786 MRI Joint Lower Extremity $ 123786 CT Thorax wo contrast $ 88213 X-ray Chest $ 11548 Screening mammography $ 14098 Mammo Computer Aided $ 11179 US Abdomen Complete $ 39695 Officeoutpatient visit new pt 30 min $ 24753 Vaginal delivery $ 729025 Lap Sleeve Gastrectomy $ 2042124
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ED and Avoidable ED
19
Potentially Avoidable ED - Trend View Overall ED
Period Change FY 2017 FY 2018 Count Rate
Measure Mbrs Rate Mbrs Rate Overall ED 16394 12626 13820 10745 -16 -15 FREQUENT ED UTILIZER (mbr1k) 1581 1218 1468 1141 -7 -6 AVOIDABLE ED 6371 4907 5288 4111 -17 -16 Potentially Avoidable ED
Period Change FY 2017 FY 2018 Count Rate
Avoid ED Condition Mbrs Rate Mbrs Rate ABDOMINAL_PAIN 1092 841 895 696 -18 -17 ENT_INFECTION 854 658 742 577 -13 -12 FEVER 715 551 700 544 -2 -1 URINARY 650 501 468 364 -28 -27 HEADACHE 558 430 434 337 -22 -21 BACK_PAIN 414 319 423 329 2 3 NAUSEA 394 303 271 211 -31 -31 ASTHMA 294 226 209 162 -29 -28 CELLULITIS 210 162 198 154 -6 -5 GASTROENTERITIS 254 196 171 133 -33 -32 OTITIS_MEDIA 201 155 160 124 -20 -20 COPD 132 102 108 084 -18 -17 DIABETES 123 095 91 071 -26 -25 BACT_PNEUMONIA 111 085 86 067 -23 -22 DENTAL 93 072 83 065 -11 -10 DEHYDRATION 98 075 81 063 -17 -17 HYPERTENSION 16 012 24 019 50 51 CHF 4 003 3 002 -25 -24 ANGINA 8 006 3 002 -63 -62 IMMUNIZATION_RELATED 2 002 0 000 -100 -100 Grand Total 6371 4907 5288 4111 -17 -16
AHRQ avoidable ED visits are based on the logic for ambulatory care sensitive ED visits from AHRQ and diagnosis code driven
696
577
544 364
337
329
211 162
154 133 ABDOMINAL_PAIN
ENT_INFECTION
FEVER
URINARY
HEADACHE
BACK_PAIN
NAUSEA
- 200 400 600 800
1000 1200
2017 Members 2018 Members
Top Ten 2018 Conditions by Rate
Top Ten Conditions by Member Count
ED Avoidable ED and the impact of new on-site clinic
20
0
1000
2000
3000
4000
5000
6000
0200400600800
10001200140016001800
Clinic Visits ED Visits
Avoidable ED VisitsED Visits (non-avoidable)Clinic EampM Visits
0
500000
1000000
1500000
2000000
2500000
3000000
3500000
$s
Clinic EampM Profess DollarsAvoidable ED Dollars
bull Clinic visits have a clear impact on ED and avoidable ED use and spend
bull Combined ED visits are down on average 157 in FY 18 from FY 17
bull Combined ED spend is down 128 in FY 18 from FY 17
Clinic Live 62017
Pitfalls and Challenges bull Face many of the challenges similar to startup health
plan bull Critical to determine how you will deliver value and
communicate the value to potential customers and brokersconsultants
bull Care management bull Network
21
Considerations in Offering Development bull Care Management Model
bull Traditional care model bull Case management bull Utilization management bull Disease management
bull Longitudinal care model with value based care philosophy bull Primary care driven bull Local care management
bull Predictive analytics and risk stratification model bull Claims history and ongoing data bull EMR data
22
Case Study 2
Case study 2 ndash Large Employer bull Business Problem Large employer wants to contract
directly with 2 major hospital systems developing professional fee schedules
bull ConsiderationsValue Prop Fee schedule should be competitive but also nuanced to minimize gap relative to current reimbursement at physician level
bull Solution Data-driven approach using current market-wide reimbursement distinguished by service level
24
Evaluate Provider Spend Top 25 Service Lines by Allowable Spend
Evaluate Provider Spend Top 20 Professional CPTs by Total Spend
Understand relative market pricing position
27
21
-1
-28
14 10
28
-22
-11 -13
24
3
20 21
8
-20
13
3 9
-39
56
-26
4
-42
60
MRI Colonoscopy Cardiac Cath Lab - OrganPanel
Memorial Hospital Beta Hospital Delta Hospital Charlie Hospital Echo Hospital Alpha Medical Center
ndash25 5 -15 10 0 39
State Charges as a Percent of Peer Average Weighted Averages for MRI Colonoscopy Cardiology and Lab
Total Percent Above Below Market Average2
Memorial Hospital Beta Hospital Delta Hospital Charlie Hospital Echo Hospital Alpha Medical Center
Develop fee schedule relative to market
28
Service Line Procedure CPT CodeDRG
Memorial Hospital
Beta Hosptial
Charlie Hospital
Delta Hospital
Echo Hospital
Alpha Medical Center
Arthroscopy Ligament Repair 29888 $ 5062 $ 9557 $ 5983 $ 10096 $ 7519 $ 2502 Knee Arthroscopy 29881 $ 5069 $ 4185 $ 3837 $ 3022 $ 3729 $ 2266 Upper GI Endoscopy 43239 $ 3075 $ 2539 $ 2012 $ 1132 $ 1565 $ 2240 Lap Sleeve Gastrectomy DRG 621 $ 20421 $ 20815 $ 12105 $ 13230 $ 14600 $ 17800 Colonoscopy and biopsy 45380 $ 3075 $ 3071 $ 2013 $ 1244 $ 1972 $ 859 Diagnostic Colonoscopy 45378 $ 3075 $ 2805 $ 2013 $ 1244 $ 1972 $ 859 MRI Brain w amp wo dye 70553 $ 1238 $ 1468 $ 1117 $ 967 $ 2805 $ 1052 MRI Joint of Lower Extremity wo dye 73721 $ 1238 $ 1398 $ 1042 $ 967 $ 925 $ 557 MRI Abdomen w amp wo dye 74183 $ 1238 $ 1468 $ 1106 $ 967 $ 2805 $ 836 X-ray Chest 71020 $ 115 $ 266 $ 305 $ 279 $ 375 $ 72 CT Thorax wo dye 71250 $ 882 $ 810 $ 505 $ 491 $ 579 $ 319 Ultrasound Abdomen Complete 76700 $ 397 $ 538 $ 545 $ 195 $ 190 $ 168 Mammogram Screening G0202 $ 141 $ 328 $ 431 $ 294 $ 425 $ 168 Computer Detection Add-on 77052 $ 112 $ 99 $ 41 $ 15 $ 45 $ 23 Comp Metabolic Panel 80053 $ 56 $ 15 $ 24 $ 56 $ 51 $ 25 Tissue Exam by Pathologist 88305 $ 236 $ 307 $ 80 $ 152 $ 78 $ 232 Cardiovascular Stress Test 93017 $ 383 $ 432 $ 1299 $ 907 $ 717 $ 797 TTE w Doppler 93306 $ 960 $ 1566 $ 1388 $ 1173 $ 1125 $ 1157
Obstetrics Vaginal Delivery DRG 755 7290$ 5730$ 4654$ 4607$ 5855$ 4688$
GI
Lab
Radiology
Medical Cardiology
Orthopedics
KEY OBSERVA TIONS bull Potential exposure on GI bull Opportunity to align price and acuity in MRI bull Opportunity to raise rates on chest x-ray and mammogram
Percentile Bands Emory Allowables Heatmap TEC ASC Heatmap Allowable Comp Analysis Portal Pricing Sheet1 image1png A few words on Bundled Payments bull Bundled payments are growing as a type of direct contracting bull In some cases third parties match-make between employers
and providers bull Contracts may vary in definitions prepost admission
coverage duration readmission cause (ie all-cause vs medically related) outlier provisions LOS caps andor per diems
bull Providers need to be strategic in pricing to enable profitable growth of market share
29
Considerations in Offering Development bull Network Development
bull Build off existing structure eg health system employee plan network bull How does this fit into your broader value based care strategy bull Employed and independent physicians bull How do you want to approach the buildout of high performance
network bull Quality focus bull Cost efficiency
bull Integrated behavioral health bull Wrap network for other markets
30
Considerations in Offering Development bull Target Market
bull Consideration of employer profile in market bull Fully-insured vs ASO bull Total cost of care vs bundled services
bull Distribution bull Direct marketing bull Brokerconsultant community
bull Plan designs bull Standard designs vs flexible ndash Dependent on target market
bull Claims administration bull Data sharing amp analytics
31
Considerations in Offering Development bull Other components of comprehensive offering
bull Pharmacy bull Preventive health bull Onsite clinics bull Wellness programs bull Technology platform
32
Sample Bundle Analysis
33
Cover page Dotson Hazelrigs Nation Mainly of charge of fixed Cardiovascular stress test TTE wDoppler complete Colonoscopy and biopsy (Combined) Diagnostic colonoscopy (Combined) Upper gi endoscopy biopsy (Combined) Knee Arthroscopy (Combined) Arthroscopy Ligament Repair Comp Metabolic Panel Surgical Path Tissue Exam MRI Abdomen MRI Brain MRI Joint Lower Extremity CT Thorax wo contrast X-ray Chest Screening mammography Mammo Computer Aided US Abdomen Complete Officeoutpatient visit new pt 30 min Vaginal delivery Lap Sleeve Gastrectomy
Piedmont Piedmont Piedmont Piedmont Northside Northside Northside Northside Gwinnett Gwinnett Gwinnett Gwinnett WellStar WellStar WellStar WellStar AMC - Tenet AMC - Tenet AMC - Tenet AMC - Tenet CPT Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing 29881 $11312 $10872 NA NA $7476 $9338 NA $23655 $11856 $3668 NA $17871 $12253 NA NA $15645 $5490 NA NA $23039 29888 NA NA NA NA NA NA NA $23784 NA $8261 NA $18000 NA NA NA $15774 NA NA NA $23168 43239 NA $4408 NA NA NA NA $5997 $8852 NA $3304 NA $7424 $1267 NA NA $9230 NA $2458 NA $8274 43644 $26468 NA NA NA $3382 $12050 NA $1861 NA NA NA $1316 $7841 NA NA $3444 $18892 $27950 NA $979 43775 NA NA NA NA NA NA NA $352 NA NA NA $302 NA NA NA $413 NA NA NA $83 45378 $2705 $2530 NA NA $4381 $3676 $4496 $1022 $2938 $2138 NA $695 $5504 NA NA $2036 NA NA NA $372 45380 $3075 $2600 NA NA $4723 $3527 $3012 $1757 $4215 $2285 NA NA $5298 NA NA $3268 NA NA NA $627 59400 $6160 NA NA NA NA $5100 NA $1851 NA NA NA $1304 $9035 NA NA $3427 $9116 $5150 NA $966 70553 $2985 NA $1153 NA $2182 NA $1192 $492 NA NA $803 $489 $1512 NA $985 $1187 NA NA NA $197 71020 $61 $69 $43 NA $113 $319 $307 NA $183 $59 $32 NA $213 $66 $40 NA $83 $53 NA NA 71250 $1837 $621 $989 NA $1490 $931 $755 NA NA $745 $401 NA $1067 $982 $616 NA NA $304 NA NA 73721 NA $1098 $1153 NA $2042 $1065 $1192 NA NA $998 $803 NA NA $1275 $985 NA NA $644 NA $178 74183 $2971 $1144 NA NA NA $1092 $1192 $6884 NA $1098 $803 NA $2960 $1197 $985 $5454 NA NA NA $7607 76700 $364 $247 $207 NA $427 $708 $614 $13267 $428 $214 $152 NA $747 $263 $189 $9139 NA $235 NA NA 77052 NA NA NA NA NA NA NA $4744 NA NA NA NA NA NA NA $3070 NA NA NA $5611 93306 $1220 $1117 NA NA $1877 $1657 $2100 $4605 $1433 $413 $945 NA $1336 $1434 $1951 $2931 NA $2399 NA $5472 G0202 $262 $187 NA NA $431 NA NA $4605 $292 NA NA NA $530 $281 NA $2931 $327 NA NA $5472
Provider Group 29881_6 29888_6 43239_6 43644_1 43775_1 45378_6 45380_6 59400_1 70553_2 71020_2 71250_2 73721_2 74183_2 76700_2 77052_2 77052_5 80053_8 88305_8 93306_2 99203_4 G0202_2 G0202_5 93017_2 Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Atlanta Gastroenterology Associates $2399 $536 348 $1628 $536 204 $2400 $536 348 Atlanta Medical Center $24889 $2266 999 $25897 $2502 935 $11449 $2240 411 $81927 $15300 435 $75815 $17800 326 $7317 $859 752 $7317 $859 752 $12821 $4688 173 $6581 $1052 526 $645 $72 796 $3265 $319 925 $3450 $557 519 $7398 $836 785 $1576 $133 1084 $73 $23 217 $635 $25 2440 $891 $232 285 $2967 $1157 156 $344 $168 105 $1265 $797 59 Atlanta Womens Health Physicians Group $29 $14 107 $40 $13 208 $396 $188 111 $278 $118 135 $450 $231 95 Gwinnett Hospital $11941 $3022 295 $21654 $10096 114 $3551 $1132 214 $34384 $10800 218 $56472 $13230 327 $3003 $1244 141 $3533 $1244 184 $8984 $4607 95 $3901 $967 303 $417 $279 49 $2247 $491 358 $4000 $967 314 $3755 $967 288 $1593 $195 717 $50 $15 233 $186 $56 233 $505 $152 233 $1750 $1173 49 $418 $294 42 $1396 $907 54 Northside Hospital $15482 $4185 270 $21651 $9557 127 $4885 $2539 92 $35176 $17000 107 $35233 $20815 69 $3883 $2805 38 $5256 $3071 71 $10911 $5730 90 $4856 $1468 231 $443 $266 67 $2379 $810 194 $3776 $1398 170 $5105 $1468 248 $942 $538 75 $167 $99 69 $379 $15 2427 $433 $307 41 $2252 $1566 44 $459 $328 40 $576 $432 33 Piedmont Hospital $14772 $3837 285 $35493 $5983 493 $5069 $2012 152 $38320 $17750 116 $37125 $12105 207 $3485 $2013 73 $4993 $2013 148 $10143 $4654 118 $5939 $1117 432 $542 $305 78 $2983 $505 491 $3410 $1042 227 $6067 $1106 449 $1364 $545 150 $75 $41 85 $231 $24 863 $657 $80 721 $2041 $1388 47 $490 $431 14 $1780 $1299 37 Piedmont Physicians Group $42 $22 87 $318 $179 78 $239 $159 50 Resurgens $8558 $2036 320 $9293 $2258 312 $4638 $2067 124 $4039 $2164 87 $4392 $2164 103 $2252 $1371 64 $459 $330 39 Wellstar Hospital $9330 $3729 150 $17479 $7519 132 $5261 $1565 236 $35794 $18200 97 $46780 $14600 220 $3707 $1972 88 $4928 $1972 150 $13549 $5855 131 $5054 $2805 80 $528 $375 41 $3222 $579 457 $3694 $925 299 $5495 $2805 96 $1355 $190 615 $66 $45 46 $73 $51 43 $133 $78 71 $1785 $1125 59 $599 $425 41 $1010 $717 41 Avg Mark UpProcedure Atlanta Medical Center 634 Gwinnett Hospital 223 Northside Hospital 233 Piedmont Hospital 259 Wellstar Hospital 155 Emory 105
Atlanta Gastroenterology Associates Atlanta Medical Center Atlanta Womens Health Gwinnett Hospital Northside Hospital Piedmont Hospital Piedmont Physicians Group Resurgens Wellstar Hospital CPT Code CPT Proc Cat Comp Avg Allow Allow Allow Allow Allow Allow Allow Allow Allow 29881 KNEE ARTHROSCOPYSURGERY 6 $3179 $2266 $3022 $4185 $3837 $2036 $3729 29888 KNEE ARTHROSCOPYSURGERY 6 $6319 $2502 $10096 $9557 $5983 $2258 $7519 43239 UPPER GI ENDOSCOPY BIOPSY 6 $1727 $536 $2240 $1132 $2539 $2012 $2067 $1565 43644 LAP GASTRIC BYPASSROUX-EN-Y 1 $15810 $15300 $10800 $17000 $17750 $18200 43775 LAP SLEEVE GASTRECTOMY 1 $17800 $13230 $20815 $12105 $14600 45378 DIAGNOSTIC COLONOSCOPY 6 $1656 $536 $859 $1244 $2805 $2013 $2164 $1972 45380 COLONOSCOPY AND BIOPSY 6 $1694 $536 $859 $1244 $3071 $2013 $2164 $1972 59400 OBSTETRICAL CARE 1 $5107 $4688 $4607 $5730 $4654 $5855 70553 MRI BRAIN WO amp WDYE 2 $1482 $1052 $967 $1468 $1117 $2805 71020 CHEST X-RAY 2 $259 $72 $279 $266 $305 $375 71250 CT THORAX WO DYE 2 $541 $319 $491 $810 $505 $579 73721 MRI JNT OF LWR EXTRE WO DYE 2 $978 $557 $967 $1398 $1042 $925 74183 MRI ABDOMEN WO amp WDYE 2 $1436 $836 $967 $1468 $1106 $2805 76700 US EXAM ABDOM COMPLETE 2 $320 $133 $195 $538 $545 $190 77052 COMP SCREEN MAMMOGRAM ADD-ON 2 $45 $23 $15 $99 $41 $45 77052 COMP SCREEN MAMMOGRAM ADD-ON 5 $14 $14 80053 COMPREHEN METABOLIC PANEL 8 $29 $25 $13 $56 $15 $24 $22 $51 88305 TISSUE EXAM BY PATHOLOGIST 8 $174 $232 $188 $152 $307 $80 $179 $78 93306 TTE WDOPPLER COMPLETE 2 $1297 $1157 $1173 $1566 $1388 $1371 $1125 93017 STRESS TEST 5 $830 $797 $907 $432 $1299 $717 99203 OFFICEOUTPATIENT VISIT NEW 4 $139 $118 $159 G0202 Screeningmammographydigital 2 $329 $168 $294 $328 $431 $330 $425 G0202 Screeningmammographydigital 5 $231 $231
Service Line Procedure CPT Code Emory Atlanta Gastroenterology Associates Resurgens Atlanta Womens Health Piedmont Physicians Group Orthopedics (ASC) Knee Arthroscopy 29881 $3467 $2036 Arthroscopy Ligament Repair 29888 $3386 $2258 GI (ASC) Upper GI Endoscopy 43239 $2758 $536 Diagnostic Colonoscopy 45378 $2348 $536 Colonoscopy and biopsy 45380 $2181 $536 Radiology Mammogram Screening G0202 $164 $231 Computer Detection Add-on 77052 $93 $14 Lab Comp Metabolic Panel 80053 $53 $13 $22 Tissue Exam by Pathologist 88305 $277 $188 $179 EampM (TEC) Office Visit new pt 99203 $269 $118 $159
Service Line Procedure CPT CodeDRG Memorial Hospital Beta Hosptial Charlie Hospital Delta Hospital Echo Hospital Alpha Medical Center Atlanta Gastroenterology Associates Resurgens Atlanta Womens Health Piedmont Physicians Group Market Avg Emory abovebelow Orthopedics Arthroscopy Ligament Repair 29888 $ 5062 $ 9557 $ 5983 $ 10096 $ 7519 $ 2502 $ 2258 $ 6319 -20 Knee Arthroscopy 29881 6 $ 5069 $ 4185 $ 3837 $ 3022 $ 3729 $ 2266 $ 2036 $ 3179 59 GI Upper GI Endoscopy 43239 6 $ 3075 $ 2539 $ 2012 $ 1132 $ 1565 $ 2240 $ 536 $ 1671 84 Lap Sleeve Gastrectomy DRG 621 $ 20421 $ 20815 $ 12105 $ 13230 $ 14600 $ 17800 $ 15710 30 Colonoscopy and biopsy 45380 $ 3075 $ 3071 $ 2013 $ 1244 $ 1972 $ 859 $ 536 $ 1616 90 Diagnostic Colonoscopy 45378 6 $ 3075 $ 2805 $ 2013 $ 1244 $ 1972 $ 859 $ 536 $ 1572 96 Radiology MRI Brain w amp wo dye 70553 2 $ 1238 $ 1468 $ 1117 $ 967 $ 2805 $ 1052 $ 1482 -16 MRI Joint of Lower Extremity wo dye 73721 2 $ 1238 $ 1398 $ 1042 $ 967 $ 925 $ 557 $ 978 27 MRI Abdomen w amp wo dye 74183 2 $ 1238 $ 1468 $ 1106 $ 967 $ 2805 $ 836 $ 1436 -14 X-ray Chest 71020 $ 115 $ 266 $ 305 $ 279 $ 375 $ 72 $ 259 -56 CT Thorax wo dye 71250 $ 882 $ 810 $ 505 $ 491 $ 579 $ 319 $ 541 63 Ultrasound Abdomen Complete 76700 $ 397 $ 538 $ 545 $ 195 $ 190 $ 168 $ 327 21 Mammogram Screening G0202 2 $ 141 $ 328 $ 431 $ 294 $ 425 $ 168 $ 231 $ 313 -55 Computer Detection Add-on 77052 2 $ 112 $ 99 $ 41 $ 15 $ 45 $ 23 $ 14 $ 39 183 Lab Comp Metabolic Panel 80053 8 $ 56 $ 15 $ 24 $ 56 $ 51 $ 25 $ 13 $ 22 $ 29 88 Tissue Exam by Pathologist 88305 8 $ 236 $ 307 $ 80 $ 152 $ 78 $ 232 $ 188 $ 179 $ 174 36 Medical Cardiology Cardiovascular Stress Test 93017 $ 383 $ 432 $ 1299 $ 907 $ 717 $ 797 $ 830 -54 TTE w Doppler 93306 2 $ 960 $ 1566 $ 1388 $ 1173 $ 1125 $ 1157 $ 1282 -25 Obstetrics Vaginal Delivery DRG 755 $ 7290 $ 5730 $ 4654 $ 4607 $ 5855 $ 4688 $ 5107 43 EampM Office Visit new pt 99203 4 $ 248 $ 118 $ 159 $ 139 78 Colonoscopy and biopsy (HOSPITAL ONLY) 45380 Surg 2530 $ 307591 Diagnostic colonoscopy (HOSPITAL ONLY) 45378 Surg 2255 $ 307591 Upper gi endoscopy biopsy (HOSPITAL ONLY) 43239 Surg 1787 $ 307591 Knee Arthroscopy (HOSPITAL ONLY) 29881 Surg 10900 $ 506893 Arthroscopy Ligament Repair (HOSPITAL ONLY) 29888 Surg 10900 $ 506200 Key 1 Facility - Inpatient 2 Facility - Imaging 3 Physician - Imaging 4 Physician 5 Global - Imaging 6 Facility - Outpatient 8 Lab 41 Physician - Primary Care 42 Physician - Specialist
Blue Cross United - EJCH EUH EUHM WW United - SJH Non Options United - SJH Options Aetna - ASC TEC (HMO) Cigna - ASC TEC (HMO) Aetna - EJCH ESJH ECHM WW Cigna - EJCH (HMO) Cigna - ESJH EUHM (HMO) List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract Description CPT Code Charge Average Final Price (all plans) Emory Mark Up Reimbursement Method ( of charge or fixed) - 1713 Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Cardiovascular stress test 93017 Cardio $543 $ 425 28 of Charge 70 $ 380 of Charge 65 $ 353 of Charge 60 $ 326 of Charge 70 $ 380 of Charge 70 $ 380 of charge 100 $ 543 of Charge 70 $ 380 of charge 100 $ 543 of charge 100 $ 543 TTE wDoppler complete 93306 Cardio $1226 $ 960 28 of Charge 70 $ 858 of Charge 65 $ 797 of Charge 60 $ 736 of Charge 70 $ 858 of Charge 70 $ 858 of charge 100 $ 1226 of Charge 70 $ 858 of charge 100 $ 1226 of charge 100 $ 1226 Colonoscopy and biopsy (HOSPITAL ONLY) 45380 Surg $2530 $ 3076 -18 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 of Charge 70 $ 1771 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Diagnostic colonoscopy (HOSPITAL ONLY) 45378 Surg $2255 $ 3076 -27 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 of Charge 70 $ 1579 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Upper gi endoscopy biopsy (HOSPITAL ONLY) 43239 Surg $1787 $ 3076 -42 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Knee Arthroscopy (HOSPITAL ONLY) 29881 Surg $10900 $ 5069 115 Fixed Rate SC 4 $ 3865 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 449300 $ 4493 Fixed Rate $ 654700 $ 6547 of Charge 70 $ 7630 Fixed Rate $ 401000 $ 4010 of Charge 70 $ 7630 Fixed Rate $ 398300 $ 3983 Fixed Rate $ 398100 $ 3981 Arthroscopy Ligament Repair (HOSPITAL ONLY) 29888 Surg $10900 $ 5062 115 Fixed Rate SC 3 $ 3121 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 556900 $ 5569 Fixed Rate $ 770100 $ 7701 of Charge 70 $ 7630 Fixed Rate $ 323900 $ 3239 of Charge 70 $ 7630 Fixed Rate $ 321700 $ 3217 Fixed Rate $ 321400 $ 3214 Comp Metabolic Panel 80053 Lab $132 $ 56 138 RBRVS Fee (100) $ 1437 of Charge 65 $ 86 of Charge 65 $ 86 of Charge 65 $ 86 of Charge 70 $ 92 RBRVS Fee (100) $ 1437 $ 14 of Charge 70 $ 92 RBRVS Fee (100) $ 1437 $ 14 RBRVS Fee (100) $ 1437 $ 14 Surgical Path Tissue Exam 88305 Lab $326 $ 236 38 of Charge 150 $ 51 of Charge 65 $ 212 of Charge 65 $ 212 of Charge 65 $ 212 of Charge 70 $ 228 of charge 100 $ 326 of Charge 70 $ 228 of charge 100 $ 326 of charge 100 $ 326 MRI Abdomen 74183 Radiology $6960 $ 1238 462 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 MRI Brain 70553 Radiology $6804 $ 1238 450 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 MRI Joint Lower Extremity 73721 Radiology $3067 $ 1238 148 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 CT Thorax wo contrast 71250 Radiology $2199 $ 882 149 Fixed Rate $ 771 Fixed Rate $ 47100 $ 471 Fixed Rate $ 81700 $ 817 Fixed Rate $ 116000 $ 1160 of Charge 70 $ 1539 Fixed Rate $ 80100 $ 801 Fixed Rate $ 79200 $ 792 Fixed Rate $ 79300 $ 793 Fixed Rate $ 79500 $ 795 X-ray Chest 71020 Radiology $280 $ 115 142 of Charge 150 $ 25 of Charge 65 $ 182 of Charge 60 $ 168 of Charge 70 $ 196 of Charge 70 $ 196 RBRVS Fee (150) $ 2534 $ 25 of Charge 70 $ 196 RBRVS Fee (150) $ 2534 $ 25 RBRVS Fee (150) $ 2534 $ 25 Screening mammography G0202 Radiology $279 $ 141 98 Fixed Rate $ 128 Fixed Rate $ 13100 $ 131 Fixed Rate $ 14300 $ 143 Fixed Rate $ 16100 $ 161 of Charge 70 $ 195 Fixed Rate $ 13300 $ 133 Fixed Rate $ 13500 $ 135 Fixed Rate $ 13000 $ 130 Fixed Rate $ 11200 $ 112 Mammo Computer Aided 77052 Radiology $75 $ 112 -33 Fixed Rate $ 9 Fixed Rate $ 13100 $ 131 Fixed Rate $ 14300 $ 143 Fixed Rate $ 16100 $ 161 of Charge 70 $ 53 Fixed Rate $ 13300 $ 133 Fixed Rate $ 13500 $ 135 Fixed Rate $ 13000 $ 130 Fixed Rate $ 11200 $ 112 US Abdomen Complete 76700 Radiology $917 $ 397 131 of Charge 150 $ 125 of Charge 65 $ 596 of Charge 60 $ 550 of Charge 70 $ 642 of Charge 70 $ 642 RBRVS Fee (150) $ 12519 $ 125 of Charge 70 $ 642 RBRVS Fee (150) $ 12519 $ 125 RBRVS Fee (150) $ 12519 $ 125 Officeoutpatient visit new pt 30 min (TEC) 99203 EampM $316 $ 248 28 of Charge 70 $ 221 of Charge 65 $ 205 of Charge 60 $ 190 of Charge 70 $ 221 of Charge 70 $ 221 of charge 100 $ 316 of Charge 70 $ 221 of charge 100 $ 316 of charge 100 $ 316 Vaginal delivery 59409 Surg $14484 $ 7290 99 Fixed Rate DRG - 775 $ 5437 2 Day Case Rate + LOC 561700 $ 5617 BaseCMS Weight 584741 $ 5847 BaseCMS Weight 726146 $ 7261 No IP Terms $ - 0 No IP BaseCMS Weight 659343 $ 6593 BaseContract Weight 479451 100 $ 14484 BaseCMS Weight 579110 $ 5791 Lap Sleeve Gastrectomy 43775 Surg $29961 $ 20421 47 Fixed Rate DRG - 621 $ 14872 BaseCMS Weight 1810697 $ 18107 BaseCMS Weight 1835178 $ 18352 BaseCMS Weight 2278911 $ 22789 No IP Terms $ - 0 No IP BaseCMS Weight 2069315 $ 20693 BaseCMS Weight 1730442 100 $ 29961 BaseCMS Weight 1817507 $ 18175 105 Colonoscopy and biopsy (ASC ONLY) Surg $ 219200 $ 2181 Diagnostic colonoscopy (ASC ONLY) Surg $ 267100 $ 2348 Upper gi endoscopy biopsy (ASC ONLY) Surg $ 207500 $ 2758 Knee Arthroscopy (ASC ONLY) Surg $ 417900 $ 3467 Arthroscopy Ligament Repair (ASC ONLY) Surg $ 504800 $ 3386
Cpt Code CPT Description Procedure Category Claims Min 25thNtile 50thNtile Emorys Rates 75thNtile 90thNtile Max 20 Below 50th Ntile 20 Above 50th Ntile 93017 CARDIOVASCULAR STRESS TEST 5 82 $80 $125 $321 $382 $568 $791 $930 $257 $386 71020 CHEST X-RAY 2 2638 $11 $45 $152 $115 $289 $373 $585 $122 $182 71020 CHEST X-RAY 5 8106 $25 $34 $38 $54 $57 $69 $30 $46 45380 COLONOSCOPY AND BIOPSY 6 1256 $541 $560 $572 $2877 $1000 $2024 $3289 $458 $686 77052 COMP SCREEN MAMMOGRAM ADD-ON 2 194 $13 $15 $25 $38 $47 $134 $20 $30 77052 COMP SCREEN MAMMOGRAM ADD-ON 5 2411 $13 $16 $20 $23 $26 $28 $16 $24 80053 COMPREHEN METABOLIC PANEL 8 13019 $9 $19 $23 $55 $24 $25 $69 $19 $28 71250 CT THORAX WO DYE 2 302 $165 $372 $545 $878 $1658 $2067 $436 $654 71250 CT THORAX WO DYE 5 209 $53 $127 $203 $289 $419 $534 $162 $244 45378 DIAGNOSTIC COLONOSCOPY 6 1479 $484 $515 $536 $2914 $831 $1971 $2828 $428 $643 29881 KNEE ARTHROSCOPYSURGERY 6 152 $1650 $1826 $2036 $5235 $3054 $4216 $6461 $1629 $2443 29888 KNEE ARTHROSCOPYSURGERY 6 82 $1682 $3615 $5081 $5145 $7553 $12924 $18532 $4065 $6097 43644 LAP GASTRIC BYPASSROUX-EN-Y 1 21 $11821 $13873 $17050 $18391 $25029 $31079 $13640 $20460 43775 LAP SLEEVE GASTRECTOMY 1 38 $4215 $8250 $13253 $20421 $19197 $21509 $24260 $10602 $15903 74183 MRI ABDOMEN WO amp WDYE 2 120 $919 $987 $1015 $1237 $1252 $2534 $3177 $812 $1218 74183 MRI ABDOMEN WO amp WDYE 5 112 $475 $490 $521 $1154 $1337 $1696 $417 $625 70553 MRI BRAIN WO amp WDYE 2 324 $633 $987 $1142 $1237 $1706 $2805 $3331 $914 $1370 70553 MRI BRAIN WO amp WDYE 5 467 $280 $539 $1023 $1277 $1363 $1726 $818 $1228 73721 MRI JNT OF LWR EXTRE WO DYE 2 304 $804 $859 $967 $1237 $1063 $1598 $2485 $774 $1160 73721 MRI JNT OF LWR EXTRE WO DYE 5 1130 $500 $520 $530 $628 $679 $859 $424 $636 59400 OBSTETRICAL CARE 1 494 $3699 $4402 $4969 $6655 $7307 $8613 $3975 $5963 99203 OFFICEOUTPATIENT VISIT NEW 4 6776 $88 $101 $112 $138 $155 $169 $90 $134 G0202 Screeningmammographydigital 2 7444 $123 $206 $285 $380 $425 $479 $228 $342 G0202 Screeningmammographydigital 5 2754 $117 $165 $195 $230 $247 $252 $156 $234 88305 TISSUE EXAM BY PATHOLOGIST 8 20834 $51 $74 $112 $235 $168 $261 $478 $90 $134 93306 TTE WDOPPLER COMPLETE 2 931 $194 $377 $739 $960 $1267 $1480 $1849 $591 $887 93306 TTE WDOPPLER COMPLETE 5 2299 $151 $296 $373 $538 $573 $834 $298 $448 43239 UPPER GI ENDOSCOPY BIOPSY 6 1264 $424 $514 $550 $800 $1838 $2833 $440 $660 76700 US EXAM ABDOM COMPLETE 2 321 $96 $165 $271 $509 $584 $857 $217 $325 76700 US EXAM ABDOM COMPLETE 5 444 $111 $129 $147 $156 $220 $279 $118 $176 Key 1 Facility - Inpatient 2 Facility - Imaging 3 Physician - Imaging 4 Physician 5 Global - Imaging 6 Facility - Outpatient 8 Lab 41 Physician - Primary Care 42 Physician - Specialist Cardiovascular stress test $ 38279 TTE wDoppler complete $ 96037 Colonoscopy and biopsy $ 287709 Diagnostic colonoscopy $ 291434 Upper gi endoscopy biopsy $ 300526 Knee Arthroscopy $ 523584 Arthroscopy Ligament Repair $ 514501 Comp Metabolic Panel $ 5552 Surgical Path Tissue Exam $ 23570 MRI Abdomen $ 123786 MRI Brain $ 123786 MRI Joint Lower Extremity $ 123786 CT Thorax wo contrast $ 88213 X-ray Chest $ 11548 Screening mammography $ 14098 Mammo Computer Aided $ 11179 US Abdomen Complete $ 39695 Officeoutpatient visit new pt 30 min $ 24753 Vaginal delivery $ 729025 Lap Sleeve Gastrectomy $ 2042124
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ED Avoidable ED and the impact of new on-site clinic
20
0
1000
2000
3000
4000
5000
6000
0200400600800
10001200140016001800
Clinic Visits ED Visits
Avoidable ED VisitsED Visits (non-avoidable)Clinic EampM Visits
0
500000
1000000
1500000
2000000
2500000
3000000
3500000
$s
Clinic EampM Profess DollarsAvoidable ED Dollars
bull Clinic visits have a clear impact on ED and avoidable ED use and spend
bull Combined ED visits are down on average 157 in FY 18 from FY 17
bull Combined ED spend is down 128 in FY 18 from FY 17
Clinic Live 62017
Pitfalls and Challenges bull Face many of the challenges similar to startup health
plan bull Critical to determine how you will deliver value and
communicate the value to potential customers and brokersconsultants
bull Care management bull Network
21
Considerations in Offering Development bull Care Management Model
bull Traditional care model bull Case management bull Utilization management bull Disease management
bull Longitudinal care model with value based care philosophy bull Primary care driven bull Local care management
bull Predictive analytics and risk stratification model bull Claims history and ongoing data bull EMR data
22
Case Study 2
Case study 2 ndash Large Employer bull Business Problem Large employer wants to contract
directly with 2 major hospital systems developing professional fee schedules
bull ConsiderationsValue Prop Fee schedule should be competitive but also nuanced to minimize gap relative to current reimbursement at physician level
bull Solution Data-driven approach using current market-wide reimbursement distinguished by service level
24
Evaluate Provider Spend Top 25 Service Lines by Allowable Spend
Evaluate Provider Spend Top 20 Professional CPTs by Total Spend
Understand relative market pricing position
27
21
-1
-28
14 10
28
-22
-11 -13
24
3
20 21
8
-20
13
3 9
-39
56
-26
4
-42
60
MRI Colonoscopy Cardiac Cath Lab - OrganPanel
Memorial Hospital Beta Hospital Delta Hospital Charlie Hospital Echo Hospital Alpha Medical Center
ndash25 5 -15 10 0 39
State Charges as a Percent of Peer Average Weighted Averages for MRI Colonoscopy Cardiology and Lab
Total Percent Above Below Market Average2
Memorial Hospital Beta Hospital Delta Hospital Charlie Hospital Echo Hospital Alpha Medical Center
Develop fee schedule relative to market
28
Service Line Procedure CPT CodeDRG
Memorial Hospital
Beta Hosptial
Charlie Hospital
Delta Hospital
Echo Hospital
Alpha Medical Center
Arthroscopy Ligament Repair 29888 $ 5062 $ 9557 $ 5983 $ 10096 $ 7519 $ 2502 Knee Arthroscopy 29881 $ 5069 $ 4185 $ 3837 $ 3022 $ 3729 $ 2266 Upper GI Endoscopy 43239 $ 3075 $ 2539 $ 2012 $ 1132 $ 1565 $ 2240 Lap Sleeve Gastrectomy DRG 621 $ 20421 $ 20815 $ 12105 $ 13230 $ 14600 $ 17800 Colonoscopy and biopsy 45380 $ 3075 $ 3071 $ 2013 $ 1244 $ 1972 $ 859 Diagnostic Colonoscopy 45378 $ 3075 $ 2805 $ 2013 $ 1244 $ 1972 $ 859 MRI Brain w amp wo dye 70553 $ 1238 $ 1468 $ 1117 $ 967 $ 2805 $ 1052 MRI Joint of Lower Extremity wo dye 73721 $ 1238 $ 1398 $ 1042 $ 967 $ 925 $ 557 MRI Abdomen w amp wo dye 74183 $ 1238 $ 1468 $ 1106 $ 967 $ 2805 $ 836 X-ray Chest 71020 $ 115 $ 266 $ 305 $ 279 $ 375 $ 72 CT Thorax wo dye 71250 $ 882 $ 810 $ 505 $ 491 $ 579 $ 319 Ultrasound Abdomen Complete 76700 $ 397 $ 538 $ 545 $ 195 $ 190 $ 168 Mammogram Screening G0202 $ 141 $ 328 $ 431 $ 294 $ 425 $ 168 Computer Detection Add-on 77052 $ 112 $ 99 $ 41 $ 15 $ 45 $ 23 Comp Metabolic Panel 80053 $ 56 $ 15 $ 24 $ 56 $ 51 $ 25 Tissue Exam by Pathologist 88305 $ 236 $ 307 $ 80 $ 152 $ 78 $ 232 Cardiovascular Stress Test 93017 $ 383 $ 432 $ 1299 $ 907 $ 717 $ 797 TTE w Doppler 93306 $ 960 $ 1566 $ 1388 $ 1173 $ 1125 $ 1157
Obstetrics Vaginal Delivery DRG 755 7290$ 5730$ 4654$ 4607$ 5855$ 4688$
GI
Lab
Radiology
Medical Cardiology
Orthopedics
KEY OBSERVA TIONS bull Potential exposure on GI bull Opportunity to align price and acuity in MRI bull Opportunity to raise rates on chest x-ray and mammogram
Percentile Bands Emory Allowables Heatmap TEC ASC Heatmap Allowable Comp Analysis Portal Pricing Sheet1 image1png A few words on Bundled Payments bull Bundled payments are growing as a type of direct contracting bull In some cases third parties match-make between employers
and providers bull Contracts may vary in definitions prepost admission
coverage duration readmission cause (ie all-cause vs medically related) outlier provisions LOS caps andor per diems
bull Providers need to be strategic in pricing to enable profitable growth of market share
29
Considerations in Offering Development bull Network Development
bull Build off existing structure eg health system employee plan network bull How does this fit into your broader value based care strategy bull Employed and independent physicians bull How do you want to approach the buildout of high performance
network bull Quality focus bull Cost efficiency
bull Integrated behavioral health bull Wrap network for other markets
30
Considerations in Offering Development bull Target Market
bull Consideration of employer profile in market bull Fully-insured vs ASO bull Total cost of care vs bundled services
bull Distribution bull Direct marketing bull Brokerconsultant community
bull Plan designs bull Standard designs vs flexible ndash Dependent on target market
bull Claims administration bull Data sharing amp analytics
31
Considerations in Offering Development bull Other components of comprehensive offering
bull Pharmacy bull Preventive health bull Onsite clinics bull Wellness programs bull Technology platform
32
Sample Bundle Analysis
33
Cover page Dotson Hazelrigs Nation Mainly of charge of fixed Cardiovascular stress test TTE wDoppler complete Colonoscopy and biopsy (Combined) Diagnostic colonoscopy (Combined) Upper gi endoscopy biopsy (Combined) Knee Arthroscopy (Combined) Arthroscopy Ligament Repair Comp Metabolic Panel Surgical Path Tissue Exam MRI Abdomen MRI Brain MRI Joint Lower Extremity CT Thorax wo contrast X-ray Chest Screening mammography Mammo Computer Aided US Abdomen Complete Officeoutpatient visit new pt 30 min Vaginal delivery Lap Sleeve Gastrectomy
Piedmont Piedmont Piedmont Piedmont Northside Northside Northside Northside Gwinnett Gwinnett Gwinnett Gwinnett WellStar WellStar WellStar WellStar AMC - Tenet AMC - Tenet AMC - Tenet AMC - Tenet CPT Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing 29881 $11312 $10872 NA NA $7476 $9338 NA $23655 $11856 $3668 NA $17871 $12253 NA NA $15645 $5490 NA NA $23039 29888 NA NA NA NA NA NA NA $23784 NA $8261 NA $18000 NA NA NA $15774 NA NA NA $23168 43239 NA $4408 NA NA NA NA $5997 $8852 NA $3304 NA $7424 $1267 NA NA $9230 NA $2458 NA $8274 43644 $26468 NA NA NA $3382 $12050 NA $1861 NA NA NA $1316 $7841 NA NA $3444 $18892 $27950 NA $979 43775 NA NA NA NA NA NA NA $352 NA NA NA $302 NA NA NA $413 NA NA NA $83 45378 $2705 $2530 NA NA $4381 $3676 $4496 $1022 $2938 $2138 NA $695 $5504 NA NA $2036 NA NA NA $372 45380 $3075 $2600 NA NA $4723 $3527 $3012 $1757 $4215 $2285 NA NA $5298 NA NA $3268 NA NA NA $627 59400 $6160 NA NA NA NA $5100 NA $1851 NA NA NA $1304 $9035 NA NA $3427 $9116 $5150 NA $966 70553 $2985 NA $1153 NA $2182 NA $1192 $492 NA NA $803 $489 $1512 NA $985 $1187 NA NA NA $197 71020 $61 $69 $43 NA $113 $319 $307 NA $183 $59 $32 NA $213 $66 $40 NA $83 $53 NA NA 71250 $1837 $621 $989 NA $1490 $931 $755 NA NA $745 $401 NA $1067 $982 $616 NA NA $304 NA NA 73721 NA $1098 $1153 NA $2042 $1065 $1192 NA NA $998 $803 NA NA $1275 $985 NA NA $644 NA $178 74183 $2971 $1144 NA NA NA $1092 $1192 $6884 NA $1098 $803 NA $2960 $1197 $985 $5454 NA NA NA $7607 76700 $364 $247 $207 NA $427 $708 $614 $13267 $428 $214 $152 NA $747 $263 $189 $9139 NA $235 NA NA 77052 NA NA NA NA NA NA NA $4744 NA NA NA NA NA NA NA $3070 NA NA NA $5611 93306 $1220 $1117 NA NA $1877 $1657 $2100 $4605 $1433 $413 $945 NA $1336 $1434 $1951 $2931 NA $2399 NA $5472 G0202 $262 $187 NA NA $431 NA NA $4605 $292 NA NA NA $530 $281 NA $2931 $327 NA NA $5472
Provider Group 29881_6 29888_6 43239_6 43644_1 43775_1 45378_6 45380_6 59400_1 70553_2 71020_2 71250_2 73721_2 74183_2 76700_2 77052_2 77052_5 80053_8 88305_8 93306_2 99203_4 G0202_2 G0202_5 93017_2 Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Atlanta Gastroenterology Associates $2399 $536 348 $1628 $536 204 $2400 $536 348 Atlanta Medical Center $24889 $2266 999 $25897 $2502 935 $11449 $2240 411 $81927 $15300 435 $75815 $17800 326 $7317 $859 752 $7317 $859 752 $12821 $4688 173 $6581 $1052 526 $645 $72 796 $3265 $319 925 $3450 $557 519 $7398 $836 785 $1576 $133 1084 $73 $23 217 $635 $25 2440 $891 $232 285 $2967 $1157 156 $344 $168 105 $1265 $797 59 Atlanta Womens Health Physicians Group $29 $14 107 $40 $13 208 $396 $188 111 $278 $118 135 $450 $231 95 Gwinnett Hospital $11941 $3022 295 $21654 $10096 114 $3551 $1132 214 $34384 $10800 218 $56472 $13230 327 $3003 $1244 141 $3533 $1244 184 $8984 $4607 95 $3901 $967 303 $417 $279 49 $2247 $491 358 $4000 $967 314 $3755 $967 288 $1593 $195 717 $50 $15 233 $186 $56 233 $505 $152 233 $1750 $1173 49 $418 $294 42 $1396 $907 54 Northside Hospital $15482 $4185 270 $21651 $9557 127 $4885 $2539 92 $35176 $17000 107 $35233 $20815 69 $3883 $2805 38 $5256 $3071 71 $10911 $5730 90 $4856 $1468 231 $443 $266 67 $2379 $810 194 $3776 $1398 170 $5105 $1468 248 $942 $538 75 $167 $99 69 $379 $15 2427 $433 $307 41 $2252 $1566 44 $459 $328 40 $576 $432 33 Piedmont Hospital $14772 $3837 285 $35493 $5983 493 $5069 $2012 152 $38320 $17750 116 $37125 $12105 207 $3485 $2013 73 $4993 $2013 148 $10143 $4654 118 $5939 $1117 432 $542 $305 78 $2983 $505 491 $3410 $1042 227 $6067 $1106 449 $1364 $545 150 $75 $41 85 $231 $24 863 $657 $80 721 $2041 $1388 47 $490 $431 14 $1780 $1299 37 Piedmont Physicians Group $42 $22 87 $318 $179 78 $239 $159 50 Resurgens $8558 $2036 320 $9293 $2258 312 $4638 $2067 124 $4039 $2164 87 $4392 $2164 103 $2252 $1371 64 $459 $330 39 Wellstar Hospital $9330 $3729 150 $17479 $7519 132 $5261 $1565 236 $35794 $18200 97 $46780 $14600 220 $3707 $1972 88 $4928 $1972 150 $13549 $5855 131 $5054 $2805 80 $528 $375 41 $3222 $579 457 $3694 $925 299 $5495 $2805 96 $1355 $190 615 $66 $45 46 $73 $51 43 $133 $78 71 $1785 $1125 59 $599 $425 41 $1010 $717 41 Avg Mark UpProcedure Atlanta Medical Center 634 Gwinnett Hospital 223 Northside Hospital 233 Piedmont Hospital 259 Wellstar Hospital 155 Emory 105
Atlanta Gastroenterology Associates Atlanta Medical Center Atlanta Womens Health Gwinnett Hospital Northside Hospital Piedmont Hospital Piedmont Physicians Group Resurgens Wellstar Hospital CPT Code CPT Proc Cat Comp Avg Allow Allow Allow Allow Allow Allow Allow Allow Allow 29881 KNEE ARTHROSCOPYSURGERY 6 $3179 $2266 $3022 $4185 $3837 $2036 $3729 29888 KNEE ARTHROSCOPYSURGERY 6 $6319 $2502 $10096 $9557 $5983 $2258 $7519 43239 UPPER GI ENDOSCOPY BIOPSY 6 $1727 $536 $2240 $1132 $2539 $2012 $2067 $1565 43644 LAP GASTRIC BYPASSROUX-EN-Y 1 $15810 $15300 $10800 $17000 $17750 $18200 43775 LAP SLEEVE GASTRECTOMY 1 $17800 $13230 $20815 $12105 $14600 45378 DIAGNOSTIC COLONOSCOPY 6 $1656 $536 $859 $1244 $2805 $2013 $2164 $1972 45380 COLONOSCOPY AND BIOPSY 6 $1694 $536 $859 $1244 $3071 $2013 $2164 $1972 59400 OBSTETRICAL CARE 1 $5107 $4688 $4607 $5730 $4654 $5855 70553 MRI BRAIN WO amp WDYE 2 $1482 $1052 $967 $1468 $1117 $2805 71020 CHEST X-RAY 2 $259 $72 $279 $266 $305 $375 71250 CT THORAX WO DYE 2 $541 $319 $491 $810 $505 $579 73721 MRI JNT OF LWR EXTRE WO DYE 2 $978 $557 $967 $1398 $1042 $925 74183 MRI ABDOMEN WO amp WDYE 2 $1436 $836 $967 $1468 $1106 $2805 76700 US EXAM ABDOM COMPLETE 2 $320 $133 $195 $538 $545 $190 77052 COMP SCREEN MAMMOGRAM ADD-ON 2 $45 $23 $15 $99 $41 $45 77052 COMP SCREEN MAMMOGRAM ADD-ON 5 $14 $14 80053 COMPREHEN METABOLIC PANEL 8 $29 $25 $13 $56 $15 $24 $22 $51 88305 TISSUE EXAM BY PATHOLOGIST 8 $174 $232 $188 $152 $307 $80 $179 $78 93306 TTE WDOPPLER COMPLETE 2 $1297 $1157 $1173 $1566 $1388 $1371 $1125 93017 STRESS TEST 5 $830 $797 $907 $432 $1299 $717 99203 OFFICEOUTPATIENT VISIT NEW 4 $139 $118 $159 G0202 Screeningmammographydigital 2 $329 $168 $294 $328 $431 $330 $425 G0202 Screeningmammographydigital 5 $231 $231
Service Line Procedure CPT Code Emory Atlanta Gastroenterology Associates Resurgens Atlanta Womens Health Piedmont Physicians Group Orthopedics (ASC) Knee Arthroscopy 29881 $3467 $2036 Arthroscopy Ligament Repair 29888 $3386 $2258 GI (ASC) Upper GI Endoscopy 43239 $2758 $536 Diagnostic Colonoscopy 45378 $2348 $536 Colonoscopy and biopsy 45380 $2181 $536 Radiology Mammogram Screening G0202 $164 $231 Computer Detection Add-on 77052 $93 $14 Lab Comp Metabolic Panel 80053 $53 $13 $22 Tissue Exam by Pathologist 88305 $277 $188 $179 EampM (TEC) Office Visit new pt 99203 $269 $118 $159
Service Line Procedure CPT CodeDRG Memorial Hospital Beta Hosptial Charlie Hospital Delta Hospital Echo Hospital Alpha Medical Center Atlanta Gastroenterology Associates Resurgens Atlanta Womens Health Piedmont Physicians Group Market Avg Emory abovebelow Orthopedics Arthroscopy Ligament Repair 29888 $ 5062 $ 9557 $ 5983 $ 10096 $ 7519 $ 2502 $ 2258 $ 6319 -20 Knee Arthroscopy 29881 6 $ 5069 $ 4185 $ 3837 $ 3022 $ 3729 $ 2266 $ 2036 $ 3179 59 GI Upper GI Endoscopy 43239 6 $ 3075 $ 2539 $ 2012 $ 1132 $ 1565 $ 2240 $ 536 $ 1671 84 Lap Sleeve Gastrectomy DRG 621 $ 20421 $ 20815 $ 12105 $ 13230 $ 14600 $ 17800 $ 15710 30 Colonoscopy and biopsy 45380 $ 3075 $ 3071 $ 2013 $ 1244 $ 1972 $ 859 $ 536 $ 1616 90 Diagnostic Colonoscopy 45378 6 $ 3075 $ 2805 $ 2013 $ 1244 $ 1972 $ 859 $ 536 $ 1572 96 Radiology MRI Brain w amp wo dye 70553 2 $ 1238 $ 1468 $ 1117 $ 967 $ 2805 $ 1052 $ 1482 -16 MRI Joint of Lower Extremity wo dye 73721 2 $ 1238 $ 1398 $ 1042 $ 967 $ 925 $ 557 $ 978 27 MRI Abdomen w amp wo dye 74183 2 $ 1238 $ 1468 $ 1106 $ 967 $ 2805 $ 836 $ 1436 -14 X-ray Chest 71020 $ 115 $ 266 $ 305 $ 279 $ 375 $ 72 $ 259 -56 CT Thorax wo dye 71250 $ 882 $ 810 $ 505 $ 491 $ 579 $ 319 $ 541 63 Ultrasound Abdomen Complete 76700 $ 397 $ 538 $ 545 $ 195 $ 190 $ 168 $ 327 21 Mammogram Screening G0202 2 $ 141 $ 328 $ 431 $ 294 $ 425 $ 168 $ 231 $ 313 -55 Computer Detection Add-on 77052 2 $ 112 $ 99 $ 41 $ 15 $ 45 $ 23 $ 14 $ 39 183 Lab Comp Metabolic Panel 80053 8 $ 56 $ 15 $ 24 $ 56 $ 51 $ 25 $ 13 $ 22 $ 29 88 Tissue Exam by Pathologist 88305 8 $ 236 $ 307 $ 80 $ 152 $ 78 $ 232 $ 188 $ 179 $ 174 36 Medical Cardiology Cardiovascular Stress Test 93017 $ 383 $ 432 $ 1299 $ 907 $ 717 $ 797 $ 830 -54 TTE w Doppler 93306 2 $ 960 $ 1566 $ 1388 $ 1173 $ 1125 $ 1157 $ 1282 -25 Obstetrics Vaginal Delivery DRG 755 $ 7290 $ 5730 $ 4654 $ 4607 $ 5855 $ 4688 $ 5107 43 EampM Office Visit new pt 99203 4 $ 248 $ 118 $ 159 $ 139 78 Colonoscopy and biopsy (HOSPITAL ONLY) 45380 Surg 2530 $ 307591 Diagnostic colonoscopy (HOSPITAL ONLY) 45378 Surg 2255 $ 307591 Upper gi endoscopy biopsy (HOSPITAL ONLY) 43239 Surg 1787 $ 307591 Knee Arthroscopy (HOSPITAL ONLY) 29881 Surg 10900 $ 506893 Arthroscopy Ligament Repair (HOSPITAL ONLY) 29888 Surg 10900 $ 506200 Key 1 Facility - Inpatient 2 Facility - Imaging 3 Physician - Imaging 4 Physician 5 Global - Imaging 6 Facility - Outpatient 8 Lab 41 Physician - Primary Care 42 Physician - Specialist
Blue Cross United - EJCH EUH EUHM WW United - SJH Non Options United - SJH Options Aetna - ASC TEC (HMO) Cigna - ASC TEC (HMO) Aetna - EJCH ESJH ECHM WW Cigna - EJCH (HMO) Cigna - ESJH EUHM (HMO) List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract Description CPT Code Charge Average Final Price (all plans) Emory Mark Up Reimbursement Method ( of charge or fixed) - 1713 Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Cardiovascular stress test 93017 Cardio $543 $ 425 28 of Charge 70 $ 380 of Charge 65 $ 353 of Charge 60 $ 326 of Charge 70 $ 380 of Charge 70 $ 380 of charge 100 $ 543 of Charge 70 $ 380 of charge 100 $ 543 of charge 100 $ 543 TTE wDoppler complete 93306 Cardio $1226 $ 960 28 of Charge 70 $ 858 of Charge 65 $ 797 of Charge 60 $ 736 of Charge 70 $ 858 of Charge 70 $ 858 of charge 100 $ 1226 of Charge 70 $ 858 of charge 100 $ 1226 of charge 100 $ 1226 Colonoscopy and biopsy (HOSPITAL ONLY) 45380 Surg $2530 $ 3076 -18 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 of Charge 70 $ 1771 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Diagnostic colonoscopy (HOSPITAL ONLY) 45378 Surg $2255 $ 3076 -27 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 of Charge 70 $ 1579 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Upper gi endoscopy biopsy (HOSPITAL ONLY) 43239 Surg $1787 $ 3076 -42 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Knee Arthroscopy (HOSPITAL ONLY) 29881 Surg $10900 $ 5069 115 Fixed Rate SC 4 $ 3865 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 449300 $ 4493 Fixed Rate $ 654700 $ 6547 of Charge 70 $ 7630 Fixed Rate $ 401000 $ 4010 of Charge 70 $ 7630 Fixed Rate $ 398300 $ 3983 Fixed Rate $ 398100 $ 3981 Arthroscopy Ligament Repair (HOSPITAL ONLY) 29888 Surg $10900 $ 5062 115 Fixed Rate SC 3 $ 3121 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 556900 $ 5569 Fixed Rate $ 770100 $ 7701 of Charge 70 $ 7630 Fixed Rate $ 323900 $ 3239 of Charge 70 $ 7630 Fixed Rate $ 321700 $ 3217 Fixed Rate $ 321400 $ 3214 Comp Metabolic Panel 80053 Lab $132 $ 56 138 RBRVS Fee (100) $ 1437 of Charge 65 $ 86 of Charge 65 $ 86 of Charge 65 $ 86 of Charge 70 $ 92 RBRVS Fee (100) $ 1437 $ 14 of Charge 70 $ 92 RBRVS Fee (100) $ 1437 $ 14 RBRVS Fee (100) $ 1437 $ 14 Surgical Path Tissue Exam 88305 Lab $326 $ 236 38 of Charge 150 $ 51 of Charge 65 $ 212 of Charge 65 $ 212 of Charge 65 $ 212 of Charge 70 $ 228 of charge 100 $ 326 of Charge 70 $ 228 of charge 100 $ 326 of charge 100 $ 326 MRI Abdomen 74183 Radiology $6960 $ 1238 462 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 MRI Brain 70553 Radiology $6804 $ 1238 450 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 MRI Joint Lower Extremity 73721 Radiology $3067 $ 1238 148 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 CT Thorax wo contrast 71250 Radiology $2199 $ 882 149 Fixed Rate $ 771 Fixed Rate $ 47100 $ 471 Fixed Rate $ 81700 $ 817 Fixed Rate $ 116000 $ 1160 of Charge 70 $ 1539 Fixed Rate $ 80100 $ 801 Fixed Rate $ 79200 $ 792 Fixed Rate $ 79300 $ 793 Fixed Rate $ 79500 $ 795 X-ray Chest 71020 Radiology $280 $ 115 142 of Charge 150 $ 25 of Charge 65 $ 182 of Charge 60 $ 168 of Charge 70 $ 196 of Charge 70 $ 196 RBRVS Fee (150) $ 2534 $ 25 of Charge 70 $ 196 RBRVS Fee (150) $ 2534 $ 25 RBRVS Fee (150) $ 2534 $ 25 Screening mammography G0202 Radiology $279 $ 141 98 Fixed Rate $ 128 Fixed Rate $ 13100 $ 131 Fixed Rate $ 14300 $ 143 Fixed Rate $ 16100 $ 161 of Charge 70 $ 195 Fixed Rate $ 13300 $ 133 Fixed Rate $ 13500 $ 135 Fixed Rate $ 13000 $ 130 Fixed Rate $ 11200 $ 112 Mammo Computer Aided 77052 Radiology $75 $ 112 -33 Fixed Rate $ 9 Fixed Rate $ 13100 $ 131 Fixed Rate $ 14300 $ 143 Fixed Rate $ 16100 $ 161 of Charge 70 $ 53 Fixed Rate $ 13300 $ 133 Fixed Rate $ 13500 $ 135 Fixed Rate $ 13000 $ 130 Fixed Rate $ 11200 $ 112 US Abdomen Complete 76700 Radiology $917 $ 397 131 of Charge 150 $ 125 of Charge 65 $ 596 of Charge 60 $ 550 of Charge 70 $ 642 of Charge 70 $ 642 RBRVS Fee (150) $ 12519 $ 125 of Charge 70 $ 642 RBRVS Fee (150) $ 12519 $ 125 RBRVS Fee (150) $ 12519 $ 125 Officeoutpatient visit new pt 30 min (TEC) 99203 EampM $316 $ 248 28 of Charge 70 $ 221 of Charge 65 $ 205 of Charge 60 $ 190 of Charge 70 $ 221 of Charge 70 $ 221 of charge 100 $ 316 of Charge 70 $ 221 of charge 100 $ 316 of charge 100 $ 316 Vaginal delivery 59409 Surg $14484 $ 7290 99 Fixed Rate DRG - 775 $ 5437 2 Day Case Rate + LOC 561700 $ 5617 BaseCMS Weight 584741 $ 5847 BaseCMS Weight 726146 $ 7261 No IP Terms $ - 0 No IP BaseCMS Weight 659343 $ 6593 BaseContract Weight 479451 100 $ 14484 BaseCMS Weight 579110 $ 5791 Lap Sleeve Gastrectomy 43775 Surg $29961 $ 20421 47 Fixed Rate DRG - 621 $ 14872 BaseCMS Weight 1810697 $ 18107 BaseCMS Weight 1835178 $ 18352 BaseCMS Weight 2278911 $ 22789 No IP Terms $ - 0 No IP BaseCMS Weight 2069315 $ 20693 BaseCMS Weight 1730442 100 $ 29961 BaseCMS Weight 1817507 $ 18175 105 Colonoscopy and biopsy (ASC ONLY) Surg $ 219200 $ 2181 Diagnostic colonoscopy (ASC ONLY) Surg $ 267100 $ 2348 Upper gi endoscopy biopsy (ASC ONLY) Surg $ 207500 $ 2758 Knee Arthroscopy (ASC ONLY) Surg $ 417900 $ 3467 Arthroscopy Ligament Repair (ASC ONLY) Surg $ 504800 $ 3386
Cpt Code CPT Description Procedure Category Claims Min 25thNtile 50thNtile Emorys Rates 75thNtile 90thNtile Max 20 Below 50th Ntile 20 Above 50th Ntile 93017 CARDIOVASCULAR STRESS TEST 5 82 $80 $125 $321 $382 $568 $791 $930 $257 $386 71020 CHEST X-RAY 2 2638 $11 $45 $152 $115 $289 $373 $585 $122 $182 71020 CHEST X-RAY 5 8106 $25 $34 $38 $54 $57 $69 $30 $46 45380 COLONOSCOPY AND BIOPSY 6 1256 $541 $560 $572 $2877 $1000 $2024 $3289 $458 $686 77052 COMP SCREEN MAMMOGRAM ADD-ON 2 194 $13 $15 $25 $38 $47 $134 $20 $30 77052 COMP SCREEN MAMMOGRAM ADD-ON 5 2411 $13 $16 $20 $23 $26 $28 $16 $24 80053 COMPREHEN METABOLIC PANEL 8 13019 $9 $19 $23 $55 $24 $25 $69 $19 $28 71250 CT THORAX WO DYE 2 302 $165 $372 $545 $878 $1658 $2067 $436 $654 71250 CT THORAX WO DYE 5 209 $53 $127 $203 $289 $419 $534 $162 $244 45378 DIAGNOSTIC COLONOSCOPY 6 1479 $484 $515 $536 $2914 $831 $1971 $2828 $428 $643 29881 KNEE ARTHROSCOPYSURGERY 6 152 $1650 $1826 $2036 $5235 $3054 $4216 $6461 $1629 $2443 29888 KNEE ARTHROSCOPYSURGERY 6 82 $1682 $3615 $5081 $5145 $7553 $12924 $18532 $4065 $6097 43644 LAP GASTRIC BYPASSROUX-EN-Y 1 21 $11821 $13873 $17050 $18391 $25029 $31079 $13640 $20460 43775 LAP SLEEVE GASTRECTOMY 1 38 $4215 $8250 $13253 $20421 $19197 $21509 $24260 $10602 $15903 74183 MRI ABDOMEN WO amp WDYE 2 120 $919 $987 $1015 $1237 $1252 $2534 $3177 $812 $1218 74183 MRI ABDOMEN WO amp WDYE 5 112 $475 $490 $521 $1154 $1337 $1696 $417 $625 70553 MRI BRAIN WO amp WDYE 2 324 $633 $987 $1142 $1237 $1706 $2805 $3331 $914 $1370 70553 MRI BRAIN WO amp WDYE 5 467 $280 $539 $1023 $1277 $1363 $1726 $818 $1228 73721 MRI JNT OF LWR EXTRE WO DYE 2 304 $804 $859 $967 $1237 $1063 $1598 $2485 $774 $1160 73721 MRI JNT OF LWR EXTRE WO DYE 5 1130 $500 $520 $530 $628 $679 $859 $424 $636 59400 OBSTETRICAL CARE 1 494 $3699 $4402 $4969 $6655 $7307 $8613 $3975 $5963 99203 OFFICEOUTPATIENT VISIT NEW 4 6776 $88 $101 $112 $138 $155 $169 $90 $134 G0202 Screeningmammographydigital 2 7444 $123 $206 $285 $380 $425 $479 $228 $342 G0202 Screeningmammographydigital 5 2754 $117 $165 $195 $230 $247 $252 $156 $234 88305 TISSUE EXAM BY PATHOLOGIST 8 20834 $51 $74 $112 $235 $168 $261 $478 $90 $134 93306 TTE WDOPPLER COMPLETE 2 931 $194 $377 $739 $960 $1267 $1480 $1849 $591 $887 93306 TTE WDOPPLER COMPLETE 5 2299 $151 $296 $373 $538 $573 $834 $298 $448 43239 UPPER GI ENDOSCOPY BIOPSY 6 1264 $424 $514 $550 $800 $1838 $2833 $440 $660 76700 US EXAM ABDOM COMPLETE 2 321 $96 $165 $271 $509 $584 $857 $217 $325 76700 US EXAM ABDOM COMPLETE 5 444 $111 $129 $147 $156 $220 $279 $118 $176 Key 1 Facility - Inpatient 2 Facility - Imaging 3 Physician - Imaging 4 Physician 5 Global - Imaging 6 Facility - Outpatient 8 Lab 41 Physician - Primary Care 42 Physician - Specialist Cardiovascular stress test $ 38279 TTE wDoppler complete $ 96037 Colonoscopy and biopsy $ 287709 Diagnostic colonoscopy $ 291434 Upper gi endoscopy biopsy $ 300526 Knee Arthroscopy $ 523584 Arthroscopy Ligament Repair $ 514501 Comp Metabolic Panel $ 5552 Surgical Path Tissue Exam $ 23570 MRI Abdomen $ 123786 MRI Brain $ 123786 MRI Joint Lower Extremity $ 123786 CT Thorax wo contrast $ 88213 X-ray Chest $ 11548 Screening mammography $ 14098 Mammo Computer Aided $ 11179 US Abdomen Complete $ 39695 Officeoutpatient visit new pt 30 min $ 24753 Vaginal delivery $ 729025 Lap Sleeve Gastrectomy $ 2042124
Page 22
Pitfalls and Challenges bull Face many of the challenges similar to startup health
plan bull Critical to determine how you will deliver value and
communicate the value to potential customers and brokersconsultants
bull Care management bull Network
21
Considerations in Offering Development bull Care Management Model
bull Traditional care model bull Case management bull Utilization management bull Disease management
bull Longitudinal care model with value based care philosophy bull Primary care driven bull Local care management
bull Predictive analytics and risk stratification model bull Claims history and ongoing data bull EMR data
22
Case Study 2
Case study 2 ndash Large Employer bull Business Problem Large employer wants to contract
directly with 2 major hospital systems developing professional fee schedules
bull ConsiderationsValue Prop Fee schedule should be competitive but also nuanced to minimize gap relative to current reimbursement at physician level
bull Solution Data-driven approach using current market-wide reimbursement distinguished by service level
24
Evaluate Provider Spend Top 25 Service Lines by Allowable Spend
Evaluate Provider Spend Top 20 Professional CPTs by Total Spend
Understand relative market pricing position
27
21
-1
-28
14 10
28
-22
-11 -13
24
3
20 21
8
-20
13
3 9
-39
56
-26
4
-42
60
MRI Colonoscopy Cardiac Cath Lab - OrganPanel
Memorial Hospital Beta Hospital Delta Hospital Charlie Hospital Echo Hospital Alpha Medical Center
ndash25 5 -15 10 0 39
State Charges as a Percent of Peer Average Weighted Averages for MRI Colonoscopy Cardiology and Lab
Total Percent Above Below Market Average2
Memorial Hospital Beta Hospital Delta Hospital Charlie Hospital Echo Hospital Alpha Medical Center
Develop fee schedule relative to market
28
Service Line Procedure CPT CodeDRG
Memorial Hospital
Beta Hosptial
Charlie Hospital
Delta Hospital
Echo Hospital
Alpha Medical Center
Arthroscopy Ligament Repair 29888 $ 5062 $ 9557 $ 5983 $ 10096 $ 7519 $ 2502 Knee Arthroscopy 29881 $ 5069 $ 4185 $ 3837 $ 3022 $ 3729 $ 2266 Upper GI Endoscopy 43239 $ 3075 $ 2539 $ 2012 $ 1132 $ 1565 $ 2240 Lap Sleeve Gastrectomy DRG 621 $ 20421 $ 20815 $ 12105 $ 13230 $ 14600 $ 17800 Colonoscopy and biopsy 45380 $ 3075 $ 3071 $ 2013 $ 1244 $ 1972 $ 859 Diagnostic Colonoscopy 45378 $ 3075 $ 2805 $ 2013 $ 1244 $ 1972 $ 859 MRI Brain w amp wo dye 70553 $ 1238 $ 1468 $ 1117 $ 967 $ 2805 $ 1052 MRI Joint of Lower Extremity wo dye 73721 $ 1238 $ 1398 $ 1042 $ 967 $ 925 $ 557 MRI Abdomen w amp wo dye 74183 $ 1238 $ 1468 $ 1106 $ 967 $ 2805 $ 836 X-ray Chest 71020 $ 115 $ 266 $ 305 $ 279 $ 375 $ 72 CT Thorax wo dye 71250 $ 882 $ 810 $ 505 $ 491 $ 579 $ 319 Ultrasound Abdomen Complete 76700 $ 397 $ 538 $ 545 $ 195 $ 190 $ 168 Mammogram Screening G0202 $ 141 $ 328 $ 431 $ 294 $ 425 $ 168 Computer Detection Add-on 77052 $ 112 $ 99 $ 41 $ 15 $ 45 $ 23 Comp Metabolic Panel 80053 $ 56 $ 15 $ 24 $ 56 $ 51 $ 25 Tissue Exam by Pathologist 88305 $ 236 $ 307 $ 80 $ 152 $ 78 $ 232 Cardiovascular Stress Test 93017 $ 383 $ 432 $ 1299 $ 907 $ 717 $ 797 TTE w Doppler 93306 $ 960 $ 1566 $ 1388 $ 1173 $ 1125 $ 1157
Obstetrics Vaginal Delivery DRG 755 7290$ 5730$ 4654$ 4607$ 5855$ 4688$
GI
Lab
Radiology
Medical Cardiology
Orthopedics
KEY OBSERVA TIONS bull Potential exposure on GI bull Opportunity to align price and acuity in MRI bull Opportunity to raise rates on chest x-ray and mammogram
Percentile Bands Emory Allowables Heatmap TEC ASC Heatmap Allowable Comp Analysis Portal Pricing Sheet1 image1png A few words on Bundled Payments bull Bundled payments are growing as a type of direct contracting bull In some cases third parties match-make between employers
and providers bull Contracts may vary in definitions prepost admission
coverage duration readmission cause (ie all-cause vs medically related) outlier provisions LOS caps andor per diems
bull Providers need to be strategic in pricing to enable profitable growth of market share
29
Considerations in Offering Development bull Network Development
bull Build off existing structure eg health system employee plan network bull How does this fit into your broader value based care strategy bull Employed and independent physicians bull How do you want to approach the buildout of high performance
network bull Quality focus bull Cost efficiency
bull Integrated behavioral health bull Wrap network for other markets
30
Considerations in Offering Development bull Target Market
bull Consideration of employer profile in market bull Fully-insured vs ASO bull Total cost of care vs bundled services
bull Distribution bull Direct marketing bull Brokerconsultant community
bull Plan designs bull Standard designs vs flexible ndash Dependent on target market
bull Claims administration bull Data sharing amp analytics
31
Considerations in Offering Development bull Other components of comprehensive offering
bull Pharmacy bull Preventive health bull Onsite clinics bull Wellness programs bull Technology platform
32
Sample Bundle Analysis
33
Cover page Dotson Hazelrigs Nation Mainly of charge of fixed Cardiovascular stress test TTE wDoppler complete Colonoscopy and biopsy (Combined) Diagnostic colonoscopy (Combined) Upper gi endoscopy biopsy (Combined) Knee Arthroscopy (Combined) Arthroscopy Ligament Repair Comp Metabolic Panel Surgical Path Tissue Exam MRI Abdomen MRI Brain MRI Joint Lower Extremity CT Thorax wo contrast X-ray Chest Screening mammography Mammo Computer Aided US Abdomen Complete Officeoutpatient visit new pt 30 min Vaginal delivery Lap Sleeve Gastrectomy
Piedmont Piedmont Piedmont Piedmont Northside Northside Northside Northside Gwinnett Gwinnett Gwinnett Gwinnett WellStar WellStar WellStar WellStar AMC - Tenet AMC - Tenet AMC - Tenet AMC - Tenet CPT Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing 29881 $11312 $10872 NA NA $7476 $9338 NA $23655 $11856 $3668 NA $17871 $12253 NA NA $15645 $5490 NA NA $23039 29888 NA NA NA NA NA NA NA $23784 NA $8261 NA $18000 NA NA NA $15774 NA NA NA $23168 43239 NA $4408 NA NA NA NA $5997 $8852 NA $3304 NA $7424 $1267 NA NA $9230 NA $2458 NA $8274 43644 $26468 NA NA NA $3382 $12050 NA $1861 NA NA NA $1316 $7841 NA NA $3444 $18892 $27950 NA $979 43775 NA NA NA NA NA NA NA $352 NA NA NA $302 NA NA NA $413 NA NA NA $83 45378 $2705 $2530 NA NA $4381 $3676 $4496 $1022 $2938 $2138 NA $695 $5504 NA NA $2036 NA NA NA $372 45380 $3075 $2600 NA NA $4723 $3527 $3012 $1757 $4215 $2285 NA NA $5298 NA NA $3268 NA NA NA $627 59400 $6160 NA NA NA NA $5100 NA $1851 NA NA NA $1304 $9035 NA NA $3427 $9116 $5150 NA $966 70553 $2985 NA $1153 NA $2182 NA $1192 $492 NA NA $803 $489 $1512 NA $985 $1187 NA NA NA $197 71020 $61 $69 $43 NA $113 $319 $307 NA $183 $59 $32 NA $213 $66 $40 NA $83 $53 NA NA 71250 $1837 $621 $989 NA $1490 $931 $755 NA NA $745 $401 NA $1067 $982 $616 NA NA $304 NA NA 73721 NA $1098 $1153 NA $2042 $1065 $1192 NA NA $998 $803 NA NA $1275 $985 NA NA $644 NA $178 74183 $2971 $1144 NA NA NA $1092 $1192 $6884 NA $1098 $803 NA $2960 $1197 $985 $5454 NA NA NA $7607 76700 $364 $247 $207 NA $427 $708 $614 $13267 $428 $214 $152 NA $747 $263 $189 $9139 NA $235 NA NA 77052 NA NA NA NA NA NA NA $4744 NA NA NA NA NA NA NA $3070 NA NA NA $5611 93306 $1220 $1117 NA NA $1877 $1657 $2100 $4605 $1433 $413 $945 NA $1336 $1434 $1951 $2931 NA $2399 NA $5472 G0202 $262 $187 NA NA $431 NA NA $4605 $292 NA NA NA $530 $281 NA $2931 $327 NA NA $5472
Provider Group 29881_6 29888_6 43239_6 43644_1 43775_1 45378_6 45380_6 59400_1 70553_2 71020_2 71250_2 73721_2 74183_2 76700_2 77052_2 77052_5 80053_8 88305_8 93306_2 99203_4 G0202_2 G0202_5 93017_2 Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Atlanta Gastroenterology Associates $2399 $536 348 $1628 $536 204 $2400 $536 348 Atlanta Medical Center $24889 $2266 999 $25897 $2502 935 $11449 $2240 411 $81927 $15300 435 $75815 $17800 326 $7317 $859 752 $7317 $859 752 $12821 $4688 173 $6581 $1052 526 $645 $72 796 $3265 $319 925 $3450 $557 519 $7398 $836 785 $1576 $133 1084 $73 $23 217 $635 $25 2440 $891 $232 285 $2967 $1157 156 $344 $168 105 $1265 $797 59 Atlanta Womens Health Physicians Group $29 $14 107 $40 $13 208 $396 $188 111 $278 $118 135 $450 $231 95 Gwinnett Hospital $11941 $3022 295 $21654 $10096 114 $3551 $1132 214 $34384 $10800 218 $56472 $13230 327 $3003 $1244 141 $3533 $1244 184 $8984 $4607 95 $3901 $967 303 $417 $279 49 $2247 $491 358 $4000 $967 314 $3755 $967 288 $1593 $195 717 $50 $15 233 $186 $56 233 $505 $152 233 $1750 $1173 49 $418 $294 42 $1396 $907 54 Northside Hospital $15482 $4185 270 $21651 $9557 127 $4885 $2539 92 $35176 $17000 107 $35233 $20815 69 $3883 $2805 38 $5256 $3071 71 $10911 $5730 90 $4856 $1468 231 $443 $266 67 $2379 $810 194 $3776 $1398 170 $5105 $1468 248 $942 $538 75 $167 $99 69 $379 $15 2427 $433 $307 41 $2252 $1566 44 $459 $328 40 $576 $432 33 Piedmont Hospital $14772 $3837 285 $35493 $5983 493 $5069 $2012 152 $38320 $17750 116 $37125 $12105 207 $3485 $2013 73 $4993 $2013 148 $10143 $4654 118 $5939 $1117 432 $542 $305 78 $2983 $505 491 $3410 $1042 227 $6067 $1106 449 $1364 $545 150 $75 $41 85 $231 $24 863 $657 $80 721 $2041 $1388 47 $490 $431 14 $1780 $1299 37 Piedmont Physicians Group $42 $22 87 $318 $179 78 $239 $159 50 Resurgens $8558 $2036 320 $9293 $2258 312 $4638 $2067 124 $4039 $2164 87 $4392 $2164 103 $2252 $1371 64 $459 $330 39 Wellstar Hospital $9330 $3729 150 $17479 $7519 132 $5261 $1565 236 $35794 $18200 97 $46780 $14600 220 $3707 $1972 88 $4928 $1972 150 $13549 $5855 131 $5054 $2805 80 $528 $375 41 $3222 $579 457 $3694 $925 299 $5495 $2805 96 $1355 $190 615 $66 $45 46 $73 $51 43 $133 $78 71 $1785 $1125 59 $599 $425 41 $1010 $717 41 Avg Mark UpProcedure Atlanta Medical Center 634 Gwinnett Hospital 223 Northside Hospital 233 Piedmont Hospital 259 Wellstar Hospital 155 Emory 105
Atlanta Gastroenterology Associates Atlanta Medical Center Atlanta Womens Health Gwinnett Hospital Northside Hospital Piedmont Hospital Piedmont Physicians Group Resurgens Wellstar Hospital CPT Code CPT Proc Cat Comp Avg Allow Allow Allow Allow Allow Allow Allow Allow Allow 29881 KNEE ARTHROSCOPYSURGERY 6 $3179 $2266 $3022 $4185 $3837 $2036 $3729 29888 KNEE ARTHROSCOPYSURGERY 6 $6319 $2502 $10096 $9557 $5983 $2258 $7519 43239 UPPER GI ENDOSCOPY BIOPSY 6 $1727 $536 $2240 $1132 $2539 $2012 $2067 $1565 43644 LAP GASTRIC BYPASSROUX-EN-Y 1 $15810 $15300 $10800 $17000 $17750 $18200 43775 LAP SLEEVE GASTRECTOMY 1 $17800 $13230 $20815 $12105 $14600 45378 DIAGNOSTIC COLONOSCOPY 6 $1656 $536 $859 $1244 $2805 $2013 $2164 $1972 45380 COLONOSCOPY AND BIOPSY 6 $1694 $536 $859 $1244 $3071 $2013 $2164 $1972 59400 OBSTETRICAL CARE 1 $5107 $4688 $4607 $5730 $4654 $5855 70553 MRI BRAIN WO amp WDYE 2 $1482 $1052 $967 $1468 $1117 $2805 71020 CHEST X-RAY 2 $259 $72 $279 $266 $305 $375 71250 CT THORAX WO DYE 2 $541 $319 $491 $810 $505 $579 73721 MRI JNT OF LWR EXTRE WO DYE 2 $978 $557 $967 $1398 $1042 $925 74183 MRI ABDOMEN WO amp WDYE 2 $1436 $836 $967 $1468 $1106 $2805 76700 US EXAM ABDOM COMPLETE 2 $320 $133 $195 $538 $545 $190 77052 COMP SCREEN MAMMOGRAM ADD-ON 2 $45 $23 $15 $99 $41 $45 77052 COMP SCREEN MAMMOGRAM ADD-ON 5 $14 $14 80053 COMPREHEN METABOLIC PANEL 8 $29 $25 $13 $56 $15 $24 $22 $51 88305 TISSUE EXAM BY PATHOLOGIST 8 $174 $232 $188 $152 $307 $80 $179 $78 93306 TTE WDOPPLER COMPLETE 2 $1297 $1157 $1173 $1566 $1388 $1371 $1125 93017 STRESS TEST 5 $830 $797 $907 $432 $1299 $717 99203 OFFICEOUTPATIENT VISIT NEW 4 $139 $118 $159 G0202 Screeningmammographydigital 2 $329 $168 $294 $328 $431 $330 $425 G0202 Screeningmammographydigital 5 $231 $231
Service Line Procedure CPT Code Emory Atlanta Gastroenterology Associates Resurgens Atlanta Womens Health Piedmont Physicians Group Orthopedics (ASC) Knee Arthroscopy 29881 $3467 $2036 Arthroscopy Ligament Repair 29888 $3386 $2258 GI (ASC) Upper GI Endoscopy 43239 $2758 $536 Diagnostic Colonoscopy 45378 $2348 $536 Colonoscopy and biopsy 45380 $2181 $536 Radiology Mammogram Screening G0202 $164 $231 Computer Detection Add-on 77052 $93 $14 Lab Comp Metabolic Panel 80053 $53 $13 $22 Tissue Exam by Pathologist 88305 $277 $188 $179 EampM (TEC) Office Visit new pt 99203 $269 $118 $159
Service Line Procedure CPT CodeDRG Memorial Hospital Beta Hosptial Charlie Hospital Delta Hospital Echo Hospital Alpha Medical Center Atlanta Gastroenterology Associates Resurgens Atlanta Womens Health Piedmont Physicians Group Market Avg Emory abovebelow Orthopedics Arthroscopy Ligament Repair 29888 $ 5062 $ 9557 $ 5983 $ 10096 $ 7519 $ 2502 $ 2258 $ 6319 -20 Knee Arthroscopy 29881 6 $ 5069 $ 4185 $ 3837 $ 3022 $ 3729 $ 2266 $ 2036 $ 3179 59 GI Upper GI Endoscopy 43239 6 $ 3075 $ 2539 $ 2012 $ 1132 $ 1565 $ 2240 $ 536 $ 1671 84 Lap Sleeve Gastrectomy DRG 621 $ 20421 $ 20815 $ 12105 $ 13230 $ 14600 $ 17800 $ 15710 30 Colonoscopy and biopsy 45380 $ 3075 $ 3071 $ 2013 $ 1244 $ 1972 $ 859 $ 536 $ 1616 90 Diagnostic Colonoscopy 45378 6 $ 3075 $ 2805 $ 2013 $ 1244 $ 1972 $ 859 $ 536 $ 1572 96 Radiology MRI Brain w amp wo dye 70553 2 $ 1238 $ 1468 $ 1117 $ 967 $ 2805 $ 1052 $ 1482 -16 MRI Joint of Lower Extremity wo dye 73721 2 $ 1238 $ 1398 $ 1042 $ 967 $ 925 $ 557 $ 978 27 MRI Abdomen w amp wo dye 74183 2 $ 1238 $ 1468 $ 1106 $ 967 $ 2805 $ 836 $ 1436 -14 X-ray Chest 71020 $ 115 $ 266 $ 305 $ 279 $ 375 $ 72 $ 259 -56 CT Thorax wo dye 71250 $ 882 $ 810 $ 505 $ 491 $ 579 $ 319 $ 541 63 Ultrasound Abdomen Complete 76700 $ 397 $ 538 $ 545 $ 195 $ 190 $ 168 $ 327 21 Mammogram Screening G0202 2 $ 141 $ 328 $ 431 $ 294 $ 425 $ 168 $ 231 $ 313 -55 Computer Detection Add-on 77052 2 $ 112 $ 99 $ 41 $ 15 $ 45 $ 23 $ 14 $ 39 183 Lab Comp Metabolic Panel 80053 8 $ 56 $ 15 $ 24 $ 56 $ 51 $ 25 $ 13 $ 22 $ 29 88 Tissue Exam by Pathologist 88305 8 $ 236 $ 307 $ 80 $ 152 $ 78 $ 232 $ 188 $ 179 $ 174 36 Medical Cardiology Cardiovascular Stress Test 93017 $ 383 $ 432 $ 1299 $ 907 $ 717 $ 797 $ 830 -54 TTE w Doppler 93306 2 $ 960 $ 1566 $ 1388 $ 1173 $ 1125 $ 1157 $ 1282 -25 Obstetrics Vaginal Delivery DRG 755 $ 7290 $ 5730 $ 4654 $ 4607 $ 5855 $ 4688 $ 5107 43 EampM Office Visit new pt 99203 4 $ 248 $ 118 $ 159 $ 139 78 Colonoscopy and biopsy (HOSPITAL ONLY) 45380 Surg 2530 $ 307591 Diagnostic colonoscopy (HOSPITAL ONLY) 45378 Surg 2255 $ 307591 Upper gi endoscopy biopsy (HOSPITAL ONLY) 43239 Surg 1787 $ 307591 Knee Arthroscopy (HOSPITAL ONLY) 29881 Surg 10900 $ 506893 Arthroscopy Ligament Repair (HOSPITAL ONLY) 29888 Surg 10900 $ 506200 Key 1 Facility - Inpatient 2 Facility - Imaging 3 Physician - Imaging 4 Physician 5 Global - Imaging 6 Facility - Outpatient 8 Lab 41 Physician - Primary Care 42 Physician - Specialist
Blue Cross United - EJCH EUH EUHM WW United - SJH Non Options United - SJH Options Aetna - ASC TEC (HMO) Cigna - ASC TEC (HMO) Aetna - EJCH ESJH ECHM WW Cigna - EJCH (HMO) Cigna - ESJH EUHM (HMO) List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract Description CPT Code Charge Average Final Price (all plans) Emory Mark Up Reimbursement Method ( of charge or fixed) - 1713 Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Cardiovascular stress test 93017 Cardio $543 $ 425 28 of Charge 70 $ 380 of Charge 65 $ 353 of Charge 60 $ 326 of Charge 70 $ 380 of Charge 70 $ 380 of charge 100 $ 543 of Charge 70 $ 380 of charge 100 $ 543 of charge 100 $ 543 TTE wDoppler complete 93306 Cardio $1226 $ 960 28 of Charge 70 $ 858 of Charge 65 $ 797 of Charge 60 $ 736 of Charge 70 $ 858 of Charge 70 $ 858 of charge 100 $ 1226 of Charge 70 $ 858 of charge 100 $ 1226 of charge 100 $ 1226 Colonoscopy and biopsy (HOSPITAL ONLY) 45380 Surg $2530 $ 3076 -18 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 of Charge 70 $ 1771 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Diagnostic colonoscopy (HOSPITAL ONLY) 45378 Surg $2255 $ 3076 -27 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 of Charge 70 $ 1579 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Upper gi endoscopy biopsy (HOSPITAL ONLY) 43239 Surg $1787 $ 3076 -42 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Knee Arthroscopy (HOSPITAL ONLY) 29881 Surg $10900 $ 5069 115 Fixed Rate SC 4 $ 3865 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 449300 $ 4493 Fixed Rate $ 654700 $ 6547 of Charge 70 $ 7630 Fixed Rate $ 401000 $ 4010 of Charge 70 $ 7630 Fixed Rate $ 398300 $ 3983 Fixed Rate $ 398100 $ 3981 Arthroscopy Ligament Repair (HOSPITAL ONLY) 29888 Surg $10900 $ 5062 115 Fixed Rate SC 3 $ 3121 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 556900 $ 5569 Fixed Rate $ 770100 $ 7701 of Charge 70 $ 7630 Fixed Rate $ 323900 $ 3239 of Charge 70 $ 7630 Fixed Rate $ 321700 $ 3217 Fixed Rate $ 321400 $ 3214 Comp Metabolic Panel 80053 Lab $132 $ 56 138 RBRVS Fee (100) $ 1437 of Charge 65 $ 86 of Charge 65 $ 86 of Charge 65 $ 86 of Charge 70 $ 92 RBRVS Fee (100) $ 1437 $ 14 of Charge 70 $ 92 RBRVS Fee (100) $ 1437 $ 14 RBRVS Fee (100) $ 1437 $ 14 Surgical Path Tissue Exam 88305 Lab $326 $ 236 38 of Charge 150 $ 51 of Charge 65 $ 212 of Charge 65 $ 212 of Charge 65 $ 212 of Charge 70 $ 228 of charge 100 $ 326 of Charge 70 $ 228 of charge 100 $ 326 of charge 100 $ 326 MRI Abdomen 74183 Radiology $6960 $ 1238 462 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 MRI Brain 70553 Radiology $6804 $ 1238 450 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 MRI Joint Lower Extremity 73721 Radiology $3067 $ 1238 148 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 CT Thorax wo contrast 71250 Radiology $2199 $ 882 149 Fixed Rate $ 771 Fixed Rate $ 47100 $ 471 Fixed Rate $ 81700 $ 817 Fixed Rate $ 116000 $ 1160 of Charge 70 $ 1539 Fixed Rate $ 80100 $ 801 Fixed Rate $ 79200 $ 792 Fixed Rate $ 79300 $ 793 Fixed Rate $ 79500 $ 795 X-ray Chest 71020 Radiology $280 $ 115 142 of Charge 150 $ 25 of Charge 65 $ 182 of Charge 60 $ 168 of Charge 70 $ 196 of Charge 70 $ 196 RBRVS Fee (150) $ 2534 $ 25 of Charge 70 $ 196 RBRVS Fee (150) $ 2534 $ 25 RBRVS Fee (150) $ 2534 $ 25 Screening mammography G0202 Radiology $279 $ 141 98 Fixed Rate $ 128 Fixed Rate $ 13100 $ 131 Fixed Rate $ 14300 $ 143 Fixed Rate $ 16100 $ 161 of Charge 70 $ 195 Fixed Rate $ 13300 $ 133 Fixed Rate $ 13500 $ 135 Fixed Rate $ 13000 $ 130 Fixed Rate $ 11200 $ 112 Mammo Computer Aided 77052 Radiology $75 $ 112 -33 Fixed Rate $ 9 Fixed Rate $ 13100 $ 131 Fixed Rate $ 14300 $ 143 Fixed Rate $ 16100 $ 161 of Charge 70 $ 53 Fixed Rate $ 13300 $ 133 Fixed Rate $ 13500 $ 135 Fixed Rate $ 13000 $ 130 Fixed Rate $ 11200 $ 112 US Abdomen Complete 76700 Radiology $917 $ 397 131 of Charge 150 $ 125 of Charge 65 $ 596 of Charge 60 $ 550 of Charge 70 $ 642 of Charge 70 $ 642 RBRVS Fee (150) $ 12519 $ 125 of Charge 70 $ 642 RBRVS Fee (150) $ 12519 $ 125 RBRVS Fee (150) $ 12519 $ 125 Officeoutpatient visit new pt 30 min (TEC) 99203 EampM $316 $ 248 28 of Charge 70 $ 221 of Charge 65 $ 205 of Charge 60 $ 190 of Charge 70 $ 221 of Charge 70 $ 221 of charge 100 $ 316 of Charge 70 $ 221 of charge 100 $ 316 of charge 100 $ 316 Vaginal delivery 59409 Surg $14484 $ 7290 99 Fixed Rate DRG - 775 $ 5437 2 Day Case Rate + LOC 561700 $ 5617 BaseCMS Weight 584741 $ 5847 BaseCMS Weight 726146 $ 7261 No IP Terms $ - 0 No IP BaseCMS Weight 659343 $ 6593 BaseContract Weight 479451 100 $ 14484 BaseCMS Weight 579110 $ 5791 Lap Sleeve Gastrectomy 43775 Surg $29961 $ 20421 47 Fixed Rate DRG - 621 $ 14872 BaseCMS Weight 1810697 $ 18107 BaseCMS Weight 1835178 $ 18352 BaseCMS Weight 2278911 $ 22789 No IP Terms $ - 0 No IP BaseCMS Weight 2069315 $ 20693 BaseCMS Weight 1730442 100 $ 29961 BaseCMS Weight 1817507 $ 18175 105 Colonoscopy and biopsy (ASC ONLY) Surg $ 219200 $ 2181 Diagnostic colonoscopy (ASC ONLY) Surg $ 267100 $ 2348 Upper gi endoscopy biopsy (ASC ONLY) Surg $ 207500 $ 2758 Knee Arthroscopy (ASC ONLY) Surg $ 417900 $ 3467 Arthroscopy Ligament Repair (ASC ONLY) Surg $ 504800 $ 3386
Cpt Code CPT Description Procedure Category Claims Min 25thNtile 50thNtile Emorys Rates 75thNtile 90thNtile Max 20 Below 50th Ntile 20 Above 50th Ntile 93017 CARDIOVASCULAR STRESS TEST 5 82 $80 $125 $321 $382 $568 $791 $930 $257 $386 71020 CHEST X-RAY 2 2638 $11 $45 $152 $115 $289 $373 $585 $122 $182 71020 CHEST X-RAY 5 8106 $25 $34 $38 $54 $57 $69 $30 $46 45380 COLONOSCOPY AND BIOPSY 6 1256 $541 $560 $572 $2877 $1000 $2024 $3289 $458 $686 77052 COMP SCREEN MAMMOGRAM ADD-ON 2 194 $13 $15 $25 $38 $47 $134 $20 $30 77052 COMP SCREEN MAMMOGRAM ADD-ON 5 2411 $13 $16 $20 $23 $26 $28 $16 $24 80053 COMPREHEN METABOLIC PANEL 8 13019 $9 $19 $23 $55 $24 $25 $69 $19 $28 71250 CT THORAX WO DYE 2 302 $165 $372 $545 $878 $1658 $2067 $436 $654 71250 CT THORAX WO DYE 5 209 $53 $127 $203 $289 $419 $534 $162 $244 45378 DIAGNOSTIC COLONOSCOPY 6 1479 $484 $515 $536 $2914 $831 $1971 $2828 $428 $643 29881 KNEE ARTHROSCOPYSURGERY 6 152 $1650 $1826 $2036 $5235 $3054 $4216 $6461 $1629 $2443 29888 KNEE ARTHROSCOPYSURGERY 6 82 $1682 $3615 $5081 $5145 $7553 $12924 $18532 $4065 $6097 43644 LAP GASTRIC BYPASSROUX-EN-Y 1 21 $11821 $13873 $17050 $18391 $25029 $31079 $13640 $20460 43775 LAP SLEEVE GASTRECTOMY 1 38 $4215 $8250 $13253 $20421 $19197 $21509 $24260 $10602 $15903 74183 MRI ABDOMEN WO amp WDYE 2 120 $919 $987 $1015 $1237 $1252 $2534 $3177 $812 $1218 74183 MRI ABDOMEN WO amp WDYE 5 112 $475 $490 $521 $1154 $1337 $1696 $417 $625 70553 MRI BRAIN WO amp WDYE 2 324 $633 $987 $1142 $1237 $1706 $2805 $3331 $914 $1370 70553 MRI BRAIN WO amp WDYE 5 467 $280 $539 $1023 $1277 $1363 $1726 $818 $1228 73721 MRI JNT OF LWR EXTRE WO DYE 2 304 $804 $859 $967 $1237 $1063 $1598 $2485 $774 $1160 73721 MRI JNT OF LWR EXTRE WO DYE 5 1130 $500 $520 $530 $628 $679 $859 $424 $636 59400 OBSTETRICAL CARE 1 494 $3699 $4402 $4969 $6655 $7307 $8613 $3975 $5963 99203 OFFICEOUTPATIENT VISIT NEW 4 6776 $88 $101 $112 $138 $155 $169 $90 $134 G0202 Screeningmammographydigital 2 7444 $123 $206 $285 $380 $425 $479 $228 $342 G0202 Screeningmammographydigital 5 2754 $117 $165 $195 $230 $247 $252 $156 $234 88305 TISSUE EXAM BY PATHOLOGIST 8 20834 $51 $74 $112 $235 $168 $261 $478 $90 $134 93306 TTE WDOPPLER COMPLETE 2 931 $194 $377 $739 $960 $1267 $1480 $1849 $591 $887 93306 TTE WDOPPLER COMPLETE 5 2299 $151 $296 $373 $538 $573 $834 $298 $448 43239 UPPER GI ENDOSCOPY BIOPSY 6 1264 $424 $514 $550 $800 $1838 $2833 $440 $660 76700 US EXAM ABDOM COMPLETE 2 321 $96 $165 $271 $509 $584 $857 $217 $325 76700 US EXAM ABDOM COMPLETE 5 444 $111 $129 $147 $156 $220 $279 $118 $176 Key 1 Facility - Inpatient 2 Facility - Imaging 3 Physician - Imaging 4 Physician 5 Global - Imaging 6 Facility - Outpatient 8 Lab 41 Physician - Primary Care 42 Physician - Specialist Cardiovascular stress test $ 38279 TTE wDoppler complete $ 96037 Colonoscopy and biopsy $ 287709 Diagnostic colonoscopy $ 291434 Upper gi endoscopy biopsy $ 300526 Knee Arthroscopy $ 523584 Arthroscopy Ligament Repair $ 514501 Comp Metabolic Panel $ 5552 Surgical Path Tissue Exam $ 23570 MRI Abdomen $ 123786 MRI Brain $ 123786 MRI Joint Lower Extremity $ 123786 CT Thorax wo contrast $ 88213 X-ray Chest $ 11548 Screening mammography $ 14098 Mammo Computer Aided $ 11179 US Abdomen Complete $ 39695 Officeoutpatient visit new pt 30 min $ 24753 Vaginal delivery $ 729025 Lap Sleeve Gastrectomy $ 2042124
Page 23
Considerations in Offering Development bull Care Management Model
bull Traditional care model bull Case management bull Utilization management bull Disease management
bull Longitudinal care model with value based care philosophy bull Primary care driven bull Local care management
bull Predictive analytics and risk stratification model bull Claims history and ongoing data bull EMR data
22
Case Study 2
Case study 2 ndash Large Employer bull Business Problem Large employer wants to contract
directly with 2 major hospital systems developing professional fee schedules
bull ConsiderationsValue Prop Fee schedule should be competitive but also nuanced to minimize gap relative to current reimbursement at physician level
bull Solution Data-driven approach using current market-wide reimbursement distinguished by service level
24
Evaluate Provider Spend Top 25 Service Lines by Allowable Spend
Evaluate Provider Spend Top 20 Professional CPTs by Total Spend
Understand relative market pricing position
27
21
-1
-28
14 10
28
-22
-11 -13
24
3
20 21
8
-20
13
3 9
-39
56
-26
4
-42
60
MRI Colonoscopy Cardiac Cath Lab - OrganPanel
Memorial Hospital Beta Hospital Delta Hospital Charlie Hospital Echo Hospital Alpha Medical Center
ndash25 5 -15 10 0 39
State Charges as a Percent of Peer Average Weighted Averages for MRI Colonoscopy Cardiology and Lab
Total Percent Above Below Market Average2
Memorial Hospital Beta Hospital Delta Hospital Charlie Hospital Echo Hospital Alpha Medical Center
Develop fee schedule relative to market
28
Service Line Procedure CPT CodeDRG
Memorial Hospital
Beta Hosptial
Charlie Hospital
Delta Hospital
Echo Hospital
Alpha Medical Center
Arthroscopy Ligament Repair 29888 $ 5062 $ 9557 $ 5983 $ 10096 $ 7519 $ 2502 Knee Arthroscopy 29881 $ 5069 $ 4185 $ 3837 $ 3022 $ 3729 $ 2266 Upper GI Endoscopy 43239 $ 3075 $ 2539 $ 2012 $ 1132 $ 1565 $ 2240 Lap Sleeve Gastrectomy DRG 621 $ 20421 $ 20815 $ 12105 $ 13230 $ 14600 $ 17800 Colonoscopy and biopsy 45380 $ 3075 $ 3071 $ 2013 $ 1244 $ 1972 $ 859 Diagnostic Colonoscopy 45378 $ 3075 $ 2805 $ 2013 $ 1244 $ 1972 $ 859 MRI Brain w amp wo dye 70553 $ 1238 $ 1468 $ 1117 $ 967 $ 2805 $ 1052 MRI Joint of Lower Extremity wo dye 73721 $ 1238 $ 1398 $ 1042 $ 967 $ 925 $ 557 MRI Abdomen w amp wo dye 74183 $ 1238 $ 1468 $ 1106 $ 967 $ 2805 $ 836 X-ray Chest 71020 $ 115 $ 266 $ 305 $ 279 $ 375 $ 72 CT Thorax wo dye 71250 $ 882 $ 810 $ 505 $ 491 $ 579 $ 319 Ultrasound Abdomen Complete 76700 $ 397 $ 538 $ 545 $ 195 $ 190 $ 168 Mammogram Screening G0202 $ 141 $ 328 $ 431 $ 294 $ 425 $ 168 Computer Detection Add-on 77052 $ 112 $ 99 $ 41 $ 15 $ 45 $ 23 Comp Metabolic Panel 80053 $ 56 $ 15 $ 24 $ 56 $ 51 $ 25 Tissue Exam by Pathologist 88305 $ 236 $ 307 $ 80 $ 152 $ 78 $ 232 Cardiovascular Stress Test 93017 $ 383 $ 432 $ 1299 $ 907 $ 717 $ 797 TTE w Doppler 93306 $ 960 $ 1566 $ 1388 $ 1173 $ 1125 $ 1157
Obstetrics Vaginal Delivery DRG 755 7290$ 5730$ 4654$ 4607$ 5855$ 4688$
GI
Lab
Radiology
Medical Cardiology
Orthopedics
KEY OBSERVA TIONS bull Potential exposure on GI bull Opportunity to align price and acuity in MRI bull Opportunity to raise rates on chest x-ray and mammogram
Percentile Bands Emory Allowables Heatmap TEC ASC Heatmap Allowable Comp Analysis Portal Pricing Sheet1 image1png A few words on Bundled Payments bull Bundled payments are growing as a type of direct contracting bull In some cases third parties match-make between employers
and providers bull Contracts may vary in definitions prepost admission
coverage duration readmission cause (ie all-cause vs medically related) outlier provisions LOS caps andor per diems
bull Providers need to be strategic in pricing to enable profitable growth of market share
29
Considerations in Offering Development bull Network Development
bull Build off existing structure eg health system employee plan network bull How does this fit into your broader value based care strategy bull Employed and independent physicians bull How do you want to approach the buildout of high performance
network bull Quality focus bull Cost efficiency
bull Integrated behavioral health bull Wrap network for other markets
30
Considerations in Offering Development bull Target Market
bull Consideration of employer profile in market bull Fully-insured vs ASO bull Total cost of care vs bundled services
bull Distribution bull Direct marketing bull Brokerconsultant community
bull Plan designs bull Standard designs vs flexible ndash Dependent on target market
bull Claims administration bull Data sharing amp analytics
31
Considerations in Offering Development bull Other components of comprehensive offering
bull Pharmacy bull Preventive health bull Onsite clinics bull Wellness programs bull Technology platform
32
Sample Bundle Analysis
33
Cover page Dotson Hazelrigs Nation Mainly of charge of fixed Cardiovascular stress test TTE wDoppler complete Colonoscopy and biopsy (Combined) Diagnostic colonoscopy (Combined) Upper gi endoscopy biopsy (Combined) Knee Arthroscopy (Combined) Arthroscopy Ligament Repair Comp Metabolic Panel Surgical Path Tissue Exam MRI Abdomen MRI Brain MRI Joint Lower Extremity CT Thorax wo contrast X-ray Chest Screening mammography Mammo Computer Aided US Abdomen Complete Officeoutpatient visit new pt 30 min Vaginal delivery Lap Sleeve Gastrectomy
Piedmont Piedmont Piedmont Piedmont Northside Northside Northside Northside Gwinnett Gwinnett Gwinnett Gwinnett WellStar WellStar WellStar WellStar AMC - Tenet AMC - Tenet AMC - Tenet AMC - Tenet CPT Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing 29881 $11312 $10872 NA NA $7476 $9338 NA $23655 $11856 $3668 NA $17871 $12253 NA NA $15645 $5490 NA NA $23039 29888 NA NA NA NA NA NA NA $23784 NA $8261 NA $18000 NA NA NA $15774 NA NA NA $23168 43239 NA $4408 NA NA NA NA $5997 $8852 NA $3304 NA $7424 $1267 NA NA $9230 NA $2458 NA $8274 43644 $26468 NA NA NA $3382 $12050 NA $1861 NA NA NA $1316 $7841 NA NA $3444 $18892 $27950 NA $979 43775 NA NA NA NA NA NA NA $352 NA NA NA $302 NA NA NA $413 NA NA NA $83 45378 $2705 $2530 NA NA $4381 $3676 $4496 $1022 $2938 $2138 NA $695 $5504 NA NA $2036 NA NA NA $372 45380 $3075 $2600 NA NA $4723 $3527 $3012 $1757 $4215 $2285 NA NA $5298 NA NA $3268 NA NA NA $627 59400 $6160 NA NA NA NA $5100 NA $1851 NA NA NA $1304 $9035 NA NA $3427 $9116 $5150 NA $966 70553 $2985 NA $1153 NA $2182 NA $1192 $492 NA NA $803 $489 $1512 NA $985 $1187 NA NA NA $197 71020 $61 $69 $43 NA $113 $319 $307 NA $183 $59 $32 NA $213 $66 $40 NA $83 $53 NA NA 71250 $1837 $621 $989 NA $1490 $931 $755 NA NA $745 $401 NA $1067 $982 $616 NA NA $304 NA NA 73721 NA $1098 $1153 NA $2042 $1065 $1192 NA NA $998 $803 NA NA $1275 $985 NA NA $644 NA $178 74183 $2971 $1144 NA NA NA $1092 $1192 $6884 NA $1098 $803 NA $2960 $1197 $985 $5454 NA NA NA $7607 76700 $364 $247 $207 NA $427 $708 $614 $13267 $428 $214 $152 NA $747 $263 $189 $9139 NA $235 NA NA 77052 NA NA NA NA NA NA NA $4744 NA NA NA NA NA NA NA $3070 NA NA NA $5611 93306 $1220 $1117 NA NA $1877 $1657 $2100 $4605 $1433 $413 $945 NA $1336 $1434 $1951 $2931 NA $2399 NA $5472 G0202 $262 $187 NA NA $431 NA NA $4605 $292 NA NA NA $530 $281 NA $2931 $327 NA NA $5472
Provider Group 29881_6 29888_6 43239_6 43644_1 43775_1 45378_6 45380_6 59400_1 70553_2 71020_2 71250_2 73721_2 74183_2 76700_2 77052_2 77052_5 80053_8 88305_8 93306_2 99203_4 G0202_2 G0202_5 93017_2 Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Atlanta Gastroenterology Associates $2399 $536 348 $1628 $536 204 $2400 $536 348 Atlanta Medical Center $24889 $2266 999 $25897 $2502 935 $11449 $2240 411 $81927 $15300 435 $75815 $17800 326 $7317 $859 752 $7317 $859 752 $12821 $4688 173 $6581 $1052 526 $645 $72 796 $3265 $319 925 $3450 $557 519 $7398 $836 785 $1576 $133 1084 $73 $23 217 $635 $25 2440 $891 $232 285 $2967 $1157 156 $344 $168 105 $1265 $797 59 Atlanta Womens Health Physicians Group $29 $14 107 $40 $13 208 $396 $188 111 $278 $118 135 $450 $231 95 Gwinnett Hospital $11941 $3022 295 $21654 $10096 114 $3551 $1132 214 $34384 $10800 218 $56472 $13230 327 $3003 $1244 141 $3533 $1244 184 $8984 $4607 95 $3901 $967 303 $417 $279 49 $2247 $491 358 $4000 $967 314 $3755 $967 288 $1593 $195 717 $50 $15 233 $186 $56 233 $505 $152 233 $1750 $1173 49 $418 $294 42 $1396 $907 54 Northside Hospital $15482 $4185 270 $21651 $9557 127 $4885 $2539 92 $35176 $17000 107 $35233 $20815 69 $3883 $2805 38 $5256 $3071 71 $10911 $5730 90 $4856 $1468 231 $443 $266 67 $2379 $810 194 $3776 $1398 170 $5105 $1468 248 $942 $538 75 $167 $99 69 $379 $15 2427 $433 $307 41 $2252 $1566 44 $459 $328 40 $576 $432 33 Piedmont Hospital $14772 $3837 285 $35493 $5983 493 $5069 $2012 152 $38320 $17750 116 $37125 $12105 207 $3485 $2013 73 $4993 $2013 148 $10143 $4654 118 $5939 $1117 432 $542 $305 78 $2983 $505 491 $3410 $1042 227 $6067 $1106 449 $1364 $545 150 $75 $41 85 $231 $24 863 $657 $80 721 $2041 $1388 47 $490 $431 14 $1780 $1299 37 Piedmont Physicians Group $42 $22 87 $318 $179 78 $239 $159 50 Resurgens $8558 $2036 320 $9293 $2258 312 $4638 $2067 124 $4039 $2164 87 $4392 $2164 103 $2252 $1371 64 $459 $330 39 Wellstar Hospital $9330 $3729 150 $17479 $7519 132 $5261 $1565 236 $35794 $18200 97 $46780 $14600 220 $3707 $1972 88 $4928 $1972 150 $13549 $5855 131 $5054 $2805 80 $528 $375 41 $3222 $579 457 $3694 $925 299 $5495 $2805 96 $1355 $190 615 $66 $45 46 $73 $51 43 $133 $78 71 $1785 $1125 59 $599 $425 41 $1010 $717 41 Avg Mark UpProcedure Atlanta Medical Center 634 Gwinnett Hospital 223 Northside Hospital 233 Piedmont Hospital 259 Wellstar Hospital 155 Emory 105
Atlanta Gastroenterology Associates Atlanta Medical Center Atlanta Womens Health Gwinnett Hospital Northside Hospital Piedmont Hospital Piedmont Physicians Group Resurgens Wellstar Hospital CPT Code CPT Proc Cat Comp Avg Allow Allow Allow Allow Allow Allow Allow Allow Allow 29881 KNEE ARTHROSCOPYSURGERY 6 $3179 $2266 $3022 $4185 $3837 $2036 $3729 29888 KNEE ARTHROSCOPYSURGERY 6 $6319 $2502 $10096 $9557 $5983 $2258 $7519 43239 UPPER GI ENDOSCOPY BIOPSY 6 $1727 $536 $2240 $1132 $2539 $2012 $2067 $1565 43644 LAP GASTRIC BYPASSROUX-EN-Y 1 $15810 $15300 $10800 $17000 $17750 $18200 43775 LAP SLEEVE GASTRECTOMY 1 $17800 $13230 $20815 $12105 $14600 45378 DIAGNOSTIC COLONOSCOPY 6 $1656 $536 $859 $1244 $2805 $2013 $2164 $1972 45380 COLONOSCOPY AND BIOPSY 6 $1694 $536 $859 $1244 $3071 $2013 $2164 $1972 59400 OBSTETRICAL CARE 1 $5107 $4688 $4607 $5730 $4654 $5855 70553 MRI BRAIN WO amp WDYE 2 $1482 $1052 $967 $1468 $1117 $2805 71020 CHEST X-RAY 2 $259 $72 $279 $266 $305 $375 71250 CT THORAX WO DYE 2 $541 $319 $491 $810 $505 $579 73721 MRI JNT OF LWR EXTRE WO DYE 2 $978 $557 $967 $1398 $1042 $925 74183 MRI ABDOMEN WO amp WDYE 2 $1436 $836 $967 $1468 $1106 $2805 76700 US EXAM ABDOM COMPLETE 2 $320 $133 $195 $538 $545 $190 77052 COMP SCREEN MAMMOGRAM ADD-ON 2 $45 $23 $15 $99 $41 $45 77052 COMP SCREEN MAMMOGRAM ADD-ON 5 $14 $14 80053 COMPREHEN METABOLIC PANEL 8 $29 $25 $13 $56 $15 $24 $22 $51 88305 TISSUE EXAM BY PATHOLOGIST 8 $174 $232 $188 $152 $307 $80 $179 $78 93306 TTE WDOPPLER COMPLETE 2 $1297 $1157 $1173 $1566 $1388 $1371 $1125 93017 STRESS TEST 5 $830 $797 $907 $432 $1299 $717 99203 OFFICEOUTPATIENT VISIT NEW 4 $139 $118 $159 G0202 Screeningmammographydigital 2 $329 $168 $294 $328 $431 $330 $425 G0202 Screeningmammographydigital 5 $231 $231
Service Line Procedure CPT Code Emory Atlanta Gastroenterology Associates Resurgens Atlanta Womens Health Piedmont Physicians Group Orthopedics (ASC) Knee Arthroscopy 29881 $3467 $2036 Arthroscopy Ligament Repair 29888 $3386 $2258 GI (ASC) Upper GI Endoscopy 43239 $2758 $536 Diagnostic Colonoscopy 45378 $2348 $536 Colonoscopy and biopsy 45380 $2181 $536 Radiology Mammogram Screening G0202 $164 $231 Computer Detection Add-on 77052 $93 $14 Lab Comp Metabolic Panel 80053 $53 $13 $22 Tissue Exam by Pathologist 88305 $277 $188 $179 EampM (TEC) Office Visit new pt 99203 $269 $118 $159
Service Line Procedure CPT CodeDRG Memorial Hospital Beta Hosptial Charlie Hospital Delta Hospital Echo Hospital Alpha Medical Center Atlanta Gastroenterology Associates Resurgens Atlanta Womens Health Piedmont Physicians Group Market Avg Emory abovebelow Orthopedics Arthroscopy Ligament Repair 29888 $ 5062 $ 9557 $ 5983 $ 10096 $ 7519 $ 2502 $ 2258 $ 6319 -20 Knee Arthroscopy 29881 6 $ 5069 $ 4185 $ 3837 $ 3022 $ 3729 $ 2266 $ 2036 $ 3179 59 GI Upper GI Endoscopy 43239 6 $ 3075 $ 2539 $ 2012 $ 1132 $ 1565 $ 2240 $ 536 $ 1671 84 Lap Sleeve Gastrectomy DRG 621 $ 20421 $ 20815 $ 12105 $ 13230 $ 14600 $ 17800 $ 15710 30 Colonoscopy and biopsy 45380 $ 3075 $ 3071 $ 2013 $ 1244 $ 1972 $ 859 $ 536 $ 1616 90 Diagnostic Colonoscopy 45378 6 $ 3075 $ 2805 $ 2013 $ 1244 $ 1972 $ 859 $ 536 $ 1572 96 Radiology MRI Brain w amp wo dye 70553 2 $ 1238 $ 1468 $ 1117 $ 967 $ 2805 $ 1052 $ 1482 -16 MRI Joint of Lower Extremity wo dye 73721 2 $ 1238 $ 1398 $ 1042 $ 967 $ 925 $ 557 $ 978 27 MRI Abdomen w amp wo dye 74183 2 $ 1238 $ 1468 $ 1106 $ 967 $ 2805 $ 836 $ 1436 -14 X-ray Chest 71020 $ 115 $ 266 $ 305 $ 279 $ 375 $ 72 $ 259 -56 CT Thorax wo dye 71250 $ 882 $ 810 $ 505 $ 491 $ 579 $ 319 $ 541 63 Ultrasound Abdomen Complete 76700 $ 397 $ 538 $ 545 $ 195 $ 190 $ 168 $ 327 21 Mammogram Screening G0202 2 $ 141 $ 328 $ 431 $ 294 $ 425 $ 168 $ 231 $ 313 -55 Computer Detection Add-on 77052 2 $ 112 $ 99 $ 41 $ 15 $ 45 $ 23 $ 14 $ 39 183 Lab Comp Metabolic Panel 80053 8 $ 56 $ 15 $ 24 $ 56 $ 51 $ 25 $ 13 $ 22 $ 29 88 Tissue Exam by Pathologist 88305 8 $ 236 $ 307 $ 80 $ 152 $ 78 $ 232 $ 188 $ 179 $ 174 36 Medical Cardiology Cardiovascular Stress Test 93017 $ 383 $ 432 $ 1299 $ 907 $ 717 $ 797 $ 830 -54 TTE w Doppler 93306 2 $ 960 $ 1566 $ 1388 $ 1173 $ 1125 $ 1157 $ 1282 -25 Obstetrics Vaginal Delivery DRG 755 $ 7290 $ 5730 $ 4654 $ 4607 $ 5855 $ 4688 $ 5107 43 EampM Office Visit new pt 99203 4 $ 248 $ 118 $ 159 $ 139 78 Colonoscopy and biopsy (HOSPITAL ONLY) 45380 Surg 2530 $ 307591 Diagnostic colonoscopy (HOSPITAL ONLY) 45378 Surg 2255 $ 307591 Upper gi endoscopy biopsy (HOSPITAL ONLY) 43239 Surg 1787 $ 307591 Knee Arthroscopy (HOSPITAL ONLY) 29881 Surg 10900 $ 506893 Arthroscopy Ligament Repair (HOSPITAL ONLY) 29888 Surg 10900 $ 506200 Key 1 Facility - Inpatient 2 Facility - Imaging 3 Physician - Imaging 4 Physician 5 Global - Imaging 6 Facility - Outpatient 8 Lab 41 Physician - Primary Care 42 Physician - Specialist
Blue Cross United - EJCH EUH EUHM WW United - SJH Non Options United - SJH Options Aetna - ASC TEC (HMO) Cigna - ASC TEC (HMO) Aetna - EJCH ESJH ECHM WW Cigna - EJCH (HMO) Cigna - ESJH EUHM (HMO) List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract Description CPT Code Charge Average Final Price (all plans) Emory Mark Up Reimbursement Method ( of charge or fixed) - 1713 Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Cardiovascular stress test 93017 Cardio $543 $ 425 28 of Charge 70 $ 380 of Charge 65 $ 353 of Charge 60 $ 326 of Charge 70 $ 380 of Charge 70 $ 380 of charge 100 $ 543 of Charge 70 $ 380 of charge 100 $ 543 of charge 100 $ 543 TTE wDoppler complete 93306 Cardio $1226 $ 960 28 of Charge 70 $ 858 of Charge 65 $ 797 of Charge 60 $ 736 of Charge 70 $ 858 of Charge 70 $ 858 of charge 100 $ 1226 of Charge 70 $ 858 of charge 100 $ 1226 of charge 100 $ 1226 Colonoscopy and biopsy (HOSPITAL ONLY) 45380 Surg $2530 $ 3076 -18 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 of Charge 70 $ 1771 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Diagnostic colonoscopy (HOSPITAL ONLY) 45378 Surg $2255 $ 3076 -27 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 of Charge 70 $ 1579 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Upper gi endoscopy biopsy (HOSPITAL ONLY) 43239 Surg $1787 $ 3076 -42 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Knee Arthroscopy (HOSPITAL ONLY) 29881 Surg $10900 $ 5069 115 Fixed Rate SC 4 $ 3865 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 449300 $ 4493 Fixed Rate $ 654700 $ 6547 of Charge 70 $ 7630 Fixed Rate $ 401000 $ 4010 of Charge 70 $ 7630 Fixed Rate $ 398300 $ 3983 Fixed Rate $ 398100 $ 3981 Arthroscopy Ligament Repair (HOSPITAL ONLY) 29888 Surg $10900 $ 5062 115 Fixed Rate SC 3 $ 3121 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 556900 $ 5569 Fixed Rate $ 770100 $ 7701 of Charge 70 $ 7630 Fixed Rate $ 323900 $ 3239 of Charge 70 $ 7630 Fixed Rate $ 321700 $ 3217 Fixed Rate $ 321400 $ 3214 Comp Metabolic Panel 80053 Lab $132 $ 56 138 RBRVS Fee (100) $ 1437 of Charge 65 $ 86 of Charge 65 $ 86 of Charge 65 $ 86 of Charge 70 $ 92 RBRVS Fee (100) $ 1437 $ 14 of Charge 70 $ 92 RBRVS Fee (100) $ 1437 $ 14 RBRVS Fee (100) $ 1437 $ 14 Surgical Path Tissue Exam 88305 Lab $326 $ 236 38 of Charge 150 $ 51 of Charge 65 $ 212 of Charge 65 $ 212 of Charge 65 $ 212 of Charge 70 $ 228 of charge 100 $ 326 of Charge 70 $ 228 of charge 100 $ 326 of charge 100 $ 326 MRI Abdomen 74183 Radiology $6960 $ 1238 462 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 MRI Brain 70553 Radiology $6804 $ 1238 450 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 MRI Joint Lower Extremity 73721 Radiology $3067 $ 1238 148 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 CT Thorax wo contrast 71250 Radiology $2199 $ 882 149 Fixed Rate $ 771 Fixed Rate $ 47100 $ 471 Fixed Rate $ 81700 $ 817 Fixed Rate $ 116000 $ 1160 of Charge 70 $ 1539 Fixed Rate $ 80100 $ 801 Fixed Rate $ 79200 $ 792 Fixed Rate $ 79300 $ 793 Fixed Rate $ 79500 $ 795 X-ray Chest 71020 Radiology $280 $ 115 142 of Charge 150 $ 25 of Charge 65 $ 182 of Charge 60 $ 168 of Charge 70 $ 196 of Charge 70 $ 196 RBRVS Fee (150) $ 2534 $ 25 of Charge 70 $ 196 RBRVS Fee (150) $ 2534 $ 25 RBRVS Fee (150) $ 2534 $ 25 Screening mammography G0202 Radiology $279 $ 141 98 Fixed Rate $ 128 Fixed Rate $ 13100 $ 131 Fixed Rate $ 14300 $ 143 Fixed Rate $ 16100 $ 161 of Charge 70 $ 195 Fixed Rate $ 13300 $ 133 Fixed Rate $ 13500 $ 135 Fixed Rate $ 13000 $ 130 Fixed Rate $ 11200 $ 112 Mammo Computer Aided 77052 Radiology $75 $ 112 -33 Fixed Rate $ 9 Fixed Rate $ 13100 $ 131 Fixed Rate $ 14300 $ 143 Fixed Rate $ 16100 $ 161 of Charge 70 $ 53 Fixed Rate $ 13300 $ 133 Fixed Rate $ 13500 $ 135 Fixed Rate $ 13000 $ 130 Fixed Rate $ 11200 $ 112 US Abdomen Complete 76700 Radiology $917 $ 397 131 of Charge 150 $ 125 of Charge 65 $ 596 of Charge 60 $ 550 of Charge 70 $ 642 of Charge 70 $ 642 RBRVS Fee (150) $ 12519 $ 125 of Charge 70 $ 642 RBRVS Fee (150) $ 12519 $ 125 RBRVS Fee (150) $ 12519 $ 125 Officeoutpatient visit new pt 30 min (TEC) 99203 EampM $316 $ 248 28 of Charge 70 $ 221 of Charge 65 $ 205 of Charge 60 $ 190 of Charge 70 $ 221 of Charge 70 $ 221 of charge 100 $ 316 of Charge 70 $ 221 of charge 100 $ 316 of charge 100 $ 316 Vaginal delivery 59409 Surg $14484 $ 7290 99 Fixed Rate DRG - 775 $ 5437 2 Day Case Rate + LOC 561700 $ 5617 BaseCMS Weight 584741 $ 5847 BaseCMS Weight 726146 $ 7261 No IP Terms $ - 0 No IP BaseCMS Weight 659343 $ 6593 BaseContract Weight 479451 100 $ 14484 BaseCMS Weight 579110 $ 5791 Lap Sleeve Gastrectomy 43775 Surg $29961 $ 20421 47 Fixed Rate DRG - 621 $ 14872 BaseCMS Weight 1810697 $ 18107 BaseCMS Weight 1835178 $ 18352 BaseCMS Weight 2278911 $ 22789 No IP Terms $ - 0 No IP BaseCMS Weight 2069315 $ 20693 BaseCMS Weight 1730442 100 $ 29961 BaseCMS Weight 1817507 $ 18175 105 Colonoscopy and biopsy (ASC ONLY) Surg $ 219200 $ 2181 Diagnostic colonoscopy (ASC ONLY) Surg $ 267100 $ 2348 Upper gi endoscopy biopsy (ASC ONLY) Surg $ 207500 $ 2758 Knee Arthroscopy (ASC ONLY) Surg $ 417900 $ 3467 Arthroscopy Ligament Repair (ASC ONLY) Surg $ 504800 $ 3386
Cpt Code CPT Description Procedure Category Claims Min 25thNtile 50thNtile Emorys Rates 75thNtile 90thNtile Max 20 Below 50th Ntile 20 Above 50th Ntile 93017 CARDIOVASCULAR STRESS TEST 5 82 $80 $125 $321 $382 $568 $791 $930 $257 $386 71020 CHEST X-RAY 2 2638 $11 $45 $152 $115 $289 $373 $585 $122 $182 71020 CHEST X-RAY 5 8106 $25 $34 $38 $54 $57 $69 $30 $46 45380 COLONOSCOPY AND BIOPSY 6 1256 $541 $560 $572 $2877 $1000 $2024 $3289 $458 $686 77052 COMP SCREEN MAMMOGRAM ADD-ON 2 194 $13 $15 $25 $38 $47 $134 $20 $30 77052 COMP SCREEN MAMMOGRAM ADD-ON 5 2411 $13 $16 $20 $23 $26 $28 $16 $24 80053 COMPREHEN METABOLIC PANEL 8 13019 $9 $19 $23 $55 $24 $25 $69 $19 $28 71250 CT THORAX WO DYE 2 302 $165 $372 $545 $878 $1658 $2067 $436 $654 71250 CT THORAX WO DYE 5 209 $53 $127 $203 $289 $419 $534 $162 $244 45378 DIAGNOSTIC COLONOSCOPY 6 1479 $484 $515 $536 $2914 $831 $1971 $2828 $428 $643 29881 KNEE ARTHROSCOPYSURGERY 6 152 $1650 $1826 $2036 $5235 $3054 $4216 $6461 $1629 $2443 29888 KNEE ARTHROSCOPYSURGERY 6 82 $1682 $3615 $5081 $5145 $7553 $12924 $18532 $4065 $6097 43644 LAP GASTRIC BYPASSROUX-EN-Y 1 21 $11821 $13873 $17050 $18391 $25029 $31079 $13640 $20460 43775 LAP SLEEVE GASTRECTOMY 1 38 $4215 $8250 $13253 $20421 $19197 $21509 $24260 $10602 $15903 74183 MRI ABDOMEN WO amp WDYE 2 120 $919 $987 $1015 $1237 $1252 $2534 $3177 $812 $1218 74183 MRI ABDOMEN WO amp WDYE 5 112 $475 $490 $521 $1154 $1337 $1696 $417 $625 70553 MRI BRAIN WO amp WDYE 2 324 $633 $987 $1142 $1237 $1706 $2805 $3331 $914 $1370 70553 MRI BRAIN WO amp WDYE 5 467 $280 $539 $1023 $1277 $1363 $1726 $818 $1228 73721 MRI JNT OF LWR EXTRE WO DYE 2 304 $804 $859 $967 $1237 $1063 $1598 $2485 $774 $1160 73721 MRI JNT OF LWR EXTRE WO DYE 5 1130 $500 $520 $530 $628 $679 $859 $424 $636 59400 OBSTETRICAL CARE 1 494 $3699 $4402 $4969 $6655 $7307 $8613 $3975 $5963 99203 OFFICEOUTPATIENT VISIT NEW 4 6776 $88 $101 $112 $138 $155 $169 $90 $134 G0202 Screeningmammographydigital 2 7444 $123 $206 $285 $380 $425 $479 $228 $342 G0202 Screeningmammographydigital 5 2754 $117 $165 $195 $230 $247 $252 $156 $234 88305 TISSUE EXAM BY PATHOLOGIST 8 20834 $51 $74 $112 $235 $168 $261 $478 $90 $134 93306 TTE WDOPPLER COMPLETE 2 931 $194 $377 $739 $960 $1267 $1480 $1849 $591 $887 93306 TTE WDOPPLER COMPLETE 5 2299 $151 $296 $373 $538 $573 $834 $298 $448 43239 UPPER GI ENDOSCOPY BIOPSY 6 1264 $424 $514 $550 $800 $1838 $2833 $440 $660 76700 US EXAM ABDOM COMPLETE 2 321 $96 $165 $271 $509 $584 $857 $217 $325 76700 US EXAM ABDOM COMPLETE 5 444 $111 $129 $147 $156 $220 $279 $118 $176 Key 1 Facility - Inpatient 2 Facility - Imaging 3 Physician - Imaging 4 Physician 5 Global - Imaging 6 Facility - Outpatient 8 Lab 41 Physician - Primary Care 42 Physician - Specialist Cardiovascular stress test $ 38279 TTE wDoppler complete $ 96037 Colonoscopy and biopsy $ 287709 Diagnostic colonoscopy $ 291434 Upper gi endoscopy biopsy $ 300526 Knee Arthroscopy $ 523584 Arthroscopy Ligament Repair $ 514501 Comp Metabolic Panel $ 5552 Surgical Path Tissue Exam $ 23570 MRI Abdomen $ 123786 MRI Brain $ 123786 MRI Joint Lower Extremity $ 123786 CT Thorax wo contrast $ 88213 X-ray Chest $ 11548 Screening mammography $ 14098 Mammo Computer Aided $ 11179 US Abdomen Complete $ 39695 Officeoutpatient visit new pt 30 min $ 24753 Vaginal delivery $ 729025 Lap Sleeve Gastrectomy $ 2042124
Page 24
Case Study 2
Case study 2 ndash Large Employer bull Business Problem Large employer wants to contract
directly with 2 major hospital systems developing professional fee schedules
bull ConsiderationsValue Prop Fee schedule should be competitive but also nuanced to minimize gap relative to current reimbursement at physician level
bull Solution Data-driven approach using current market-wide reimbursement distinguished by service level
24
Evaluate Provider Spend Top 25 Service Lines by Allowable Spend
Evaluate Provider Spend Top 20 Professional CPTs by Total Spend
Understand relative market pricing position
27
21
-1
-28
14 10
28
-22
-11 -13
24
3
20 21
8
-20
13
3 9
-39
56
-26
4
-42
60
MRI Colonoscopy Cardiac Cath Lab - OrganPanel
Memorial Hospital Beta Hospital Delta Hospital Charlie Hospital Echo Hospital Alpha Medical Center
ndash25 5 -15 10 0 39
State Charges as a Percent of Peer Average Weighted Averages for MRI Colonoscopy Cardiology and Lab
Total Percent Above Below Market Average2
Memorial Hospital Beta Hospital Delta Hospital Charlie Hospital Echo Hospital Alpha Medical Center
Develop fee schedule relative to market
28
Service Line Procedure CPT CodeDRG
Memorial Hospital
Beta Hosptial
Charlie Hospital
Delta Hospital
Echo Hospital
Alpha Medical Center
Arthroscopy Ligament Repair 29888 $ 5062 $ 9557 $ 5983 $ 10096 $ 7519 $ 2502 Knee Arthroscopy 29881 $ 5069 $ 4185 $ 3837 $ 3022 $ 3729 $ 2266 Upper GI Endoscopy 43239 $ 3075 $ 2539 $ 2012 $ 1132 $ 1565 $ 2240 Lap Sleeve Gastrectomy DRG 621 $ 20421 $ 20815 $ 12105 $ 13230 $ 14600 $ 17800 Colonoscopy and biopsy 45380 $ 3075 $ 3071 $ 2013 $ 1244 $ 1972 $ 859 Diagnostic Colonoscopy 45378 $ 3075 $ 2805 $ 2013 $ 1244 $ 1972 $ 859 MRI Brain w amp wo dye 70553 $ 1238 $ 1468 $ 1117 $ 967 $ 2805 $ 1052 MRI Joint of Lower Extremity wo dye 73721 $ 1238 $ 1398 $ 1042 $ 967 $ 925 $ 557 MRI Abdomen w amp wo dye 74183 $ 1238 $ 1468 $ 1106 $ 967 $ 2805 $ 836 X-ray Chest 71020 $ 115 $ 266 $ 305 $ 279 $ 375 $ 72 CT Thorax wo dye 71250 $ 882 $ 810 $ 505 $ 491 $ 579 $ 319 Ultrasound Abdomen Complete 76700 $ 397 $ 538 $ 545 $ 195 $ 190 $ 168 Mammogram Screening G0202 $ 141 $ 328 $ 431 $ 294 $ 425 $ 168 Computer Detection Add-on 77052 $ 112 $ 99 $ 41 $ 15 $ 45 $ 23 Comp Metabolic Panel 80053 $ 56 $ 15 $ 24 $ 56 $ 51 $ 25 Tissue Exam by Pathologist 88305 $ 236 $ 307 $ 80 $ 152 $ 78 $ 232 Cardiovascular Stress Test 93017 $ 383 $ 432 $ 1299 $ 907 $ 717 $ 797 TTE w Doppler 93306 $ 960 $ 1566 $ 1388 $ 1173 $ 1125 $ 1157
Obstetrics Vaginal Delivery DRG 755 7290$ 5730$ 4654$ 4607$ 5855$ 4688$
GI
Lab
Radiology
Medical Cardiology
Orthopedics
KEY OBSERVA TIONS bull Potential exposure on GI bull Opportunity to align price and acuity in MRI bull Opportunity to raise rates on chest x-ray and mammogram
Percentile Bands Emory Allowables Heatmap TEC ASC Heatmap Allowable Comp Analysis Portal Pricing Sheet1 image1png A few words on Bundled Payments bull Bundled payments are growing as a type of direct contracting bull In some cases third parties match-make between employers
and providers bull Contracts may vary in definitions prepost admission
coverage duration readmission cause (ie all-cause vs medically related) outlier provisions LOS caps andor per diems
bull Providers need to be strategic in pricing to enable profitable growth of market share
29
Considerations in Offering Development bull Network Development
bull Build off existing structure eg health system employee plan network bull How does this fit into your broader value based care strategy bull Employed and independent physicians bull How do you want to approach the buildout of high performance
network bull Quality focus bull Cost efficiency
bull Integrated behavioral health bull Wrap network for other markets
30
Considerations in Offering Development bull Target Market
bull Consideration of employer profile in market bull Fully-insured vs ASO bull Total cost of care vs bundled services
bull Distribution bull Direct marketing bull Brokerconsultant community
bull Plan designs bull Standard designs vs flexible ndash Dependent on target market
bull Claims administration bull Data sharing amp analytics
31
Considerations in Offering Development bull Other components of comprehensive offering
bull Pharmacy bull Preventive health bull Onsite clinics bull Wellness programs bull Technology platform
32
Sample Bundle Analysis
33
Cover page Dotson Hazelrigs Nation Mainly of charge of fixed Cardiovascular stress test TTE wDoppler complete Colonoscopy and biopsy (Combined) Diagnostic colonoscopy (Combined) Upper gi endoscopy biopsy (Combined) Knee Arthroscopy (Combined) Arthroscopy Ligament Repair Comp Metabolic Panel Surgical Path Tissue Exam MRI Abdomen MRI Brain MRI Joint Lower Extremity CT Thorax wo contrast X-ray Chest Screening mammography Mammo Computer Aided US Abdomen Complete Officeoutpatient visit new pt 30 min Vaginal delivery Lap Sleeve Gastrectomy
Piedmont Piedmont Piedmont Piedmont Northside Northside Northside Northside Gwinnett Gwinnett Gwinnett Gwinnett WellStar WellStar WellStar WellStar AMC - Tenet AMC - Tenet AMC - Tenet AMC - Tenet CPT Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing 29881 $11312 $10872 NA NA $7476 $9338 NA $23655 $11856 $3668 NA $17871 $12253 NA NA $15645 $5490 NA NA $23039 29888 NA NA NA NA NA NA NA $23784 NA $8261 NA $18000 NA NA NA $15774 NA NA NA $23168 43239 NA $4408 NA NA NA NA $5997 $8852 NA $3304 NA $7424 $1267 NA NA $9230 NA $2458 NA $8274 43644 $26468 NA NA NA $3382 $12050 NA $1861 NA NA NA $1316 $7841 NA NA $3444 $18892 $27950 NA $979 43775 NA NA NA NA NA NA NA $352 NA NA NA $302 NA NA NA $413 NA NA NA $83 45378 $2705 $2530 NA NA $4381 $3676 $4496 $1022 $2938 $2138 NA $695 $5504 NA NA $2036 NA NA NA $372 45380 $3075 $2600 NA NA $4723 $3527 $3012 $1757 $4215 $2285 NA NA $5298 NA NA $3268 NA NA NA $627 59400 $6160 NA NA NA NA $5100 NA $1851 NA NA NA $1304 $9035 NA NA $3427 $9116 $5150 NA $966 70553 $2985 NA $1153 NA $2182 NA $1192 $492 NA NA $803 $489 $1512 NA $985 $1187 NA NA NA $197 71020 $61 $69 $43 NA $113 $319 $307 NA $183 $59 $32 NA $213 $66 $40 NA $83 $53 NA NA 71250 $1837 $621 $989 NA $1490 $931 $755 NA NA $745 $401 NA $1067 $982 $616 NA NA $304 NA NA 73721 NA $1098 $1153 NA $2042 $1065 $1192 NA NA $998 $803 NA NA $1275 $985 NA NA $644 NA $178 74183 $2971 $1144 NA NA NA $1092 $1192 $6884 NA $1098 $803 NA $2960 $1197 $985 $5454 NA NA NA $7607 76700 $364 $247 $207 NA $427 $708 $614 $13267 $428 $214 $152 NA $747 $263 $189 $9139 NA $235 NA NA 77052 NA NA NA NA NA NA NA $4744 NA NA NA NA NA NA NA $3070 NA NA NA $5611 93306 $1220 $1117 NA NA $1877 $1657 $2100 $4605 $1433 $413 $945 NA $1336 $1434 $1951 $2931 NA $2399 NA $5472 G0202 $262 $187 NA NA $431 NA NA $4605 $292 NA NA NA $530 $281 NA $2931 $327 NA NA $5472
Provider Group 29881_6 29888_6 43239_6 43644_1 43775_1 45378_6 45380_6 59400_1 70553_2 71020_2 71250_2 73721_2 74183_2 76700_2 77052_2 77052_5 80053_8 88305_8 93306_2 99203_4 G0202_2 G0202_5 93017_2 Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Atlanta Gastroenterology Associates $2399 $536 348 $1628 $536 204 $2400 $536 348 Atlanta Medical Center $24889 $2266 999 $25897 $2502 935 $11449 $2240 411 $81927 $15300 435 $75815 $17800 326 $7317 $859 752 $7317 $859 752 $12821 $4688 173 $6581 $1052 526 $645 $72 796 $3265 $319 925 $3450 $557 519 $7398 $836 785 $1576 $133 1084 $73 $23 217 $635 $25 2440 $891 $232 285 $2967 $1157 156 $344 $168 105 $1265 $797 59 Atlanta Womens Health Physicians Group $29 $14 107 $40 $13 208 $396 $188 111 $278 $118 135 $450 $231 95 Gwinnett Hospital $11941 $3022 295 $21654 $10096 114 $3551 $1132 214 $34384 $10800 218 $56472 $13230 327 $3003 $1244 141 $3533 $1244 184 $8984 $4607 95 $3901 $967 303 $417 $279 49 $2247 $491 358 $4000 $967 314 $3755 $967 288 $1593 $195 717 $50 $15 233 $186 $56 233 $505 $152 233 $1750 $1173 49 $418 $294 42 $1396 $907 54 Northside Hospital $15482 $4185 270 $21651 $9557 127 $4885 $2539 92 $35176 $17000 107 $35233 $20815 69 $3883 $2805 38 $5256 $3071 71 $10911 $5730 90 $4856 $1468 231 $443 $266 67 $2379 $810 194 $3776 $1398 170 $5105 $1468 248 $942 $538 75 $167 $99 69 $379 $15 2427 $433 $307 41 $2252 $1566 44 $459 $328 40 $576 $432 33 Piedmont Hospital $14772 $3837 285 $35493 $5983 493 $5069 $2012 152 $38320 $17750 116 $37125 $12105 207 $3485 $2013 73 $4993 $2013 148 $10143 $4654 118 $5939 $1117 432 $542 $305 78 $2983 $505 491 $3410 $1042 227 $6067 $1106 449 $1364 $545 150 $75 $41 85 $231 $24 863 $657 $80 721 $2041 $1388 47 $490 $431 14 $1780 $1299 37 Piedmont Physicians Group $42 $22 87 $318 $179 78 $239 $159 50 Resurgens $8558 $2036 320 $9293 $2258 312 $4638 $2067 124 $4039 $2164 87 $4392 $2164 103 $2252 $1371 64 $459 $330 39 Wellstar Hospital $9330 $3729 150 $17479 $7519 132 $5261 $1565 236 $35794 $18200 97 $46780 $14600 220 $3707 $1972 88 $4928 $1972 150 $13549 $5855 131 $5054 $2805 80 $528 $375 41 $3222 $579 457 $3694 $925 299 $5495 $2805 96 $1355 $190 615 $66 $45 46 $73 $51 43 $133 $78 71 $1785 $1125 59 $599 $425 41 $1010 $717 41 Avg Mark UpProcedure Atlanta Medical Center 634 Gwinnett Hospital 223 Northside Hospital 233 Piedmont Hospital 259 Wellstar Hospital 155 Emory 105
Atlanta Gastroenterology Associates Atlanta Medical Center Atlanta Womens Health Gwinnett Hospital Northside Hospital Piedmont Hospital Piedmont Physicians Group Resurgens Wellstar Hospital CPT Code CPT Proc Cat Comp Avg Allow Allow Allow Allow Allow Allow Allow Allow Allow 29881 KNEE ARTHROSCOPYSURGERY 6 $3179 $2266 $3022 $4185 $3837 $2036 $3729 29888 KNEE ARTHROSCOPYSURGERY 6 $6319 $2502 $10096 $9557 $5983 $2258 $7519 43239 UPPER GI ENDOSCOPY BIOPSY 6 $1727 $536 $2240 $1132 $2539 $2012 $2067 $1565 43644 LAP GASTRIC BYPASSROUX-EN-Y 1 $15810 $15300 $10800 $17000 $17750 $18200 43775 LAP SLEEVE GASTRECTOMY 1 $17800 $13230 $20815 $12105 $14600 45378 DIAGNOSTIC COLONOSCOPY 6 $1656 $536 $859 $1244 $2805 $2013 $2164 $1972 45380 COLONOSCOPY AND BIOPSY 6 $1694 $536 $859 $1244 $3071 $2013 $2164 $1972 59400 OBSTETRICAL CARE 1 $5107 $4688 $4607 $5730 $4654 $5855 70553 MRI BRAIN WO amp WDYE 2 $1482 $1052 $967 $1468 $1117 $2805 71020 CHEST X-RAY 2 $259 $72 $279 $266 $305 $375 71250 CT THORAX WO DYE 2 $541 $319 $491 $810 $505 $579 73721 MRI JNT OF LWR EXTRE WO DYE 2 $978 $557 $967 $1398 $1042 $925 74183 MRI ABDOMEN WO amp WDYE 2 $1436 $836 $967 $1468 $1106 $2805 76700 US EXAM ABDOM COMPLETE 2 $320 $133 $195 $538 $545 $190 77052 COMP SCREEN MAMMOGRAM ADD-ON 2 $45 $23 $15 $99 $41 $45 77052 COMP SCREEN MAMMOGRAM ADD-ON 5 $14 $14 80053 COMPREHEN METABOLIC PANEL 8 $29 $25 $13 $56 $15 $24 $22 $51 88305 TISSUE EXAM BY PATHOLOGIST 8 $174 $232 $188 $152 $307 $80 $179 $78 93306 TTE WDOPPLER COMPLETE 2 $1297 $1157 $1173 $1566 $1388 $1371 $1125 93017 STRESS TEST 5 $830 $797 $907 $432 $1299 $717 99203 OFFICEOUTPATIENT VISIT NEW 4 $139 $118 $159 G0202 Screeningmammographydigital 2 $329 $168 $294 $328 $431 $330 $425 G0202 Screeningmammographydigital 5 $231 $231
Service Line Procedure CPT Code Emory Atlanta Gastroenterology Associates Resurgens Atlanta Womens Health Piedmont Physicians Group Orthopedics (ASC) Knee Arthroscopy 29881 $3467 $2036 Arthroscopy Ligament Repair 29888 $3386 $2258 GI (ASC) Upper GI Endoscopy 43239 $2758 $536 Diagnostic Colonoscopy 45378 $2348 $536 Colonoscopy and biopsy 45380 $2181 $536 Radiology Mammogram Screening G0202 $164 $231 Computer Detection Add-on 77052 $93 $14 Lab Comp Metabolic Panel 80053 $53 $13 $22 Tissue Exam by Pathologist 88305 $277 $188 $179 EampM (TEC) Office Visit new pt 99203 $269 $118 $159
Service Line Procedure CPT CodeDRG Memorial Hospital Beta Hosptial Charlie Hospital Delta Hospital Echo Hospital Alpha Medical Center Atlanta Gastroenterology Associates Resurgens Atlanta Womens Health Piedmont Physicians Group Market Avg Emory abovebelow Orthopedics Arthroscopy Ligament Repair 29888 $ 5062 $ 9557 $ 5983 $ 10096 $ 7519 $ 2502 $ 2258 $ 6319 -20 Knee Arthroscopy 29881 6 $ 5069 $ 4185 $ 3837 $ 3022 $ 3729 $ 2266 $ 2036 $ 3179 59 GI Upper GI Endoscopy 43239 6 $ 3075 $ 2539 $ 2012 $ 1132 $ 1565 $ 2240 $ 536 $ 1671 84 Lap Sleeve Gastrectomy DRG 621 $ 20421 $ 20815 $ 12105 $ 13230 $ 14600 $ 17800 $ 15710 30 Colonoscopy and biopsy 45380 $ 3075 $ 3071 $ 2013 $ 1244 $ 1972 $ 859 $ 536 $ 1616 90 Diagnostic Colonoscopy 45378 6 $ 3075 $ 2805 $ 2013 $ 1244 $ 1972 $ 859 $ 536 $ 1572 96 Radiology MRI Brain w amp wo dye 70553 2 $ 1238 $ 1468 $ 1117 $ 967 $ 2805 $ 1052 $ 1482 -16 MRI Joint of Lower Extremity wo dye 73721 2 $ 1238 $ 1398 $ 1042 $ 967 $ 925 $ 557 $ 978 27 MRI Abdomen w amp wo dye 74183 2 $ 1238 $ 1468 $ 1106 $ 967 $ 2805 $ 836 $ 1436 -14 X-ray Chest 71020 $ 115 $ 266 $ 305 $ 279 $ 375 $ 72 $ 259 -56 CT Thorax wo dye 71250 $ 882 $ 810 $ 505 $ 491 $ 579 $ 319 $ 541 63 Ultrasound Abdomen Complete 76700 $ 397 $ 538 $ 545 $ 195 $ 190 $ 168 $ 327 21 Mammogram Screening G0202 2 $ 141 $ 328 $ 431 $ 294 $ 425 $ 168 $ 231 $ 313 -55 Computer Detection Add-on 77052 2 $ 112 $ 99 $ 41 $ 15 $ 45 $ 23 $ 14 $ 39 183 Lab Comp Metabolic Panel 80053 8 $ 56 $ 15 $ 24 $ 56 $ 51 $ 25 $ 13 $ 22 $ 29 88 Tissue Exam by Pathologist 88305 8 $ 236 $ 307 $ 80 $ 152 $ 78 $ 232 $ 188 $ 179 $ 174 36 Medical Cardiology Cardiovascular Stress Test 93017 $ 383 $ 432 $ 1299 $ 907 $ 717 $ 797 $ 830 -54 TTE w Doppler 93306 2 $ 960 $ 1566 $ 1388 $ 1173 $ 1125 $ 1157 $ 1282 -25 Obstetrics Vaginal Delivery DRG 755 $ 7290 $ 5730 $ 4654 $ 4607 $ 5855 $ 4688 $ 5107 43 EampM Office Visit new pt 99203 4 $ 248 $ 118 $ 159 $ 139 78 Colonoscopy and biopsy (HOSPITAL ONLY) 45380 Surg 2530 $ 307591 Diagnostic colonoscopy (HOSPITAL ONLY) 45378 Surg 2255 $ 307591 Upper gi endoscopy biopsy (HOSPITAL ONLY) 43239 Surg 1787 $ 307591 Knee Arthroscopy (HOSPITAL ONLY) 29881 Surg 10900 $ 506893 Arthroscopy Ligament Repair (HOSPITAL ONLY) 29888 Surg 10900 $ 506200 Key 1 Facility - Inpatient 2 Facility - Imaging 3 Physician - Imaging 4 Physician 5 Global - Imaging 6 Facility - Outpatient 8 Lab 41 Physician - Primary Care 42 Physician - Specialist
Blue Cross United - EJCH EUH EUHM WW United - SJH Non Options United - SJH Options Aetna - ASC TEC (HMO) Cigna - ASC TEC (HMO) Aetna - EJCH ESJH ECHM WW Cigna - EJCH (HMO) Cigna - ESJH EUHM (HMO) List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract Description CPT Code Charge Average Final Price (all plans) Emory Mark Up Reimbursement Method ( of charge or fixed) - 1713 Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Cardiovascular stress test 93017 Cardio $543 $ 425 28 of Charge 70 $ 380 of Charge 65 $ 353 of Charge 60 $ 326 of Charge 70 $ 380 of Charge 70 $ 380 of charge 100 $ 543 of Charge 70 $ 380 of charge 100 $ 543 of charge 100 $ 543 TTE wDoppler complete 93306 Cardio $1226 $ 960 28 of Charge 70 $ 858 of Charge 65 $ 797 of Charge 60 $ 736 of Charge 70 $ 858 of Charge 70 $ 858 of charge 100 $ 1226 of Charge 70 $ 858 of charge 100 $ 1226 of charge 100 $ 1226 Colonoscopy and biopsy (HOSPITAL ONLY) 45380 Surg $2530 $ 3076 -18 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 of Charge 70 $ 1771 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Diagnostic colonoscopy (HOSPITAL ONLY) 45378 Surg $2255 $ 3076 -27 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 of Charge 70 $ 1579 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Upper gi endoscopy biopsy (HOSPITAL ONLY) 43239 Surg $1787 $ 3076 -42 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Knee Arthroscopy (HOSPITAL ONLY) 29881 Surg $10900 $ 5069 115 Fixed Rate SC 4 $ 3865 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 449300 $ 4493 Fixed Rate $ 654700 $ 6547 of Charge 70 $ 7630 Fixed Rate $ 401000 $ 4010 of Charge 70 $ 7630 Fixed Rate $ 398300 $ 3983 Fixed Rate $ 398100 $ 3981 Arthroscopy Ligament Repair (HOSPITAL ONLY) 29888 Surg $10900 $ 5062 115 Fixed Rate SC 3 $ 3121 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 556900 $ 5569 Fixed Rate $ 770100 $ 7701 of Charge 70 $ 7630 Fixed Rate $ 323900 $ 3239 of Charge 70 $ 7630 Fixed Rate $ 321700 $ 3217 Fixed Rate $ 321400 $ 3214 Comp Metabolic Panel 80053 Lab $132 $ 56 138 RBRVS Fee (100) $ 1437 of Charge 65 $ 86 of Charge 65 $ 86 of Charge 65 $ 86 of Charge 70 $ 92 RBRVS Fee (100) $ 1437 $ 14 of Charge 70 $ 92 RBRVS Fee (100) $ 1437 $ 14 RBRVS Fee (100) $ 1437 $ 14 Surgical Path Tissue Exam 88305 Lab $326 $ 236 38 of Charge 150 $ 51 of Charge 65 $ 212 of Charge 65 $ 212 of Charge 65 $ 212 of Charge 70 $ 228 of charge 100 $ 326 of Charge 70 $ 228 of charge 100 $ 326 of charge 100 $ 326 MRI Abdomen 74183 Radiology $6960 $ 1238 462 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 MRI Brain 70553 Radiology $6804 $ 1238 450 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 MRI Joint Lower Extremity 73721 Radiology $3067 $ 1238 148 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 CT Thorax wo contrast 71250 Radiology $2199 $ 882 149 Fixed Rate $ 771 Fixed Rate $ 47100 $ 471 Fixed Rate $ 81700 $ 817 Fixed Rate $ 116000 $ 1160 of Charge 70 $ 1539 Fixed Rate $ 80100 $ 801 Fixed Rate $ 79200 $ 792 Fixed Rate $ 79300 $ 793 Fixed Rate $ 79500 $ 795 X-ray Chest 71020 Radiology $280 $ 115 142 of Charge 150 $ 25 of Charge 65 $ 182 of Charge 60 $ 168 of Charge 70 $ 196 of Charge 70 $ 196 RBRVS Fee (150) $ 2534 $ 25 of Charge 70 $ 196 RBRVS Fee (150) $ 2534 $ 25 RBRVS Fee (150) $ 2534 $ 25 Screening mammography G0202 Radiology $279 $ 141 98 Fixed Rate $ 128 Fixed Rate $ 13100 $ 131 Fixed Rate $ 14300 $ 143 Fixed Rate $ 16100 $ 161 of Charge 70 $ 195 Fixed Rate $ 13300 $ 133 Fixed Rate $ 13500 $ 135 Fixed Rate $ 13000 $ 130 Fixed Rate $ 11200 $ 112 Mammo Computer Aided 77052 Radiology $75 $ 112 -33 Fixed Rate $ 9 Fixed Rate $ 13100 $ 131 Fixed Rate $ 14300 $ 143 Fixed Rate $ 16100 $ 161 of Charge 70 $ 53 Fixed Rate $ 13300 $ 133 Fixed Rate $ 13500 $ 135 Fixed Rate $ 13000 $ 130 Fixed Rate $ 11200 $ 112 US Abdomen Complete 76700 Radiology $917 $ 397 131 of Charge 150 $ 125 of Charge 65 $ 596 of Charge 60 $ 550 of Charge 70 $ 642 of Charge 70 $ 642 RBRVS Fee (150) $ 12519 $ 125 of Charge 70 $ 642 RBRVS Fee (150) $ 12519 $ 125 RBRVS Fee (150) $ 12519 $ 125 Officeoutpatient visit new pt 30 min (TEC) 99203 EampM $316 $ 248 28 of Charge 70 $ 221 of Charge 65 $ 205 of Charge 60 $ 190 of Charge 70 $ 221 of Charge 70 $ 221 of charge 100 $ 316 of Charge 70 $ 221 of charge 100 $ 316 of charge 100 $ 316 Vaginal delivery 59409 Surg $14484 $ 7290 99 Fixed Rate DRG - 775 $ 5437 2 Day Case Rate + LOC 561700 $ 5617 BaseCMS Weight 584741 $ 5847 BaseCMS Weight 726146 $ 7261 No IP Terms $ - 0 No IP BaseCMS Weight 659343 $ 6593 BaseContract Weight 479451 100 $ 14484 BaseCMS Weight 579110 $ 5791 Lap Sleeve Gastrectomy 43775 Surg $29961 $ 20421 47 Fixed Rate DRG - 621 $ 14872 BaseCMS Weight 1810697 $ 18107 BaseCMS Weight 1835178 $ 18352 BaseCMS Weight 2278911 $ 22789 No IP Terms $ - 0 No IP BaseCMS Weight 2069315 $ 20693 BaseCMS Weight 1730442 100 $ 29961 BaseCMS Weight 1817507 $ 18175 105 Colonoscopy and biopsy (ASC ONLY) Surg $ 219200 $ 2181 Diagnostic colonoscopy (ASC ONLY) Surg $ 267100 $ 2348 Upper gi endoscopy biopsy (ASC ONLY) Surg $ 207500 $ 2758 Knee Arthroscopy (ASC ONLY) Surg $ 417900 $ 3467 Arthroscopy Ligament Repair (ASC ONLY) Surg $ 504800 $ 3386
Cpt Code CPT Description Procedure Category Claims Min 25thNtile 50thNtile Emorys Rates 75thNtile 90thNtile Max 20 Below 50th Ntile 20 Above 50th Ntile 93017 CARDIOVASCULAR STRESS TEST 5 82 $80 $125 $321 $382 $568 $791 $930 $257 $386 71020 CHEST X-RAY 2 2638 $11 $45 $152 $115 $289 $373 $585 $122 $182 71020 CHEST X-RAY 5 8106 $25 $34 $38 $54 $57 $69 $30 $46 45380 COLONOSCOPY AND BIOPSY 6 1256 $541 $560 $572 $2877 $1000 $2024 $3289 $458 $686 77052 COMP SCREEN MAMMOGRAM ADD-ON 2 194 $13 $15 $25 $38 $47 $134 $20 $30 77052 COMP SCREEN MAMMOGRAM ADD-ON 5 2411 $13 $16 $20 $23 $26 $28 $16 $24 80053 COMPREHEN METABOLIC PANEL 8 13019 $9 $19 $23 $55 $24 $25 $69 $19 $28 71250 CT THORAX WO DYE 2 302 $165 $372 $545 $878 $1658 $2067 $436 $654 71250 CT THORAX WO DYE 5 209 $53 $127 $203 $289 $419 $534 $162 $244 45378 DIAGNOSTIC COLONOSCOPY 6 1479 $484 $515 $536 $2914 $831 $1971 $2828 $428 $643 29881 KNEE ARTHROSCOPYSURGERY 6 152 $1650 $1826 $2036 $5235 $3054 $4216 $6461 $1629 $2443 29888 KNEE ARTHROSCOPYSURGERY 6 82 $1682 $3615 $5081 $5145 $7553 $12924 $18532 $4065 $6097 43644 LAP GASTRIC BYPASSROUX-EN-Y 1 21 $11821 $13873 $17050 $18391 $25029 $31079 $13640 $20460 43775 LAP SLEEVE GASTRECTOMY 1 38 $4215 $8250 $13253 $20421 $19197 $21509 $24260 $10602 $15903 74183 MRI ABDOMEN WO amp WDYE 2 120 $919 $987 $1015 $1237 $1252 $2534 $3177 $812 $1218 74183 MRI ABDOMEN WO amp WDYE 5 112 $475 $490 $521 $1154 $1337 $1696 $417 $625 70553 MRI BRAIN WO amp WDYE 2 324 $633 $987 $1142 $1237 $1706 $2805 $3331 $914 $1370 70553 MRI BRAIN WO amp WDYE 5 467 $280 $539 $1023 $1277 $1363 $1726 $818 $1228 73721 MRI JNT OF LWR EXTRE WO DYE 2 304 $804 $859 $967 $1237 $1063 $1598 $2485 $774 $1160 73721 MRI JNT OF LWR EXTRE WO DYE 5 1130 $500 $520 $530 $628 $679 $859 $424 $636 59400 OBSTETRICAL CARE 1 494 $3699 $4402 $4969 $6655 $7307 $8613 $3975 $5963 99203 OFFICEOUTPATIENT VISIT NEW 4 6776 $88 $101 $112 $138 $155 $169 $90 $134 G0202 Screeningmammographydigital 2 7444 $123 $206 $285 $380 $425 $479 $228 $342 G0202 Screeningmammographydigital 5 2754 $117 $165 $195 $230 $247 $252 $156 $234 88305 TISSUE EXAM BY PATHOLOGIST 8 20834 $51 $74 $112 $235 $168 $261 $478 $90 $134 93306 TTE WDOPPLER COMPLETE 2 931 $194 $377 $739 $960 $1267 $1480 $1849 $591 $887 93306 TTE WDOPPLER COMPLETE 5 2299 $151 $296 $373 $538 $573 $834 $298 $448 43239 UPPER GI ENDOSCOPY BIOPSY 6 1264 $424 $514 $550 $800 $1838 $2833 $440 $660 76700 US EXAM ABDOM COMPLETE 2 321 $96 $165 $271 $509 $584 $857 $217 $325 76700 US EXAM ABDOM COMPLETE 5 444 $111 $129 $147 $156 $220 $279 $118 $176 Key 1 Facility - Inpatient 2 Facility - Imaging 3 Physician - Imaging 4 Physician 5 Global - Imaging 6 Facility - Outpatient 8 Lab 41 Physician - Primary Care 42 Physician - Specialist Cardiovascular stress test $ 38279 TTE wDoppler complete $ 96037 Colonoscopy and biopsy $ 287709 Diagnostic colonoscopy $ 291434 Upper gi endoscopy biopsy $ 300526 Knee Arthroscopy $ 523584 Arthroscopy Ligament Repair $ 514501 Comp Metabolic Panel $ 5552 Surgical Path Tissue Exam $ 23570 MRI Abdomen $ 123786 MRI Brain $ 123786 MRI Joint Lower Extremity $ 123786 CT Thorax wo contrast $ 88213 X-ray Chest $ 11548 Screening mammography $ 14098 Mammo Computer Aided $ 11179 US Abdomen Complete $ 39695 Officeoutpatient visit new pt 30 min $ 24753 Vaginal delivery $ 729025 Lap Sleeve Gastrectomy $ 2042124
Page 25
Case study 2 ndash Large Employer bull Business Problem Large employer wants to contract
directly with 2 major hospital systems developing professional fee schedules
bull ConsiderationsValue Prop Fee schedule should be competitive but also nuanced to minimize gap relative to current reimbursement at physician level
bull Solution Data-driven approach using current market-wide reimbursement distinguished by service level
24
Evaluate Provider Spend Top 25 Service Lines by Allowable Spend
Evaluate Provider Spend Top 20 Professional CPTs by Total Spend
Understand relative market pricing position
27
21
-1
-28
14 10
28
-22
-11 -13
24
3
20 21
8
-20
13
3 9
-39
56
-26
4
-42
60
MRI Colonoscopy Cardiac Cath Lab - OrganPanel
Memorial Hospital Beta Hospital Delta Hospital Charlie Hospital Echo Hospital Alpha Medical Center
ndash25 5 -15 10 0 39
State Charges as a Percent of Peer Average Weighted Averages for MRI Colonoscopy Cardiology and Lab
Total Percent Above Below Market Average2
Memorial Hospital Beta Hospital Delta Hospital Charlie Hospital Echo Hospital Alpha Medical Center
Develop fee schedule relative to market
28
Service Line Procedure CPT CodeDRG
Memorial Hospital
Beta Hosptial
Charlie Hospital
Delta Hospital
Echo Hospital
Alpha Medical Center
Arthroscopy Ligament Repair 29888 $ 5062 $ 9557 $ 5983 $ 10096 $ 7519 $ 2502 Knee Arthroscopy 29881 $ 5069 $ 4185 $ 3837 $ 3022 $ 3729 $ 2266 Upper GI Endoscopy 43239 $ 3075 $ 2539 $ 2012 $ 1132 $ 1565 $ 2240 Lap Sleeve Gastrectomy DRG 621 $ 20421 $ 20815 $ 12105 $ 13230 $ 14600 $ 17800 Colonoscopy and biopsy 45380 $ 3075 $ 3071 $ 2013 $ 1244 $ 1972 $ 859 Diagnostic Colonoscopy 45378 $ 3075 $ 2805 $ 2013 $ 1244 $ 1972 $ 859 MRI Brain w amp wo dye 70553 $ 1238 $ 1468 $ 1117 $ 967 $ 2805 $ 1052 MRI Joint of Lower Extremity wo dye 73721 $ 1238 $ 1398 $ 1042 $ 967 $ 925 $ 557 MRI Abdomen w amp wo dye 74183 $ 1238 $ 1468 $ 1106 $ 967 $ 2805 $ 836 X-ray Chest 71020 $ 115 $ 266 $ 305 $ 279 $ 375 $ 72 CT Thorax wo dye 71250 $ 882 $ 810 $ 505 $ 491 $ 579 $ 319 Ultrasound Abdomen Complete 76700 $ 397 $ 538 $ 545 $ 195 $ 190 $ 168 Mammogram Screening G0202 $ 141 $ 328 $ 431 $ 294 $ 425 $ 168 Computer Detection Add-on 77052 $ 112 $ 99 $ 41 $ 15 $ 45 $ 23 Comp Metabolic Panel 80053 $ 56 $ 15 $ 24 $ 56 $ 51 $ 25 Tissue Exam by Pathologist 88305 $ 236 $ 307 $ 80 $ 152 $ 78 $ 232 Cardiovascular Stress Test 93017 $ 383 $ 432 $ 1299 $ 907 $ 717 $ 797 TTE w Doppler 93306 $ 960 $ 1566 $ 1388 $ 1173 $ 1125 $ 1157
Obstetrics Vaginal Delivery DRG 755 7290$ 5730$ 4654$ 4607$ 5855$ 4688$
GI
Lab
Radiology
Medical Cardiology
Orthopedics
KEY OBSERVA TIONS bull Potential exposure on GI bull Opportunity to align price and acuity in MRI bull Opportunity to raise rates on chest x-ray and mammogram
Percentile Bands Emory Allowables Heatmap TEC ASC Heatmap Allowable Comp Analysis Portal Pricing Sheet1 image1png A few words on Bundled Payments bull Bundled payments are growing as a type of direct contracting bull In some cases third parties match-make between employers
and providers bull Contracts may vary in definitions prepost admission
coverage duration readmission cause (ie all-cause vs medically related) outlier provisions LOS caps andor per diems
bull Providers need to be strategic in pricing to enable profitable growth of market share
29
Considerations in Offering Development bull Network Development
bull Build off existing structure eg health system employee plan network bull How does this fit into your broader value based care strategy bull Employed and independent physicians bull How do you want to approach the buildout of high performance
network bull Quality focus bull Cost efficiency
bull Integrated behavioral health bull Wrap network for other markets
30
Considerations in Offering Development bull Target Market
bull Consideration of employer profile in market bull Fully-insured vs ASO bull Total cost of care vs bundled services
bull Distribution bull Direct marketing bull Brokerconsultant community
bull Plan designs bull Standard designs vs flexible ndash Dependent on target market
bull Claims administration bull Data sharing amp analytics
31
Considerations in Offering Development bull Other components of comprehensive offering
bull Pharmacy bull Preventive health bull Onsite clinics bull Wellness programs bull Technology platform
32
Sample Bundle Analysis
33
Cover page Dotson Hazelrigs Nation Mainly of charge of fixed Cardiovascular stress test TTE wDoppler complete Colonoscopy and biopsy (Combined) Diagnostic colonoscopy (Combined) Upper gi endoscopy biopsy (Combined) Knee Arthroscopy (Combined) Arthroscopy Ligament Repair Comp Metabolic Panel Surgical Path Tissue Exam MRI Abdomen MRI Brain MRI Joint Lower Extremity CT Thorax wo contrast X-ray Chest Screening mammography Mammo Computer Aided US Abdomen Complete Officeoutpatient visit new pt 30 min Vaginal delivery Lap Sleeve Gastrectomy
Piedmont Piedmont Piedmont Piedmont Northside Northside Northside Northside Gwinnett Gwinnett Gwinnett Gwinnett WellStar WellStar WellStar WellStar AMC - Tenet AMC - Tenet AMC - Tenet AMC - Tenet CPT Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing 29881 $11312 $10872 NA NA $7476 $9338 NA $23655 $11856 $3668 NA $17871 $12253 NA NA $15645 $5490 NA NA $23039 29888 NA NA NA NA NA NA NA $23784 NA $8261 NA $18000 NA NA NA $15774 NA NA NA $23168 43239 NA $4408 NA NA NA NA $5997 $8852 NA $3304 NA $7424 $1267 NA NA $9230 NA $2458 NA $8274 43644 $26468 NA NA NA $3382 $12050 NA $1861 NA NA NA $1316 $7841 NA NA $3444 $18892 $27950 NA $979 43775 NA NA NA NA NA NA NA $352 NA NA NA $302 NA NA NA $413 NA NA NA $83 45378 $2705 $2530 NA NA $4381 $3676 $4496 $1022 $2938 $2138 NA $695 $5504 NA NA $2036 NA NA NA $372 45380 $3075 $2600 NA NA $4723 $3527 $3012 $1757 $4215 $2285 NA NA $5298 NA NA $3268 NA NA NA $627 59400 $6160 NA NA NA NA $5100 NA $1851 NA NA NA $1304 $9035 NA NA $3427 $9116 $5150 NA $966 70553 $2985 NA $1153 NA $2182 NA $1192 $492 NA NA $803 $489 $1512 NA $985 $1187 NA NA NA $197 71020 $61 $69 $43 NA $113 $319 $307 NA $183 $59 $32 NA $213 $66 $40 NA $83 $53 NA NA 71250 $1837 $621 $989 NA $1490 $931 $755 NA NA $745 $401 NA $1067 $982 $616 NA NA $304 NA NA 73721 NA $1098 $1153 NA $2042 $1065 $1192 NA NA $998 $803 NA NA $1275 $985 NA NA $644 NA $178 74183 $2971 $1144 NA NA NA $1092 $1192 $6884 NA $1098 $803 NA $2960 $1197 $985 $5454 NA NA NA $7607 76700 $364 $247 $207 NA $427 $708 $614 $13267 $428 $214 $152 NA $747 $263 $189 $9139 NA $235 NA NA 77052 NA NA NA NA NA NA NA $4744 NA NA NA NA NA NA NA $3070 NA NA NA $5611 93306 $1220 $1117 NA NA $1877 $1657 $2100 $4605 $1433 $413 $945 NA $1336 $1434 $1951 $2931 NA $2399 NA $5472 G0202 $262 $187 NA NA $431 NA NA $4605 $292 NA NA NA $530 $281 NA $2931 $327 NA NA $5472
Provider Group 29881_6 29888_6 43239_6 43644_1 43775_1 45378_6 45380_6 59400_1 70553_2 71020_2 71250_2 73721_2 74183_2 76700_2 77052_2 77052_5 80053_8 88305_8 93306_2 99203_4 G0202_2 G0202_5 93017_2 Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Atlanta Gastroenterology Associates $2399 $536 348 $1628 $536 204 $2400 $536 348 Atlanta Medical Center $24889 $2266 999 $25897 $2502 935 $11449 $2240 411 $81927 $15300 435 $75815 $17800 326 $7317 $859 752 $7317 $859 752 $12821 $4688 173 $6581 $1052 526 $645 $72 796 $3265 $319 925 $3450 $557 519 $7398 $836 785 $1576 $133 1084 $73 $23 217 $635 $25 2440 $891 $232 285 $2967 $1157 156 $344 $168 105 $1265 $797 59 Atlanta Womens Health Physicians Group $29 $14 107 $40 $13 208 $396 $188 111 $278 $118 135 $450 $231 95 Gwinnett Hospital $11941 $3022 295 $21654 $10096 114 $3551 $1132 214 $34384 $10800 218 $56472 $13230 327 $3003 $1244 141 $3533 $1244 184 $8984 $4607 95 $3901 $967 303 $417 $279 49 $2247 $491 358 $4000 $967 314 $3755 $967 288 $1593 $195 717 $50 $15 233 $186 $56 233 $505 $152 233 $1750 $1173 49 $418 $294 42 $1396 $907 54 Northside Hospital $15482 $4185 270 $21651 $9557 127 $4885 $2539 92 $35176 $17000 107 $35233 $20815 69 $3883 $2805 38 $5256 $3071 71 $10911 $5730 90 $4856 $1468 231 $443 $266 67 $2379 $810 194 $3776 $1398 170 $5105 $1468 248 $942 $538 75 $167 $99 69 $379 $15 2427 $433 $307 41 $2252 $1566 44 $459 $328 40 $576 $432 33 Piedmont Hospital $14772 $3837 285 $35493 $5983 493 $5069 $2012 152 $38320 $17750 116 $37125 $12105 207 $3485 $2013 73 $4993 $2013 148 $10143 $4654 118 $5939 $1117 432 $542 $305 78 $2983 $505 491 $3410 $1042 227 $6067 $1106 449 $1364 $545 150 $75 $41 85 $231 $24 863 $657 $80 721 $2041 $1388 47 $490 $431 14 $1780 $1299 37 Piedmont Physicians Group $42 $22 87 $318 $179 78 $239 $159 50 Resurgens $8558 $2036 320 $9293 $2258 312 $4638 $2067 124 $4039 $2164 87 $4392 $2164 103 $2252 $1371 64 $459 $330 39 Wellstar Hospital $9330 $3729 150 $17479 $7519 132 $5261 $1565 236 $35794 $18200 97 $46780 $14600 220 $3707 $1972 88 $4928 $1972 150 $13549 $5855 131 $5054 $2805 80 $528 $375 41 $3222 $579 457 $3694 $925 299 $5495 $2805 96 $1355 $190 615 $66 $45 46 $73 $51 43 $133 $78 71 $1785 $1125 59 $599 $425 41 $1010 $717 41 Avg Mark UpProcedure Atlanta Medical Center 634 Gwinnett Hospital 223 Northside Hospital 233 Piedmont Hospital 259 Wellstar Hospital 155 Emory 105
Atlanta Gastroenterology Associates Atlanta Medical Center Atlanta Womens Health Gwinnett Hospital Northside Hospital Piedmont Hospital Piedmont Physicians Group Resurgens Wellstar Hospital CPT Code CPT Proc Cat Comp Avg Allow Allow Allow Allow Allow Allow Allow Allow Allow 29881 KNEE ARTHROSCOPYSURGERY 6 $3179 $2266 $3022 $4185 $3837 $2036 $3729 29888 KNEE ARTHROSCOPYSURGERY 6 $6319 $2502 $10096 $9557 $5983 $2258 $7519 43239 UPPER GI ENDOSCOPY BIOPSY 6 $1727 $536 $2240 $1132 $2539 $2012 $2067 $1565 43644 LAP GASTRIC BYPASSROUX-EN-Y 1 $15810 $15300 $10800 $17000 $17750 $18200 43775 LAP SLEEVE GASTRECTOMY 1 $17800 $13230 $20815 $12105 $14600 45378 DIAGNOSTIC COLONOSCOPY 6 $1656 $536 $859 $1244 $2805 $2013 $2164 $1972 45380 COLONOSCOPY AND BIOPSY 6 $1694 $536 $859 $1244 $3071 $2013 $2164 $1972 59400 OBSTETRICAL CARE 1 $5107 $4688 $4607 $5730 $4654 $5855 70553 MRI BRAIN WO amp WDYE 2 $1482 $1052 $967 $1468 $1117 $2805 71020 CHEST X-RAY 2 $259 $72 $279 $266 $305 $375 71250 CT THORAX WO DYE 2 $541 $319 $491 $810 $505 $579 73721 MRI JNT OF LWR EXTRE WO DYE 2 $978 $557 $967 $1398 $1042 $925 74183 MRI ABDOMEN WO amp WDYE 2 $1436 $836 $967 $1468 $1106 $2805 76700 US EXAM ABDOM COMPLETE 2 $320 $133 $195 $538 $545 $190 77052 COMP SCREEN MAMMOGRAM ADD-ON 2 $45 $23 $15 $99 $41 $45 77052 COMP SCREEN MAMMOGRAM ADD-ON 5 $14 $14 80053 COMPREHEN METABOLIC PANEL 8 $29 $25 $13 $56 $15 $24 $22 $51 88305 TISSUE EXAM BY PATHOLOGIST 8 $174 $232 $188 $152 $307 $80 $179 $78 93306 TTE WDOPPLER COMPLETE 2 $1297 $1157 $1173 $1566 $1388 $1371 $1125 93017 STRESS TEST 5 $830 $797 $907 $432 $1299 $717 99203 OFFICEOUTPATIENT VISIT NEW 4 $139 $118 $159 G0202 Screeningmammographydigital 2 $329 $168 $294 $328 $431 $330 $425 G0202 Screeningmammographydigital 5 $231 $231
Service Line Procedure CPT Code Emory Atlanta Gastroenterology Associates Resurgens Atlanta Womens Health Piedmont Physicians Group Orthopedics (ASC) Knee Arthroscopy 29881 $3467 $2036 Arthroscopy Ligament Repair 29888 $3386 $2258 GI (ASC) Upper GI Endoscopy 43239 $2758 $536 Diagnostic Colonoscopy 45378 $2348 $536 Colonoscopy and biopsy 45380 $2181 $536 Radiology Mammogram Screening G0202 $164 $231 Computer Detection Add-on 77052 $93 $14 Lab Comp Metabolic Panel 80053 $53 $13 $22 Tissue Exam by Pathologist 88305 $277 $188 $179 EampM (TEC) Office Visit new pt 99203 $269 $118 $159
Service Line Procedure CPT CodeDRG Memorial Hospital Beta Hosptial Charlie Hospital Delta Hospital Echo Hospital Alpha Medical Center Atlanta Gastroenterology Associates Resurgens Atlanta Womens Health Piedmont Physicians Group Market Avg Emory abovebelow Orthopedics Arthroscopy Ligament Repair 29888 $ 5062 $ 9557 $ 5983 $ 10096 $ 7519 $ 2502 $ 2258 $ 6319 -20 Knee Arthroscopy 29881 6 $ 5069 $ 4185 $ 3837 $ 3022 $ 3729 $ 2266 $ 2036 $ 3179 59 GI Upper GI Endoscopy 43239 6 $ 3075 $ 2539 $ 2012 $ 1132 $ 1565 $ 2240 $ 536 $ 1671 84 Lap Sleeve Gastrectomy DRG 621 $ 20421 $ 20815 $ 12105 $ 13230 $ 14600 $ 17800 $ 15710 30 Colonoscopy and biopsy 45380 $ 3075 $ 3071 $ 2013 $ 1244 $ 1972 $ 859 $ 536 $ 1616 90 Diagnostic Colonoscopy 45378 6 $ 3075 $ 2805 $ 2013 $ 1244 $ 1972 $ 859 $ 536 $ 1572 96 Radiology MRI Brain w amp wo dye 70553 2 $ 1238 $ 1468 $ 1117 $ 967 $ 2805 $ 1052 $ 1482 -16 MRI Joint of Lower Extremity wo dye 73721 2 $ 1238 $ 1398 $ 1042 $ 967 $ 925 $ 557 $ 978 27 MRI Abdomen w amp wo dye 74183 2 $ 1238 $ 1468 $ 1106 $ 967 $ 2805 $ 836 $ 1436 -14 X-ray Chest 71020 $ 115 $ 266 $ 305 $ 279 $ 375 $ 72 $ 259 -56 CT Thorax wo dye 71250 $ 882 $ 810 $ 505 $ 491 $ 579 $ 319 $ 541 63 Ultrasound Abdomen Complete 76700 $ 397 $ 538 $ 545 $ 195 $ 190 $ 168 $ 327 21 Mammogram Screening G0202 2 $ 141 $ 328 $ 431 $ 294 $ 425 $ 168 $ 231 $ 313 -55 Computer Detection Add-on 77052 2 $ 112 $ 99 $ 41 $ 15 $ 45 $ 23 $ 14 $ 39 183 Lab Comp Metabolic Panel 80053 8 $ 56 $ 15 $ 24 $ 56 $ 51 $ 25 $ 13 $ 22 $ 29 88 Tissue Exam by Pathologist 88305 8 $ 236 $ 307 $ 80 $ 152 $ 78 $ 232 $ 188 $ 179 $ 174 36 Medical Cardiology Cardiovascular Stress Test 93017 $ 383 $ 432 $ 1299 $ 907 $ 717 $ 797 $ 830 -54 TTE w Doppler 93306 2 $ 960 $ 1566 $ 1388 $ 1173 $ 1125 $ 1157 $ 1282 -25 Obstetrics Vaginal Delivery DRG 755 $ 7290 $ 5730 $ 4654 $ 4607 $ 5855 $ 4688 $ 5107 43 EampM Office Visit new pt 99203 4 $ 248 $ 118 $ 159 $ 139 78 Colonoscopy and biopsy (HOSPITAL ONLY) 45380 Surg 2530 $ 307591 Diagnostic colonoscopy (HOSPITAL ONLY) 45378 Surg 2255 $ 307591 Upper gi endoscopy biopsy (HOSPITAL ONLY) 43239 Surg 1787 $ 307591 Knee Arthroscopy (HOSPITAL ONLY) 29881 Surg 10900 $ 506893 Arthroscopy Ligament Repair (HOSPITAL ONLY) 29888 Surg 10900 $ 506200 Key 1 Facility - Inpatient 2 Facility - Imaging 3 Physician - Imaging 4 Physician 5 Global - Imaging 6 Facility - Outpatient 8 Lab 41 Physician - Primary Care 42 Physician - Specialist
Blue Cross United - EJCH EUH EUHM WW United - SJH Non Options United - SJH Options Aetna - ASC TEC (HMO) Cigna - ASC TEC (HMO) Aetna - EJCH ESJH ECHM WW Cigna - EJCH (HMO) Cigna - ESJH EUHM (HMO) List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract Description CPT Code Charge Average Final Price (all plans) Emory Mark Up Reimbursement Method ( of charge or fixed) - 1713 Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Cardiovascular stress test 93017 Cardio $543 $ 425 28 of Charge 70 $ 380 of Charge 65 $ 353 of Charge 60 $ 326 of Charge 70 $ 380 of Charge 70 $ 380 of charge 100 $ 543 of Charge 70 $ 380 of charge 100 $ 543 of charge 100 $ 543 TTE wDoppler complete 93306 Cardio $1226 $ 960 28 of Charge 70 $ 858 of Charge 65 $ 797 of Charge 60 $ 736 of Charge 70 $ 858 of Charge 70 $ 858 of charge 100 $ 1226 of Charge 70 $ 858 of charge 100 $ 1226 of charge 100 $ 1226 Colonoscopy and biopsy (HOSPITAL ONLY) 45380 Surg $2530 $ 3076 -18 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 of Charge 70 $ 1771 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Diagnostic colonoscopy (HOSPITAL ONLY) 45378 Surg $2255 $ 3076 -27 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 of Charge 70 $ 1579 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Upper gi endoscopy biopsy (HOSPITAL ONLY) 43239 Surg $1787 $ 3076 -42 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Knee Arthroscopy (HOSPITAL ONLY) 29881 Surg $10900 $ 5069 115 Fixed Rate SC 4 $ 3865 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 449300 $ 4493 Fixed Rate $ 654700 $ 6547 of Charge 70 $ 7630 Fixed Rate $ 401000 $ 4010 of Charge 70 $ 7630 Fixed Rate $ 398300 $ 3983 Fixed Rate $ 398100 $ 3981 Arthroscopy Ligament Repair (HOSPITAL ONLY) 29888 Surg $10900 $ 5062 115 Fixed Rate SC 3 $ 3121 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 556900 $ 5569 Fixed Rate $ 770100 $ 7701 of Charge 70 $ 7630 Fixed Rate $ 323900 $ 3239 of Charge 70 $ 7630 Fixed Rate $ 321700 $ 3217 Fixed Rate $ 321400 $ 3214 Comp Metabolic Panel 80053 Lab $132 $ 56 138 RBRVS Fee (100) $ 1437 of Charge 65 $ 86 of Charge 65 $ 86 of Charge 65 $ 86 of Charge 70 $ 92 RBRVS Fee (100) $ 1437 $ 14 of Charge 70 $ 92 RBRVS Fee (100) $ 1437 $ 14 RBRVS Fee (100) $ 1437 $ 14 Surgical Path Tissue Exam 88305 Lab $326 $ 236 38 of Charge 150 $ 51 of Charge 65 $ 212 of Charge 65 $ 212 of Charge 65 $ 212 of Charge 70 $ 228 of charge 100 $ 326 of Charge 70 $ 228 of charge 100 $ 326 of charge 100 $ 326 MRI Abdomen 74183 Radiology $6960 $ 1238 462 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 MRI Brain 70553 Radiology $6804 $ 1238 450 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 MRI Joint Lower Extremity 73721 Radiology $3067 $ 1238 148 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 CT Thorax wo contrast 71250 Radiology $2199 $ 882 149 Fixed Rate $ 771 Fixed Rate $ 47100 $ 471 Fixed Rate $ 81700 $ 817 Fixed Rate $ 116000 $ 1160 of Charge 70 $ 1539 Fixed Rate $ 80100 $ 801 Fixed Rate $ 79200 $ 792 Fixed Rate $ 79300 $ 793 Fixed Rate $ 79500 $ 795 X-ray Chest 71020 Radiology $280 $ 115 142 of Charge 150 $ 25 of Charge 65 $ 182 of Charge 60 $ 168 of Charge 70 $ 196 of Charge 70 $ 196 RBRVS Fee (150) $ 2534 $ 25 of Charge 70 $ 196 RBRVS Fee (150) $ 2534 $ 25 RBRVS Fee (150) $ 2534 $ 25 Screening mammography G0202 Radiology $279 $ 141 98 Fixed Rate $ 128 Fixed Rate $ 13100 $ 131 Fixed Rate $ 14300 $ 143 Fixed Rate $ 16100 $ 161 of Charge 70 $ 195 Fixed Rate $ 13300 $ 133 Fixed Rate $ 13500 $ 135 Fixed Rate $ 13000 $ 130 Fixed Rate $ 11200 $ 112 Mammo Computer Aided 77052 Radiology $75 $ 112 -33 Fixed Rate $ 9 Fixed Rate $ 13100 $ 131 Fixed Rate $ 14300 $ 143 Fixed Rate $ 16100 $ 161 of Charge 70 $ 53 Fixed Rate $ 13300 $ 133 Fixed Rate $ 13500 $ 135 Fixed Rate $ 13000 $ 130 Fixed Rate $ 11200 $ 112 US Abdomen Complete 76700 Radiology $917 $ 397 131 of Charge 150 $ 125 of Charge 65 $ 596 of Charge 60 $ 550 of Charge 70 $ 642 of Charge 70 $ 642 RBRVS Fee (150) $ 12519 $ 125 of Charge 70 $ 642 RBRVS Fee (150) $ 12519 $ 125 RBRVS Fee (150) $ 12519 $ 125 Officeoutpatient visit new pt 30 min (TEC) 99203 EampM $316 $ 248 28 of Charge 70 $ 221 of Charge 65 $ 205 of Charge 60 $ 190 of Charge 70 $ 221 of Charge 70 $ 221 of charge 100 $ 316 of Charge 70 $ 221 of charge 100 $ 316 of charge 100 $ 316 Vaginal delivery 59409 Surg $14484 $ 7290 99 Fixed Rate DRG - 775 $ 5437 2 Day Case Rate + LOC 561700 $ 5617 BaseCMS Weight 584741 $ 5847 BaseCMS Weight 726146 $ 7261 No IP Terms $ - 0 No IP BaseCMS Weight 659343 $ 6593 BaseContract Weight 479451 100 $ 14484 BaseCMS Weight 579110 $ 5791 Lap Sleeve Gastrectomy 43775 Surg $29961 $ 20421 47 Fixed Rate DRG - 621 $ 14872 BaseCMS Weight 1810697 $ 18107 BaseCMS Weight 1835178 $ 18352 BaseCMS Weight 2278911 $ 22789 No IP Terms $ - 0 No IP BaseCMS Weight 2069315 $ 20693 BaseCMS Weight 1730442 100 $ 29961 BaseCMS Weight 1817507 $ 18175 105 Colonoscopy and biopsy (ASC ONLY) Surg $ 219200 $ 2181 Diagnostic colonoscopy (ASC ONLY) Surg $ 267100 $ 2348 Upper gi endoscopy biopsy (ASC ONLY) Surg $ 207500 $ 2758 Knee Arthroscopy (ASC ONLY) Surg $ 417900 $ 3467 Arthroscopy Ligament Repair (ASC ONLY) Surg $ 504800 $ 3386
Cpt Code CPT Description Procedure Category Claims Min 25thNtile 50thNtile Emorys Rates 75thNtile 90thNtile Max 20 Below 50th Ntile 20 Above 50th Ntile 93017 CARDIOVASCULAR STRESS TEST 5 82 $80 $125 $321 $382 $568 $791 $930 $257 $386 71020 CHEST X-RAY 2 2638 $11 $45 $152 $115 $289 $373 $585 $122 $182 71020 CHEST X-RAY 5 8106 $25 $34 $38 $54 $57 $69 $30 $46 45380 COLONOSCOPY AND BIOPSY 6 1256 $541 $560 $572 $2877 $1000 $2024 $3289 $458 $686 77052 COMP SCREEN MAMMOGRAM ADD-ON 2 194 $13 $15 $25 $38 $47 $134 $20 $30 77052 COMP SCREEN MAMMOGRAM ADD-ON 5 2411 $13 $16 $20 $23 $26 $28 $16 $24 80053 COMPREHEN METABOLIC PANEL 8 13019 $9 $19 $23 $55 $24 $25 $69 $19 $28 71250 CT THORAX WO DYE 2 302 $165 $372 $545 $878 $1658 $2067 $436 $654 71250 CT THORAX WO DYE 5 209 $53 $127 $203 $289 $419 $534 $162 $244 45378 DIAGNOSTIC COLONOSCOPY 6 1479 $484 $515 $536 $2914 $831 $1971 $2828 $428 $643 29881 KNEE ARTHROSCOPYSURGERY 6 152 $1650 $1826 $2036 $5235 $3054 $4216 $6461 $1629 $2443 29888 KNEE ARTHROSCOPYSURGERY 6 82 $1682 $3615 $5081 $5145 $7553 $12924 $18532 $4065 $6097 43644 LAP GASTRIC BYPASSROUX-EN-Y 1 21 $11821 $13873 $17050 $18391 $25029 $31079 $13640 $20460 43775 LAP SLEEVE GASTRECTOMY 1 38 $4215 $8250 $13253 $20421 $19197 $21509 $24260 $10602 $15903 74183 MRI ABDOMEN WO amp WDYE 2 120 $919 $987 $1015 $1237 $1252 $2534 $3177 $812 $1218 74183 MRI ABDOMEN WO amp WDYE 5 112 $475 $490 $521 $1154 $1337 $1696 $417 $625 70553 MRI BRAIN WO amp WDYE 2 324 $633 $987 $1142 $1237 $1706 $2805 $3331 $914 $1370 70553 MRI BRAIN WO amp WDYE 5 467 $280 $539 $1023 $1277 $1363 $1726 $818 $1228 73721 MRI JNT OF LWR EXTRE WO DYE 2 304 $804 $859 $967 $1237 $1063 $1598 $2485 $774 $1160 73721 MRI JNT OF LWR EXTRE WO DYE 5 1130 $500 $520 $530 $628 $679 $859 $424 $636 59400 OBSTETRICAL CARE 1 494 $3699 $4402 $4969 $6655 $7307 $8613 $3975 $5963 99203 OFFICEOUTPATIENT VISIT NEW 4 6776 $88 $101 $112 $138 $155 $169 $90 $134 G0202 Screeningmammographydigital 2 7444 $123 $206 $285 $380 $425 $479 $228 $342 G0202 Screeningmammographydigital 5 2754 $117 $165 $195 $230 $247 $252 $156 $234 88305 TISSUE EXAM BY PATHOLOGIST 8 20834 $51 $74 $112 $235 $168 $261 $478 $90 $134 93306 TTE WDOPPLER COMPLETE 2 931 $194 $377 $739 $960 $1267 $1480 $1849 $591 $887 93306 TTE WDOPPLER COMPLETE 5 2299 $151 $296 $373 $538 $573 $834 $298 $448 43239 UPPER GI ENDOSCOPY BIOPSY 6 1264 $424 $514 $550 $800 $1838 $2833 $440 $660 76700 US EXAM ABDOM COMPLETE 2 321 $96 $165 $271 $509 $584 $857 $217 $325 76700 US EXAM ABDOM COMPLETE 5 444 $111 $129 $147 $156 $220 $279 $118 $176 Key 1 Facility - Inpatient 2 Facility - Imaging 3 Physician - Imaging 4 Physician 5 Global - Imaging 6 Facility - Outpatient 8 Lab 41 Physician - Primary Care 42 Physician - Specialist Cardiovascular stress test $ 38279 TTE wDoppler complete $ 96037 Colonoscopy and biopsy $ 287709 Diagnostic colonoscopy $ 291434 Upper gi endoscopy biopsy $ 300526 Knee Arthroscopy $ 523584 Arthroscopy Ligament Repair $ 514501 Comp Metabolic Panel $ 5552 Surgical Path Tissue Exam $ 23570 MRI Abdomen $ 123786 MRI Brain $ 123786 MRI Joint Lower Extremity $ 123786 CT Thorax wo contrast $ 88213 X-ray Chest $ 11548 Screening mammography $ 14098 Mammo Computer Aided $ 11179 US Abdomen Complete $ 39695 Officeoutpatient visit new pt 30 min $ 24753 Vaginal delivery $ 729025 Lap Sleeve Gastrectomy $ 2042124
Page 26
Evaluate Provider Spend Top 25 Service Lines by Allowable Spend
Evaluate Provider Spend Top 20 Professional CPTs by Total Spend
Understand relative market pricing position
27
21
-1
-28
14 10
28
-22
-11 -13
24
3
20 21
8
-20
13
3 9
-39
56
-26
4
-42
60
MRI Colonoscopy Cardiac Cath Lab - OrganPanel
Memorial Hospital Beta Hospital Delta Hospital Charlie Hospital Echo Hospital Alpha Medical Center
ndash25 5 -15 10 0 39
State Charges as a Percent of Peer Average Weighted Averages for MRI Colonoscopy Cardiology and Lab
Total Percent Above Below Market Average2
Memorial Hospital Beta Hospital Delta Hospital Charlie Hospital Echo Hospital Alpha Medical Center
Develop fee schedule relative to market
28
Service Line Procedure CPT CodeDRG
Memorial Hospital
Beta Hosptial
Charlie Hospital
Delta Hospital
Echo Hospital
Alpha Medical Center
Arthroscopy Ligament Repair 29888 $ 5062 $ 9557 $ 5983 $ 10096 $ 7519 $ 2502 Knee Arthroscopy 29881 $ 5069 $ 4185 $ 3837 $ 3022 $ 3729 $ 2266 Upper GI Endoscopy 43239 $ 3075 $ 2539 $ 2012 $ 1132 $ 1565 $ 2240 Lap Sleeve Gastrectomy DRG 621 $ 20421 $ 20815 $ 12105 $ 13230 $ 14600 $ 17800 Colonoscopy and biopsy 45380 $ 3075 $ 3071 $ 2013 $ 1244 $ 1972 $ 859 Diagnostic Colonoscopy 45378 $ 3075 $ 2805 $ 2013 $ 1244 $ 1972 $ 859 MRI Brain w amp wo dye 70553 $ 1238 $ 1468 $ 1117 $ 967 $ 2805 $ 1052 MRI Joint of Lower Extremity wo dye 73721 $ 1238 $ 1398 $ 1042 $ 967 $ 925 $ 557 MRI Abdomen w amp wo dye 74183 $ 1238 $ 1468 $ 1106 $ 967 $ 2805 $ 836 X-ray Chest 71020 $ 115 $ 266 $ 305 $ 279 $ 375 $ 72 CT Thorax wo dye 71250 $ 882 $ 810 $ 505 $ 491 $ 579 $ 319 Ultrasound Abdomen Complete 76700 $ 397 $ 538 $ 545 $ 195 $ 190 $ 168 Mammogram Screening G0202 $ 141 $ 328 $ 431 $ 294 $ 425 $ 168 Computer Detection Add-on 77052 $ 112 $ 99 $ 41 $ 15 $ 45 $ 23 Comp Metabolic Panel 80053 $ 56 $ 15 $ 24 $ 56 $ 51 $ 25 Tissue Exam by Pathologist 88305 $ 236 $ 307 $ 80 $ 152 $ 78 $ 232 Cardiovascular Stress Test 93017 $ 383 $ 432 $ 1299 $ 907 $ 717 $ 797 TTE w Doppler 93306 $ 960 $ 1566 $ 1388 $ 1173 $ 1125 $ 1157
Obstetrics Vaginal Delivery DRG 755 7290$ 5730$ 4654$ 4607$ 5855$ 4688$
GI
Lab
Radiology
Medical Cardiology
Orthopedics
KEY OBSERVA TIONS bull Potential exposure on GI bull Opportunity to align price and acuity in MRI bull Opportunity to raise rates on chest x-ray and mammogram
Percentile Bands Emory Allowables Heatmap TEC ASC Heatmap Allowable Comp Analysis Portal Pricing Sheet1 image1png A few words on Bundled Payments bull Bundled payments are growing as a type of direct contracting bull In some cases third parties match-make between employers
and providers bull Contracts may vary in definitions prepost admission
coverage duration readmission cause (ie all-cause vs medically related) outlier provisions LOS caps andor per diems
bull Providers need to be strategic in pricing to enable profitable growth of market share
29
Considerations in Offering Development bull Network Development
bull Build off existing structure eg health system employee plan network bull How does this fit into your broader value based care strategy bull Employed and independent physicians bull How do you want to approach the buildout of high performance
network bull Quality focus bull Cost efficiency
bull Integrated behavioral health bull Wrap network for other markets
30
Considerations in Offering Development bull Target Market
bull Consideration of employer profile in market bull Fully-insured vs ASO bull Total cost of care vs bundled services
bull Distribution bull Direct marketing bull Brokerconsultant community
bull Plan designs bull Standard designs vs flexible ndash Dependent on target market
bull Claims administration bull Data sharing amp analytics
31
Considerations in Offering Development bull Other components of comprehensive offering
bull Pharmacy bull Preventive health bull Onsite clinics bull Wellness programs bull Technology platform
32
Sample Bundle Analysis
33
Cover page Dotson Hazelrigs Nation Mainly of charge of fixed Cardiovascular stress test TTE wDoppler complete Colonoscopy and biopsy (Combined) Diagnostic colonoscopy (Combined) Upper gi endoscopy biopsy (Combined) Knee Arthroscopy (Combined) Arthroscopy Ligament Repair Comp Metabolic Panel Surgical Path Tissue Exam MRI Abdomen MRI Brain MRI Joint Lower Extremity CT Thorax wo contrast X-ray Chest Screening mammography Mammo Computer Aided US Abdomen Complete Officeoutpatient visit new pt 30 min Vaginal delivery Lap Sleeve Gastrectomy
Piedmont Piedmont Piedmont Piedmont Northside Northside Northside Northside Gwinnett Gwinnett Gwinnett Gwinnett WellStar WellStar WellStar WellStar AMC - Tenet AMC - Tenet AMC - Tenet AMC - Tenet CPT Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing 29881 $11312 $10872 NA NA $7476 $9338 NA $23655 $11856 $3668 NA $17871 $12253 NA NA $15645 $5490 NA NA $23039 29888 NA NA NA NA NA NA NA $23784 NA $8261 NA $18000 NA NA NA $15774 NA NA NA $23168 43239 NA $4408 NA NA NA NA $5997 $8852 NA $3304 NA $7424 $1267 NA NA $9230 NA $2458 NA $8274 43644 $26468 NA NA NA $3382 $12050 NA $1861 NA NA NA $1316 $7841 NA NA $3444 $18892 $27950 NA $979 43775 NA NA NA NA NA NA NA $352 NA NA NA $302 NA NA NA $413 NA NA NA $83 45378 $2705 $2530 NA NA $4381 $3676 $4496 $1022 $2938 $2138 NA $695 $5504 NA NA $2036 NA NA NA $372 45380 $3075 $2600 NA NA $4723 $3527 $3012 $1757 $4215 $2285 NA NA $5298 NA NA $3268 NA NA NA $627 59400 $6160 NA NA NA NA $5100 NA $1851 NA NA NA $1304 $9035 NA NA $3427 $9116 $5150 NA $966 70553 $2985 NA $1153 NA $2182 NA $1192 $492 NA NA $803 $489 $1512 NA $985 $1187 NA NA NA $197 71020 $61 $69 $43 NA $113 $319 $307 NA $183 $59 $32 NA $213 $66 $40 NA $83 $53 NA NA 71250 $1837 $621 $989 NA $1490 $931 $755 NA NA $745 $401 NA $1067 $982 $616 NA NA $304 NA NA 73721 NA $1098 $1153 NA $2042 $1065 $1192 NA NA $998 $803 NA NA $1275 $985 NA NA $644 NA $178 74183 $2971 $1144 NA NA NA $1092 $1192 $6884 NA $1098 $803 NA $2960 $1197 $985 $5454 NA NA NA $7607 76700 $364 $247 $207 NA $427 $708 $614 $13267 $428 $214 $152 NA $747 $263 $189 $9139 NA $235 NA NA 77052 NA NA NA NA NA NA NA $4744 NA NA NA NA NA NA NA $3070 NA NA NA $5611 93306 $1220 $1117 NA NA $1877 $1657 $2100 $4605 $1433 $413 $945 NA $1336 $1434 $1951 $2931 NA $2399 NA $5472 G0202 $262 $187 NA NA $431 NA NA $4605 $292 NA NA NA $530 $281 NA $2931 $327 NA NA $5472
Provider Group 29881_6 29888_6 43239_6 43644_1 43775_1 45378_6 45380_6 59400_1 70553_2 71020_2 71250_2 73721_2 74183_2 76700_2 77052_2 77052_5 80053_8 88305_8 93306_2 99203_4 G0202_2 G0202_5 93017_2 Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Atlanta Gastroenterology Associates $2399 $536 348 $1628 $536 204 $2400 $536 348 Atlanta Medical Center $24889 $2266 999 $25897 $2502 935 $11449 $2240 411 $81927 $15300 435 $75815 $17800 326 $7317 $859 752 $7317 $859 752 $12821 $4688 173 $6581 $1052 526 $645 $72 796 $3265 $319 925 $3450 $557 519 $7398 $836 785 $1576 $133 1084 $73 $23 217 $635 $25 2440 $891 $232 285 $2967 $1157 156 $344 $168 105 $1265 $797 59 Atlanta Womens Health Physicians Group $29 $14 107 $40 $13 208 $396 $188 111 $278 $118 135 $450 $231 95 Gwinnett Hospital $11941 $3022 295 $21654 $10096 114 $3551 $1132 214 $34384 $10800 218 $56472 $13230 327 $3003 $1244 141 $3533 $1244 184 $8984 $4607 95 $3901 $967 303 $417 $279 49 $2247 $491 358 $4000 $967 314 $3755 $967 288 $1593 $195 717 $50 $15 233 $186 $56 233 $505 $152 233 $1750 $1173 49 $418 $294 42 $1396 $907 54 Northside Hospital $15482 $4185 270 $21651 $9557 127 $4885 $2539 92 $35176 $17000 107 $35233 $20815 69 $3883 $2805 38 $5256 $3071 71 $10911 $5730 90 $4856 $1468 231 $443 $266 67 $2379 $810 194 $3776 $1398 170 $5105 $1468 248 $942 $538 75 $167 $99 69 $379 $15 2427 $433 $307 41 $2252 $1566 44 $459 $328 40 $576 $432 33 Piedmont Hospital $14772 $3837 285 $35493 $5983 493 $5069 $2012 152 $38320 $17750 116 $37125 $12105 207 $3485 $2013 73 $4993 $2013 148 $10143 $4654 118 $5939 $1117 432 $542 $305 78 $2983 $505 491 $3410 $1042 227 $6067 $1106 449 $1364 $545 150 $75 $41 85 $231 $24 863 $657 $80 721 $2041 $1388 47 $490 $431 14 $1780 $1299 37 Piedmont Physicians Group $42 $22 87 $318 $179 78 $239 $159 50 Resurgens $8558 $2036 320 $9293 $2258 312 $4638 $2067 124 $4039 $2164 87 $4392 $2164 103 $2252 $1371 64 $459 $330 39 Wellstar Hospital $9330 $3729 150 $17479 $7519 132 $5261 $1565 236 $35794 $18200 97 $46780 $14600 220 $3707 $1972 88 $4928 $1972 150 $13549 $5855 131 $5054 $2805 80 $528 $375 41 $3222 $579 457 $3694 $925 299 $5495 $2805 96 $1355 $190 615 $66 $45 46 $73 $51 43 $133 $78 71 $1785 $1125 59 $599 $425 41 $1010 $717 41 Avg Mark UpProcedure Atlanta Medical Center 634 Gwinnett Hospital 223 Northside Hospital 233 Piedmont Hospital 259 Wellstar Hospital 155 Emory 105
Atlanta Gastroenterology Associates Atlanta Medical Center Atlanta Womens Health Gwinnett Hospital Northside Hospital Piedmont Hospital Piedmont Physicians Group Resurgens Wellstar Hospital CPT Code CPT Proc Cat Comp Avg Allow Allow Allow Allow Allow Allow Allow Allow Allow 29881 KNEE ARTHROSCOPYSURGERY 6 $3179 $2266 $3022 $4185 $3837 $2036 $3729 29888 KNEE ARTHROSCOPYSURGERY 6 $6319 $2502 $10096 $9557 $5983 $2258 $7519 43239 UPPER GI ENDOSCOPY BIOPSY 6 $1727 $536 $2240 $1132 $2539 $2012 $2067 $1565 43644 LAP GASTRIC BYPASSROUX-EN-Y 1 $15810 $15300 $10800 $17000 $17750 $18200 43775 LAP SLEEVE GASTRECTOMY 1 $17800 $13230 $20815 $12105 $14600 45378 DIAGNOSTIC COLONOSCOPY 6 $1656 $536 $859 $1244 $2805 $2013 $2164 $1972 45380 COLONOSCOPY AND BIOPSY 6 $1694 $536 $859 $1244 $3071 $2013 $2164 $1972 59400 OBSTETRICAL CARE 1 $5107 $4688 $4607 $5730 $4654 $5855 70553 MRI BRAIN WO amp WDYE 2 $1482 $1052 $967 $1468 $1117 $2805 71020 CHEST X-RAY 2 $259 $72 $279 $266 $305 $375 71250 CT THORAX WO DYE 2 $541 $319 $491 $810 $505 $579 73721 MRI JNT OF LWR EXTRE WO DYE 2 $978 $557 $967 $1398 $1042 $925 74183 MRI ABDOMEN WO amp WDYE 2 $1436 $836 $967 $1468 $1106 $2805 76700 US EXAM ABDOM COMPLETE 2 $320 $133 $195 $538 $545 $190 77052 COMP SCREEN MAMMOGRAM ADD-ON 2 $45 $23 $15 $99 $41 $45 77052 COMP SCREEN MAMMOGRAM ADD-ON 5 $14 $14 80053 COMPREHEN METABOLIC PANEL 8 $29 $25 $13 $56 $15 $24 $22 $51 88305 TISSUE EXAM BY PATHOLOGIST 8 $174 $232 $188 $152 $307 $80 $179 $78 93306 TTE WDOPPLER COMPLETE 2 $1297 $1157 $1173 $1566 $1388 $1371 $1125 93017 STRESS TEST 5 $830 $797 $907 $432 $1299 $717 99203 OFFICEOUTPATIENT VISIT NEW 4 $139 $118 $159 G0202 Screeningmammographydigital 2 $329 $168 $294 $328 $431 $330 $425 G0202 Screeningmammographydigital 5 $231 $231
Service Line Procedure CPT Code Emory Atlanta Gastroenterology Associates Resurgens Atlanta Womens Health Piedmont Physicians Group Orthopedics (ASC) Knee Arthroscopy 29881 $3467 $2036 Arthroscopy Ligament Repair 29888 $3386 $2258 GI (ASC) Upper GI Endoscopy 43239 $2758 $536 Diagnostic Colonoscopy 45378 $2348 $536 Colonoscopy and biopsy 45380 $2181 $536 Radiology Mammogram Screening G0202 $164 $231 Computer Detection Add-on 77052 $93 $14 Lab Comp Metabolic Panel 80053 $53 $13 $22 Tissue Exam by Pathologist 88305 $277 $188 $179 EampM (TEC) Office Visit new pt 99203 $269 $118 $159
Service Line Procedure CPT CodeDRG Memorial Hospital Beta Hosptial Charlie Hospital Delta Hospital Echo Hospital Alpha Medical Center Atlanta Gastroenterology Associates Resurgens Atlanta Womens Health Piedmont Physicians Group Market Avg Emory abovebelow Orthopedics Arthroscopy Ligament Repair 29888 $ 5062 $ 9557 $ 5983 $ 10096 $ 7519 $ 2502 $ 2258 $ 6319 -20 Knee Arthroscopy 29881 6 $ 5069 $ 4185 $ 3837 $ 3022 $ 3729 $ 2266 $ 2036 $ 3179 59 GI Upper GI Endoscopy 43239 6 $ 3075 $ 2539 $ 2012 $ 1132 $ 1565 $ 2240 $ 536 $ 1671 84 Lap Sleeve Gastrectomy DRG 621 $ 20421 $ 20815 $ 12105 $ 13230 $ 14600 $ 17800 $ 15710 30 Colonoscopy and biopsy 45380 $ 3075 $ 3071 $ 2013 $ 1244 $ 1972 $ 859 $ 536 $ 1616 90 Diagnostic Colonoscopy 45378 6 $ 3075 $ 2805 $ 2013 $ 1244 $ 1972 $ 859 $ 536 $ 1572 96 Radiology MRI Brain w amp wo dye 70553 2 $ 1238 $ 1468 $ 1117 $ 967 $ 2805 $ 1052 $ 1482 -16 MRI Joint of Lower Extremity wo dye 73721 2 $ 1238 $ 1398 $ 1042 $ 967 $ 925 $ 557 $ 978 27 MRI Abdomen w amp wo dye 74183 2 $ 1238 $ 1468 $ 1106 $ 967 $ 2805 $ 836 $ 1436 -14 X-ray Chest 71020 $ 115 $ 266 $ 305 $ 279 $ 375 $ 72 $ 259 -56 CT Thorax wo dye 71250 $ 882 $ 810 $ 505 $ 491 $ 579 $ 319 $ 541 63 Ultrasound Abdomen Complete 76700 $ 397 $ 538 $ 545 $ 195 $ 190 $ 168 $ 327 21 Mammogram Screening G0202 2 $ 141 $ 328 $ 431 $ 294 $ 425 $ 168 $ 231 $ 313 -55 Computer Detection Add-on 77052 2 $ 112 $ 99 $ 41 $ 15 $ 45 $ 23 $ 14 $ 39 183 Lab Comp Metabolic Panel 80053 8 $ 56 $ 15 $ 24 $ 56 $ 51 $ 25 $ 13 $ 22 $ 29 88 Tissue Exam by Pathologist 88305 8 $ 236 $ 307 $ 80 $ 152 $ 78 $ 232 $ 188 $ 179 $ 174 36 Medical Cardiology Cardiovascular Stress Test 93017 $ 383 $ 432 $ 1299 $ 907 $ 717 $ 797 $ 830 -54 TTE w Doppler 93306 2 $ 960 $ 1566 $ 1388 $ 1173 $ 1125 $ 1157 $ 1282 -25 Obstetrics Vaginal Delivery DRG 755 $ 7290 $ 5730 $ 4654 $ 4607 $ 5855 $ 4688 $ 5107 43 EampM Office Visit new pt 99203 4 $ 248 $ 118 $ 159 $ 139 78 Colonoscopy and biopsy (HOSPITAL ONLY) 45380 Surg 2530 $ 307591 Diagnostic colonoscopy (HOSPITAL ONLY) 45378 Surg 2255 $ 307591 Upper gi endoscopy biopsy (HOSPITAL ONLY) 43239 Surg 1787 $ 307591 Knee Arthroscopy (HOSPITAL ONLY) 29881 Surg 10900 $ 506893 Arthroscopy Ligament Repair (HOSPITAL ONLY) 29888 Surg 10900 $ 506200 Key 1 Facility - Inpatient 2 Facility - Imaging 3 Physician - Imaging 4 Physician 5 Global - Imaging 6 Facility - Outpatient 8 Lab 41 Physician - Primary Care 42 Physician - Specialist
Blue Cross United - EJCH EUH EUHM WW United - SJH Non Options United - SJH Options Aetna - ASC TEC (HMO) Cigna - ASC TEC (HMO) Aetna - EJCH ESJH ECHM WW Cigna - EJCH (HMO) Cigna - ESJH EUHM (HMO) List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract Description CPT Code Charge Average Final Price (all plans) Emory Mark Up Reimbursement Method ( of charge or fixed) - 1713 Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Cardiovascular stress test 93017 Cardio $543 $ 425 28 of Charge 70 $ 380 of Charge 65 $ 353 of Charge 60 $ 326 of Charge 70 $ 380 of Charge 70 $ 380 of charge 100 $ 543 of Charge 70 $ 380 of charge 100 $ 543 of charge 100 $ 543 TTE wDoppler complete 93306 Cardio $1226 $ 960 28 of Charge 70 $ 858 of Charge 65 $ 797 of Charge 60 $ 736 of Charge 70 $ 858 of Charge 70 $ 858 of charge 100 $ 1226 of Charge 70 $ 858 of charge 100 $ 1226 of charge 100 $ 1226 Colonoscopy and biopsy (HOSPITAL ONLY) 45380 Surg $2530 $ 3076 -18 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 of Charge 70 $ 1771 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Diagnostic colonoscopy (HOSPITAL ONLY) 45378 Surg $2255 $ 3076 -27 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 of Charge 70 $ 1579 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Upper gi endoscopy biopsy (HOSPITAL ONLY) 43239 Surg $1787 $ 3076 -42 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Knee Arthroscopy (HOSPITAL ONLY) 29881 Surg $10900 $ 5069 115 Fixed Rate SC 4 $ 3865 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 449300 $ 4493 Fixed Rate $ 654700 $ 6547 of Charge 70 $ 7630 Fixed Rate $ 401000 $ 4010 of Charge 70 $ 7630 Fixed Rate $ 398300 $ 3983 Fixed Rate $ 398100 $ 3981 Arthroscopy Ligament Repair (HOSPITAL ONLY) 29888 Surg $10900 $ 5062 115 Fixed Rate SC 3 $ 3121 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 556900 $ 5569 Fixed Rate $ 770100 $ 7701 of Charge 70 $ 7630 Fixed Rate $ 323900 $ 3239 of Charge 70 $ 7630 Fixed Rate $ 321700 $ 3217 Fixed Rate $ 321400 $ 3214 Comp Metabolic Panel 80053 Lab $132 $ 56 138 RBRVS Fee (100) $ 1437 of Charge 65 $ 86 of Charge 65 $ 86 of Charge 65 $ 86 of Charge 70 $ 92 RBRVS Fee (100) $ 1437 $ 14 of Charge 70 $ 92 RBRVS Fee (100) $ 1437 $ 14 RBRVS Fee (100) $ 1437 $ 14 Surgical Path Tissue Exam 88305 Lab $326 $ 236 38 of Charge 150 $ 51 of Charge 65 $ 212 of Charge 65 $ 212 of Charge 65 $ 212 of Charge 70 $ 228 of charge 100 $ 326 of Charge 70 $ 228 of charge 100 $ 326 of charge 100 $ 326 MRI Abdomen 74183 Radiology $6960 $ 1238 462 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 MRI Brain 70553 Radiology $6804 $ 1238 450 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 MRI Joint Lower Extremity 73721 Radiology $3067 $ 1238 148 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 CT Thorax wo contrast 71250 Radiology $2199 $ 882 149 Fixed Rate $ 771 Fixed Rate $ 47100 $ 471 Fixed Rate $ 81700 $ 817 Fixed Rate $ 116000 $ 1160 of Charge 70 $ 1539 Fixed Rate $ 80100 $ 801 Fixed Rate $ 79200 $ 792 Fixed Rate $ 79300 $ 793 Fixed Rate $ 79500 $ 795 X-ray Chest 71020 Radiology $280 $ 115 142 of Charge 150 $ 25 of Charge 65 $ 182 of Charge 60 $ 168 of Charge 70 $ 196 of Charge 70 $ 196 RBRVS Fee (150) $ 2534 $ 25 of Charge 70 $ 196 RBRVS Fee (150) $ 2534 $ 25 RBRVS Fee (150) $ 2534 $ 25 Screening mammography G0202 Radiology $279 $ 141 98 Fixed Rate $ 128 Fixed Rate $ 13100 $ 131 Fixed Rate $ 14300 $ 143 Fixed Rate $ 16100 $ 161 of Charge 70 $ 195 Fixed Rate $ 13300 $ 133 Fixed Rate $ 13500 $ 135 Fixed Rate $ 13000 $ 130 Fixed Rate $ 11200 $ 112 Mammo Computer Aided 77052 Radiology $75 $ 112 -33 Fixed Rate $ 9 Fixed Rate $ 13100 $ 131 Fixed Rate $ 14300 $ 143 Fixed Rate $ 16100 $ 161 of Charge 70 $ 53 Fixed Rate $ 13300 $ 133 Fixed Rate $ 13500 $ 135 Fixed Rate $ 13000 $ 130 Fixed Rate $ 11200 $ 112 US Abdomen Complete 76700 Radiology $917 $ 397 131 of Charge 150 $ 125 of Charge 65 $ 596 of Charge 60 $ 550 of Charge 70 $ 642 of Charge 70 $ 642 RBRVS Fee (150) $ 12519 $ 125 of Charge 70 $ 642 RBRVS Fee (150) $ 12519 $ 125 RBRVS Fee (150) $ 12519 $ 125 Officeoutpatient visit new pt 30 min (TEC) 99203 EampM $316 $ 248 28 of Charge 70 $ 221 of Charge 65 $ 205 of Charge 60 $ 190 of Charge 70 $ 221 of Charge 70 $ 221 of charge 100 $ 316 of Charge 70 $ 221 of charge 100 $ 316 of charge 100 $ 316 Vaginal delivery 59409 Surg $14484 $ 7290 99 Fixed Rate DRG - 775 $ 5437 2 Day Case Rate + LOC 561700 $ 5617 BaseCMS Weight 584741 $ 5847 BaseCMS Weight 726146 $ 7261 No IP Terms $ - 0 No IP BaseCMS Weight 659343 $ 6593 BaseContract Weight 479451 100 $ 14484 BaseCMS Weight 579110 $ 5791 Lap Sleeve Gastrectomy 43775 Surg $29961 $ 20421 47 Fixed Rate DRG - 621 $ 14872 BaseCMS Weight 1810697 $ 18107 BaseCMS Weight 1835178 $ 18352 BaseCMS Weight 2278911 $ 22789 No IP Terms $ - 0 No IP BaseCMS Weight 2069315 $ 20693 BaseCMS Weight 1730442 100 $ 29961 BaseCMS Weight 1817507 $ 18175 105 Colonoscopy and biopsy (ASC ONLY) Surg $ 219200 $ 2181 Diagnostic colonoscopy (ASC ONLY) Surg $ 267100 $ 2348 Upper gi endoscopy biopsy (ASC ONLY) Surg $ 207500 $ 2758 Knee Arthroscopy (ASC ONLY) Surg $ 417900 $ 3467 Arthroscopy Ligament Repair (ASC ONLY) Surg $ 504800 $ 3386
Cpt Code CPT Description Procedure Category Claims Min 25thNtile 50thNtile Emorys Rates 75thNtile 90thNtile Max 20 Below 50th Ntile 20 Above 50th Ntile 93017 CARDIOVASCULAR STRESS TEST 5 82 $80 $125 $321 $382 $568 $791 $930 $257 $386 71020 CHEST X-RAY 2 2638 $11 $45 $152 $115 $289 $373 $585 $122 $182 71020 CHEST X-RAY 5 8106 $25 $34 $38 $54 $57 $69 $30 $46 45380 COLONOSCOPY AND BIOPSY 6 1256 $541 $560 $572 $2877 $1000 $2024 $3289 $458 $686 77052 COMP SCREEN MAMMOGRAM ADD-ON 2 194 $13 $15 $25 $38 $47 $134 $20 $30 77052 COMP SCREEN MAMMOGRAM ADD-ON 5 2411 $13 $16 $20 $23 $26 $28 $16 $24 80053 COMPREHEN METABOLIC PANEL 8 13019 $9 $19 $23 $55 $24 $25 $69 $19 $28 71250 CT THORAX WO DYE 2 302 $165 $372 $545 $878 $1658 $2067 $436 $654 71250 CT THORAX WO DYE 5 209 $53 $127 $203 $289 $419 $534 $162 $244 45378 DIAGNOSTIC COLONOSCOPY 6 1479 $484 $515 $536 $2914 $831 $1971 $2828 $428 $643 29881 KNEE ARTHROSCOPYSURGERY 6 152 $1650 $1826 $2036 $5235 $3054 $4216 $6461 $1629 $2443 29888 KNEE ARTHROSCOPYSURGERY 6 82 $1682 $3615 $5081 $5145 $7553 $12924 $18532 $4065 $6097 43644 LAP GASTRIC BYPASSROUX-EN-Y 1 21 $11821 $13873 $17050 $18391 $25029 $31079 $13640 $20460 43775 LAP SLEEVE GASTRECTOMY 1 38 $4215 $8250 $13253 $20421 $19197 $21509 $24260 $10602 $15903 74183 MRI ABDOMEN WO amp WDYE 2 120 $919 $987 $1015 $1237 $1252 $2534 $3177 $812 $1218 74183 MRI ABDOMEN WO amp WDYE 5 112 $475 $490 $521 $1154 $1337 $1696 $417 $625 70553 MRI BRAIN WO amp WDYE 2 324 $633 $987 $1142 $1237 $1706 $2805 $3331 $914 $1370 70553 MRI BRAIN WO amp WDYE 5 467 $280 $539 $1023 $1277 $1363 $1726 $818 $1228 73721 MRI JNT OF LWR EXTRE WO DYE 2 304 $804 $859 $967 $1237 $1063 $1598 $2485 $774 $1160 73721 MRI JNT OF LWR EXTRE WO DYE 5 1130 $500 $520 $530 $628 $679 $859 $424 $636 59400 OBSTETRICAL CARE 1 494 $3699 $4402 $4969 $6655 $7307 $8613 $3975 $5963 99203 OFFICEOUTPATIENT VISIT NEW 4 6776 $88 $101 $112 $138 $155 $169 $90 $134 G0202 Screeningmammographydigital 2 7444 $123 $206 $285 $380 $425 $479 $228 $342 G0202 Screeningmammographydigital 5 2754 $117 $165 $195 $230 $247 $252 $156 $234 88305 TISSUE EXAM BY PATHOLOGIST 8 20834 $51 $74 $112 $235 $168 $261 $478 $90 $134 93306 TTE WDOPPLER COMPLETE 2 931 $194 $377 $739 $960 $1267 $1480 $1849 $591 $887 93306 TTE WDOPPLER COMPLETE 5 2299 $151 $296 $373 $538 $573 $834 $298 $448 43239 UPPER GI ENDOSCOPY BIOPSY 6 1264 $424 $514 $550 $800 $1838 $2833 $440 $660 76700 US EXAM ABDOM COMPLETE 2 321 $96 $165 $271 $509 $584 $857 $217 $325 76700 US EXAM ABDOM COMPLETE 5 444 $111 $129 $147 $156 $220 $279 $118 $176 Key 1 Facility - Inpatient 2 Facility - Imaging 3 Physician - Imaging 4 Physician 5 Global - Imaging 6 Facility - Outpatient 8 Lab 41 Physician - Primary Care 42 Physician - Specialist Cardiovascular stress test $ 38279 TTE wDoppler complete $ 96037 Colonoscopy and biopsy $ 287709 Diagnostic colonoscopy $ 291434 Upper gi endoscopy biopsy $ 300526 Knee Arthroscopy $ 523584 Arthroscopy Ligament Repair $ 514501 Comp Metabolic Panel $ 5552 Surgical Path Tissue Exam $ 23570 MRI Abdomen $ 123786 MRI Brain $ 123786 MRI Joint Lower Extremity $ 123786 CT Thorax wo contrast $ 88213 X-ray Chest $ 11548 Screening mammography $ 14098 Mammo Computer Aided $ 11179 US Abdomen Complete $ 39695 Officeoutpatient visit new pt 30 min $ 24753 Vaginal delivery $ 729025 Lap Sleeve Gastrectomy $ 2042124
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Evaluate Provider Spend Top 20 Professional CPTs by Total Spend
Understand relative market pricing position
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MRI Colonoscopy Cardiac Cath Lab - OrganPanel
Memorial Hospital Beta Hospital Delta Hospital Charlie Hospital Echo Hospital Alpha Medical Center
ndash25 5 -15 10 0 39
State Charges as a Percent of Peer Average Weighted Averages for MRI Colonoscopy Cardiology and Lab
Total Percent Above Below Market Average2
Memorial Hospital Beta Hospital Delta Hospital Charlie Hospital Echo Hospital Alpha Medical Center
Develop fee schedule relative to market
28
Service Line Procedure CPT CodeDRG
Memorial Hospital
Beta Hosptial
Charlie Hospital
Delta Hospital
Echo Hospital
Alpha Medical Center
Arthroscopy Ligament Repair 29888 $ 5062 $ 9557 $ 5983 $ 10096 $ 7519 $ 2502 Knee Arthroscopy 29881 $ 5069 $ 4185 $ 3837 $ 3022 $ 3729 $ 2266 Upper GI Endoscopy 43239 $ 3075 $ 2539 $ 2012 $ 1132 $ 1565 $ 2240 Lap Sleeve Gastrectomy DRG 621 $ 20421 $ 20815 $ 12105 $ 13230 $ 14600 $ 17800 Colonoscopy and biopsy 45380 $ 3075 $ 3071 $ 2013 $ 1244 $ 1972 $ 859 Diagnostic Colonoscopy 45378 $ 3075 $ 2805 $ 2013 $ 1244 $ 1972 $ 859 MRI Brain w amp wo dye 70553 $ 1238 $ 1468 $ 1117 $ 967 $ 2805 $ 1052 MRI Joint of Lower Extremity wo dye 73721 $ 1238 $ 1398 $ 1042 $ 967 $ 925 $ 557 MRI Abdomen w amp wo dye 74183 $ 1238 $ 1468 $ 1106 $ 967 $ 2805 $ 836 X-ray Chest 71020 $ 115 $ 266 $ 305 $ 279 $ 375 $ 72 CT Thorax wo dye 71250 $ 882 $ 810 $ 505 $ 491 $ 579 $ 319 Ultrasound Abdomen Complete 76700 $ 397 $ 538 $ 545 $ 195 $ 190 $ 168 Mammogram Screening G0202 $ 141 $ 328 $ 431 $ 294 $ 425 $ 168 Computer Detection Add-on 77052 $ 112 $ 99 $ 41 $ 15 $ 45 $ 23 Comp Metabolic Panel 80053 $ 56 $ 15 $ 24 $ 56 $ 51 $ 25 Tissue Exam by Pathologist 88305 $ 236 $ 307 $ 80 $ 152 $ 78 $ 232 Cardiovascular Stress Test 93017 $ 383 $ 432 $ 1299 $ 907 $ 717 $ 797 TTE w Doppler 93306 $ 960 $ 1566 $ 1388 $ 1173 $ 1125 $ 1157
Obstetrics Vaginal Delivery DRG 755 7290$ 5730$ 4654$ 4607$ 5855$ 4688$
GI
Lab
Radiology
Medical Cardiology
Orthopedics
KEY OBSERVA TIONS bull Potential exposure on GI bull Opportunity to align price and acuity in MRI bull Opportunity to raise rates on chest x-ray and mammogram
Percentile Bands Emory Allowables Heatmap TEC ASC Heatmap Allowable Comp Analysis Portal Pricing Sheet1 image1png A few words on Bundled Payments bull Bundled payments are growing as a type of direct contracting bull In some cases third parties match-make between employers
and providers bull Contracts may vary in definitions prepost admission
coverage duration readmission cause (ie all-cause vs medically related) outlier provisions LOS caps andor per diems
bull Providers need to be strategic in pricing to enable profitable growth of market share
29
Considerations in Offering Development bull Network Development
bull Build off existing structure eg health system employee plan network bull How does this fit into your broader value based care strategy bull Employed and independent physicians bull How do you want to approach the buildout of high performance
network bull Quality focus bull Cost efficiency
bull Integrated behavioral health bull Wrap network for other markets
30
Considerations in Offering Development bull Target Market
bull Consideration of employer profile in market bull Fully-insured vs ASO bull Total cost of care vs bundled services
bull Distribution bull Direct marketing bull Brokerconsultant community
bull Plan designs bull Standard designs vs flexible ndash Dependent on target market
bull Claims administration bull Data sharing amp analytics
31
Considerations in Offering Development bull Other components of comprehensive offering
bull Pharmacy bull Preventive health bull Onsite clinics bull Wellness programs bull Technology platform
32
Sample Bundle Analysis
33
Cover page Dotson Hazelrigs Nation Mainly of charge of fixed Cardiovascular stress test TTE wDoppler complete Colonoscopy and biopsy (Combined) Diagnostic colonoscopy (Combined) Upper gi endoscopy biopsy (Combined) Knee Arthroscopy (Combined) Arthroscopy Ligament Repair Comp Metabolic Panel Surgical Path Tissue Exam MRI Abdomen MRI Brain MRI Joint Lower Extremity CT Thorax wo contrast X-ray Chest Screening mammography Mammo Computer Aided US Abdomen Complete Officeoutpatient visit new pt 30 min Vaginal delivery Lap Sleeve Gastrectomy
Piedmont Piedmont Piedmont Piedmont Northside Northside Northside Northside Gwinnett Gwinnett Gwinnett Gwinnett WellStar WellStar WellStar WellStar AMC - Tenet AMC - Tenet AMC - Tenet AMC - Tenet CPT Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing 29881 $11312 $10872 NA NA $7476 $9338 NA $23655 $11856 $3668 NA $17871 $12253 NA NA $15645 $5490 NA NA $23039 29888 NA NA NA NA NA NA NA $23784 NA $8261 NA $18000 NA NA NA $15774 NA NA NA $23168 43239 NA $4408 NA NA NA NA $5997 $8852 NA $3304 NA $7424 $1267 NA NA $9230 NA $2458 NA $8274 43644 $26468 NA NA NA $3382 $12050 NA $1861 NA NA NA $1316 $7841 NA NA $3444 $18892 $27950 NA $979 43775 NA NA NA NA NA NA NA $352 NA NA NA $302 NA NA NA $413 NA NA NA $83 45378 $2705 $2530 NA NA $4381 $3676 $4496 $1022 $2938 $2138 NA $695 $5504 NA NA $2036 NA NA NA $372 45380 $3075 $2600 NA NA $4723 $3527 $3012 $1757 $4215 $2285 NA NA $5298 NA NA $3268 NA NA NA $627 59400 $6160 NA NA NA NA $5100 NA $1851 NA NA NA $1304 $9035 NA NA $3427 $9116 $5150 NA $966 70553 $2985 NA $1153 NA $2182 NA $1192 $492 NA NA $803 $489 $1512 NA $985 $1187 NA NA NA $197 71020 $61 $69 $43 NA $113 $319 $307 NA $183 $59 $32 NA $213 $66 $40 NA $83 $53 NA NA 71250 $1837 $621 $989 NA $1490 $931 $755 NA NA $745 $401 NA $1067 $982 $616 NA NA $304 NA NA 73721 NA $1098 $1153 NA $2042 $1065 $1192 NA NA $998 $803 NA NA $1275 $985 NA NA $644 NA $178 74183 $2971 $1144 NA NA NA $1092 $1192 $6884 NA $1098 $803 NA $2960 $1197 $985 $5454 NA NA NA $7607 76700 $364 $247 $207 NA $427 $708 $614 $13267 $428 $214 $152 NA $747 $263 $189 $9139 NA $235 NA NA 77052 NA NA NA NA NA NA NA $4744 NA NA NA NA NA NA NA $3070 NA NA NA $5611 93306 $1220 $1117 NA NA $1877 $1657 $2100 $4605 $1433 $413 $945 NA $1336 $1434 $1951 $2931 NA $2399 NA $5472 G0202 $262 $187 NA NA $431 NA NA $4605 $292 NA NA NA $530 $281 NA $2931 $327 NA NA $5472
Provider Group 29881_6 29888_6 43239_6 43644_1 43775_1 45378_6 45380_6 59400_1 70553_2 71020_2 71250_2 73721_2 74183_2 76700_2 77052_2 77052_5 80053_8 88305_8 93306_2 99203_4 G0202_2 G0202_5 93017_2 Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Atlanta Gastroenterology Associates $2399 $536 348 $1628 $536 204 $2400 $536 348 Atlanta Medical Center $24889 $2266 999 $25897 $2502 935 $11449 $2240 411 $81927 $15300 435 $75815 $17800 326 $7317 $859 752 $7317 $859 752 $12821 $4688 173 $6581 $1052 526 $645 $72 796 $3265 $319 925 $3450 $557 519 $7398 $836 785 $1576 $133 1084 $73 $23 217 $635 $25 2440 $891 $232 285 $2967 $1157 156 $344 $168 105 $1265 $797 59 Atlanta Womens Health Physicians Group $29 $14 107 $40 $13 208 $396 $188 111 $278 $118 135 $450 $231 95 Gwinnett Hospital $11941 $3022 295 $21654 $10096 114 $3551 $1132 214 $34384 $10800 218 $56472 $13230 327 $3003 $1244 141 $3533 $1244 184 $8984 $4607 95 $3901 $967 303 $417 $279 49 $2247 $491 358 $4000 $967 314 $3755 $967 288 $1593 $195 717 $50 $15 233 $186 $56 233 $505 $152 233 $1750 $1173 49 $418 $294 42 $1396 $907 54 Northside Hospital $15482 $4185 270 $21651 $9557 127 $4885 $2539 92 $35176 $17000 107 $35233 $20815 69 $3883 $2805 38 $5256 $3071 71 $10911 $5730 90 $4856 $1468 231 $443 $266 67 $2379 $810 194 $3776 $1398 170 $5105 $1468 248 $942 $538 75 $167 $99 69 $379 $15 2427 $433 $307 41 $2252 $1566 44 $459 $328 40 $576 $432 33 Piedmont Hospital $14772 $3837 285 $35493 $5983 493 $5069 $2012 152 $38320 $17750 116 $37125 $12105 207 $3485 $2013 73 $4993 $2013 148 $10143 $4654 118 $5939 $1117 432 $542 $305 78 $2983 $505 491 $3410 $1042 227 $6067 $1106 449 $1364 $545 150 $75 $41 85 $231 $24 863 $657 $80 721 $2041 $1388 47 $490 $431 14 $1780 $1299 37 Piedmont Physicians Group $42 $22 87 $318 $179 78 $239 $159 50 Resurgens $8558 $2036 320 $9293 $2258 312 $4638 $2067 124 $4039 $2164 87 $4392 $2164 103 $2252 $1371 64 $459 $330 39 Wellstar Hospital $9330 $3729 150 $17479 $7519 132 $5261 $1565 236 $35794 $18200 97 $46780 $14600 220 $3707 $1972 88 $4928 $1972 150 $13549 $5855 131 $5054 $2805 80 $528 $375 41 $3222 $579 457 $3694 $925 299 $5495 $2805 96 $1355 $190 615 $66 $45 46 $73 $51 43 $133 $78 71 $1785 $1125 59 $599 $425 41 $1010 $717 41 Avg Mark UpProcedure Atlanta Medical Center 634 Gwinnett Hospital 223 Northside Hospital 233 Piedmont Hospital 259 Wellstar Hospital 155 Emory 105
Atlanta Gastroenterology Associates Atlanta Medical Center Atlanta Womens Health Gwinnett Hospital Northside Hospital Piedmont Hospital Piedmont Physicians Group Resurgens Wellstar Hospital CPT Code CPT Proc Cat Comp Avg Allow Allow Allow Allow Allow Allow Allow Allow Allow 29881 KNEE ARTHROSCOPYSURGERY 6 $3179 $2266 $3022 $4185 $3837 $2036 $3729 29888 KNEE ARTHROSCOPYSURGERY 6 $6319 $2502 $10096 $9557 $5983 $2258 $7519 43239 UPPER GI ENDOSCOPY BIOPSY 6 $1727 $536 $2240 $1132 $2539 $2012 $2067 $1565 43644 LAP GASTRIC BYPASSROUX-EN-Y 1 $15810 $15300 $10800 $17000 $17750 $18200 43775 LAP SLEEVE GASTRECTOMY 1 $17800 $13230 $20815 $12105 $14600 45378 DIAGNOSTIC COLONOSCOPY 6 $1656 $536 $859 $1244 $2805 $2013 $2164 $1972 45380 COLONOSCOPY AND BIOPSY 6 $1694 $536 $859 $1244 $3071 $2013 $2164 $1972 59400 OBSTETRICAL CARE 1 $5107 $4688 $4607 $5730 $4654 $5855 70553 MRI BRAIN WO amp WDYE 2 $1482 $1052 $967 $1468 $1117 $2805 71020 CHEST X-RAY 2 $259 $72 $279 $266 $305 $375 71250 CT THORAX WO DYE 2 $541 $319 $491 $810 $505 $579 73721 MRI JNT OF LWR EXTRE WO DYE 2 $978 $557 $967 $1398 $1042 $925 74183 MRI ABDOMEN WO amp WDYE 2 $1436 $836 $967 $1468 $1106 $2805 76700 US EXAM ABDOM COMPLETE 2 $320 $133 $195 $538 $545 $190 77052 COMP SCREEN MAMMOGRAM ADD-ON 2 $45 $23 $15 $99 $41 $45 77052 COMP SCREEN MAMMOGRAM ADD-ON 5 $14 $14 80053 COMPREHEN METABOLIC PANEL 8 $29 $25 $13 $56 $15 $24 $22 $51 88305 TISSUE EXAM BY PATHOLOGIST 8 $174 $232 $188 $152 $307 $80 $179 $78 93306 TTE WDOPPLER COMPLETE 2 $1297 $1157 $1173 $1566 $1388 $1371 $1125 93017 STRESS TEST 5 $830 $797 $907 $432 $1299 $717 99203 OFFICEOUTPATIENT VISIT NEW 4 $139 $118 $159 G0202 Screeningmammographydigital 2 $329 $168 $294 $328 $431 $330 $425 G0202 Screeningmammographydigital 5 $231 $231
Service Line Procedure CPT Code Emory Atlanta Gastroenterology Associates Resurgens Atlanta Womens Health Piedmont Physicians Group Orthopedics (ASC) Knee Arthroscopy 29881 $3467 $2036 Arthroscopy Ligament Repair 29888 $3386 $2258 GI (ASC) Upper GI Endoscopy 43239 $2758 $536 Diagnostic Colonoscopy 45378 $2348 $536 Colonoscopy and biopsy 45380 $2181 $536 Radiology Mammogram Screening G0202 $164 $231 Computer Detection Add-on 77052 $93 $14 Lab Comp Metabolic Panel 80053 $53 $13 $22 Tissue Exam by Pathologist 88305 $277 $188 $179 EampM (TEC) Office Visit new pt 99203 $269 $118 $159
Service Line Procedure CPT CodeDRG Memorial Hospital Beta Hosptial Charlie Hospital Delta Hospital Echo Hospital Alpha Medical Center Atlanta Gastroenterology Associates Resurgens Atlanta Womens Health Piedmont Physicians Group Market Avg Emory abovebelow Orthopedics Arthroscopy Ligament Repair 29888 $ 5062 $ 9557 $ 5983 $ 10096 $ 7519 $ 2502 $ 2258 $ 6319 -20 Knee Arthroscopy 29881 6 $ 5069 $ 4185 $ 3837 $ 3022 $ 3729 $ 2266 $ 2036 $ 3179 59 GI Upper GI Endoscopy 43239 6 $ 3075 $ 2539 $ 2012 $ 1132 $ 1565 $ 2240 $ 536 $ 1671 84 Lap Sleeve Gastrectomy DRG 621 $ 20421 $ 20815 $ 12105 $ 13230 $ 14600 $ 17800 $ 15710 30 Colonoscopy and biopsy 45380 $ 3075 $ 3071 $ 2013 $ 1244 $ 1972 $ 859 $ 536 $ 1616 90 Diagnostic Colonoscopy 45378 6 $ 3075 $ 2805 $ 2013 $ 1244 $ 1972 $ 859 $ 536 $ 1572 96 Radiology MRI Brain w amp wo dye 70553 2 $ 1238 $ 1468 $ 1117 $ 967 $ 2805 $ 1052 $ 1482 -16 MRI Joint of Lower Extremity wo dye 73721 2 $ 1238 $ 1398 $ 1042 $ 967 $ 925 $ 557 $ 978 27 MRI Abdomen w amp wo dye 74183 2 $ 1238 $ 1468 $ 1106 $ 967 $ 2805 $ 836 $ 1436 -14 X-ray Chest 71020 $ 115 $ 266 $ 305 $ 279 $ 375 $ 72 $ 259 -56 CT Thorax wo dye 71250 $ 882 $ 810 $ 505 $ 491 $ 579 $ 319 $ 541 63 Ultrasound Abdomen Complete 76700 $ 397 $ 538 $ 545 $ 195 $ 190 $ 168 $ 327 21 Mammogram Screening G0202 2 $ 141 $ 328 $ 431 $ 294 $ 425 $ 168 $ 231 $ 313 -55 Computer Detection Add-on 77052 2 $ 112 $ 99 $ 41 $ 15 $ 45 $ 23 $ 14 $ 39 183 Lab Comp Metabolic Panel 80053 8 $ 56 $ 15 $ 24 $ 56 $ 51 $ 25 $ 13 $ 22 $ 29 88 Tissue Exam by Pathologist 88305 8 $ 236 $ 307 $ 80 $ 152 $ 78 $ 232 $ 188 $ 179 $ 174 36 Medical Cardiology Cardiovascular Stress Test 93017 $ 383 $ 432 $ 1299 $ 907 $ 717 $ 797 $ 830 -54 TTE w Doppler 93306 2 $ 960 $ 1566 $ 1388 $ 1173 $ 1125 $ 1157 $ 1282 -25 Obstetrics Vaginal Delivery DRG 755 $ 7290 $ 5730 $ 4654 $ 4607 $ 5855 $ 4688 $ 5107 43 EampM Office Visit new pt 99203 4 $ 248 $ 118 $ 159 $ 139 78 Colonoscopy and biopsy (HOSPITAL ONLY) 45380 Surg 2530 $ 307591 Diagnostic colonoscopy (HOSPITAL ONLY) 45378 Surg 2255 $ 307591 Upper gi endoscopy biopsy (HOSPITAL ONLY) 43239 Surg 1787 $ 307591 Knee Arthroscopy (HOSPITAL ONLY) 29881 Surg 10900 $ 506893 Arthroscopy Ligament Repair (HOSPITAL ONLY) 29888 Surg 10900 $ 506200 Key 1 Facility - Inpatient 2 Facility - Imaging 3 Physician - Imaging 4 Physician 5 Global - Imaging 6 Facility - Outpatient 8 Lab 41 Physician - Primary Care 42 Physician - Specialist
Blue Cross United - EJCH EUH EUHM WW United - SJH Non Options United - SJH Options Aetna - ASC TEC (HMO) Cigna - ASC TEC (HMO) Aetna - EJCH ESJH ECHM WW Cigna - EJCH (HMO) Cigna - ESJH EUHM (HMO) List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract Description CPT Code Charge Average Final Price (all plans) Emory Mark Up Reimbursement Method ( of charge or fixed) - 1713 Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Cardiovascular stress test 93017 Cardio $543 $ 425 28 of Charge 70 $ 380 of Charge 65 $ 353 of Charge 60 $ 326 of Charge 70 $ 380 of Charge 70 $ 380 of charge 100 $ 543 of Charge 70 $ 380 of charge 100 $ 543 of charge 100 $ 543 TTE wDoppler complete 93306 Cardio $1226 $ 960 28 of Charge 70 $ 858 of Charge 65 $ 797 of Charge 60 $ 736 of Charge 70 $ 858 of Charge 70 $ 858 of charge 100 $ 1226 of Charge 70 $ 858 of charge 100 $ 1226 of charge 100 $ 1226 Colonoscopy and biopsy (HOSPITAL ONLY) 45380 Surg $2530 $ 3076 -18 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 of Charge 70 $ 1771 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Diagnostic colonoscopy (HOSPITAL ONLY) 45378 Surg $2255 $ 3076 -27 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 of Charge 70 $ 1579 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Upper gi endoscopy biopsy (HOSPITAL ONLY) 43239 Surg $1787 $ 3076 -42 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Knee Arthroscopy (HOSPITAL ONLY) 29881 Surg $10900 $ 5069 115 Fixed Rate SC 4 $ 3865 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 449300 $ 4493 Fixed Rate $ 654700 $ 6547 of Charge 70 $ 7630 Fixed Rate $ 401000 $ 4010 of Charge 70 $ 7630 Fixed Rate $ 398300 $ 3983 Fixed Rate $ 398100 $ 3981 Arthroscopy Ligament Repair (HOSPITAL ONLY) 29888 Surg $10900 $ 5062 115 Fixed Rate SC 3 $ 3121 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 556900 $ 5569 Fixed Rate $ 770100 $ 7701 of Charge 70 $ 7630 Fixed Rate $ 323900 $ 3239 of Charge 70 $ 7630 Fixed Rate $ 321700 $ 3217 Fixed Rate $ 321400 $ 3214 Comp Metabolic Panel 80053 Lab $132 $ 56 138 RBRVS Fee (100) $ 1437 of Charge 65 $ 86 of Charge 65 $ 86 of Charge 65 $ 86 of Charge 70 $ 92 RBRVS Fee (100) $ 1437 $ 14 of Charge 70 $ 92 RBRVS Fee (100) $ 1437 $ 14 RBRVS Fee (100) $ 1437 $ 14 Surgical Path Tissue Exam 88305 Lab $326 $ 236 38 of Charge 150 $ 51 of Charge 65 $ 212 of Charge 65 $ 212 of Charge 65 $ 212 of Charge 70 $ 228 of charge 100 $ 326 of Charge 70 $ 228 of charge 100 $ 326 of charge 100 $ 326 MRI Abdomen 74183 Radiology $6960 $ 1238 462 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 MRI Brain 70553 Radiology $6804 $ 1238 450 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 MRI Joint Lower Extremity 73721 Radiology $3067 $ 1238 148 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 CT Thorax wo contrast 71250 Radiology $2199 $ 882 149 Fixed Rate $ 771 Fixed Rate $ 47100 $ 471 Fixed Rate $ 81700 $ 817 Fixed Rate $ 116000 $ 1160 of Charge 70 $ 1539 Fixed Rate $ 80100 $ 801 Fixed Rate $ 79200 $ 792 Fixed Rate $ 79300 $ 793 Fixed Rate $ 79500 $ 795 X-ray Chest 71020 Radiology $280 $ 115 142 of Charge 150 $ 25 of Charge 65 $ 182 of Charge 60 $ 168 of Charge 70 $ 196 of Charge 70 $ 196 RBRVS Fee (150) $ 2534 $ 25 of Charge 70 $ 196 RBRVS Fee (150) $ 2534 $ 25 RBRVS Fee (150) $ 2534 $ 25 Screening mammography G0202 Radiology $279 $ 141 98 Fixed Rate $ 128 Fixed Rate $ 13100 $ 131 Fixed Rate $ 14300 $ 143 Fixed Rate $ 16100 $ 161 of Charge 70 $ 195 Fixed Rate $ 13300 $ 133 Fixed Rate $ 13500 $ 135 Fixed Rate $ 13000 $ 130 Fixed Rate $ 11200 $ 112 Mammo Computer Aided 77052 Radiology $75 $ 112 -33 Fixed Rate $ 9 Fixed Rate $ 13100 $ 131 Fixed Rate $ 14300 $ 143 Fixed Rate $ 16100 $ 161 of Charge 70 $ 53 Fixed Rate $ 13300 $ 133 Fixed Rate $ 13500 $ 135 Fixed Rate $ 13000 $ 130 Fixed Rate $ 11200 $ 112 US Abdomen Complete 76700 Radiology $917 $ 397 131 of Charge 150 $ 125 of Charge 65 $ 596 of Charge 60 $ 550 of Charge 70 $ 642 of Charge 70 $ 642 RBRVS Fee (150) $ 12519 $ 125 of Charge 70 $ 642 RBRVS Fee (150) $ 12519 $ 125 RBRVS Fee (150) $ 12519 $ 125 Officeoutpatient visit new pt 30 min (TEC) 99203 EampM $316 $ 248 28 of Charge 70 $ 221 of Charge 65 $ 205 of Charge 60 $ 190 of Charge 70 $ 221 of Charge 70 $ 221 of charge 100 $ 316 of Charge 70 $ 221 of charge 100 $ 316 of charge 100 $ 316 Vaginal delivery 59409 Surg $14484 $ 7290 99 Fixed Rate DRG - 775 $ 5437 2 Day Case Rate + LOC 561700 $ 5617 BaseCMS Weight 584741 $ 5847 BaseCMS Weight 726146 $ 7261 No IP Terms $ - 0 No IP BaseCMS Weight 659343 $ 6593 BaseContract Weight 479451 100 $ 14484 BaseCMS Weight 579110 $ 5791 Lap Sleeve Gastrectomy 43775 Surg $29961 $ 20421 47 Fixed Rate DRG - 621 $ 14872 BaseCMS Weight 1810697 $ 18107 BaseCMS Weight 1835178 $ 18352 BaseCMS Weight 2278911 $ 22789 No IP Terms $ - 0 No IP BaseCMS Weight 2069315 $ 20693 BaseCMS Weight 1730442 100 $ 29961 BaseCMS Weight 1817507 $ 18175 105 Colonoscopy and biopsy (ASC ONLY) Surg $ 219200 $ 2181 Diagnostic colonoscopy (ASC ONLY) Surg $ 267100 $ 2348 Upper gi endoscopy biopsy (ASC ONLY) Surg $ 207500 $ 2758 Knee Arthroscopy (ASC ONLY) Surg $ 417900 $ 3467 Arthroscopy Ligament Repair (ASC ONLY) Surg $ 504800 $ 3386
Cpt Code CPT Description Procedure Category Claims Min 25thNtile 50thNtile Emorys Rates 75thNtile 90thNtile Max 20 Below 50th Ntile 20 Above 50th Ntile 93017 CARDIOVASCULAR STRESS TEST 5 82 $80 $125 $321 $382 $568 $791 $930 $257 $386 71020 CHEST X-RAY 2 2638 $11 $45 $152 $115 $289 $373 $585 $122 $182 71020 CHEST X-RAY 5 8106 $25 $34 $38 $54 $57 $69 $30 $46 45380 COLONOSCOPY AND BIOPSY 6 1256 $541 $560 $572 $2877 $1000 $2024 $3289 $458 $686 77052 COMP SCREEN MAMMOGRAM ADD-ON 2 194 $13 $15 $25 $38 $47 $134 $20 $30 77052 COMP SCREEN MAMMOGRAM ADD-ON 5 2411 $13 $16 $20 $23 $26 $28 $16 $24 80053 COMPREHEN METABOLIC PANEL 8 13019 $9 $19 $23 $55 $24 $25 $69 $19 $28 71250 CT THORAX WO DYE 2 302 $165 $372 $545 $878 $1658 $2067 $436 $654 71250 CT THORAX WO DYE 5 209 $53 $127 $203 $289 $419 $534 $162 $244 45378 DIAGNOSTIC COLONOSCOPY 6 1479 $484 $515 $536 $2914 $831 $1971 $2828 $428 $643 29881 KNEE ARTHROSCOPYSURGERY 6 152 $1650 $1826 $2036 $5235 $3054 $4216 $6461 $1629 $2443 29888 KNEE ARTHROSCOPYSURGERY 6 82 $1682 $3615 $5081 $5145 $7553 $12924 $18532 $4065 $6097 43644 LAP GASTRIC BYPASSROUX-EN-Y 1 21 $11821 $13873 $17050 $18391 $25029 $31079 $13640 $20460 43775 LAP SLEEVE GASTRECTOMY 1 38 $4215 $8250 $13253 $20421 $19197 $21509 $24260 $10602 $15903 74183 MRI ABDOMEN WO amp WDYE 2 120 $919 $987 $1015 $1237 $1252 $2534 $3177 $812 $1218 74183 MRI ABDOMEN WO amp WDYE 5 112 $475 $490 $521 $1154 $1337 $1696 $417 $625 70553 MRI BRAIN WO amp WDYE 2 324 $633 $987 $1142 $1237 $1706 $2805 $3331 $914 $1370 70553 MRI BRAIN WO amp WDYE 5 467 $280 $539 $1023 $1277 $1363 $1726 $818 $1228 73721 MRI JNT OF LWR EXTRE WO DYE 2 304 $804 $859 $967 $1237 $1063 $1598 $2485 $774 $1160 73721 MRI JNT OF LWR EXTRE WO DYE 5 1130 $500 $520 $530 $628 $679 $859 $424 $636 59400 OBSTETRICAL CARE 1 494 $3699 $4402 $4969 $6655 $7307 $8613 $3975 $5963 99203 OFFICEOUTPATIENT VISIT NEW 4 6776 $88 $101 $112 $138 $155 $169 $90 $134 G0202 Screeningmammographydigital 2 7444 $123 $206 $285 $380 $425 $479 $228 $342 G0202 Screeningmammographydigital 5 2754 $117 $165 $195 $230 $247 $252 $156 $234 88305 TISSUE EXAM BY PATHOLOGIST 8 20834 $51 $74 $112 $235 $168 $261 $478 $90 $134 93306 TTE WDOPPLER COMPLETE 2 931 $194 $377 $739 $960 $1267 $1480 $1849 $591 $887 93306 TTE WDOPPLER COMPLETE 5 2299 $151 $296 $373 $538 $573 $834 $298 $448 43239 UPPER GI ENDOSCOPY BIOPSY 6 1264 $424 $514 $550 $800 $1838 $2833 $440 $660 76700 US EXAM ABDOM COMPLETE 2 321 $96 $165 $271 $509 $584 $857 $217 $325 76700 US EXAM ABDOM COMPLETE 5 444 $111 $129 $147 $156 $220 $279 $118 $176 Key 1 Facility - Inpatient 2 Facility - Imaging 3 Physician - Imaging 4 Physician 5 Global - Imaging 6 Facility - Outpatient 8 Lab 41 Physician - Primary Care 42 Physician - Specialist Cardiovascular stress test $ 38279 TTE wDoppler complete $ 96037 Colonoscopy and biopsy $ 287709 Diagnostic colonoscopy $ 291434 Upper gi endoscopy biopsy $ 300526 Knee Arthroscopy $ 523584 Arthroscopy Ligament Repair $ 514501 Comp Metabolic Panel $ 5552 Surgical Path Tissue Exam $ 23570 MRI Abdomen $ 123786 MRI Brain $ 123786 MRI Joint Lower Extremity $ 123786 CT Thorax wo contrast $ 88213 X-ray Chest $ 11548 Screening mammography $ 14098 Mammo Computer Aided $ 11179 US Abdomen Complete $ 39695 Officeoutpatient visit new pt 30 min $ 24753 Vaginal delivery $ 729025 Lap Sleeve Gastrectomy $ 2042124
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Understand relative market pricing position
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MRI Colonoscopy Cardiac Cath Lab - OrganPanel
Memorial Hospital Beta Hospital Delta Hospital Charlie Hospital Echo Hospital Alpha Medical Center
ndash25 5 -15 10 0 39
State Charges as a Percent of Peer Average Weighted Averages for MRI Colonoscopy Cardiology and Lab
Total Percent Above Below Market Average2
Memorial Hospital Beta Hospital Delta Hospital Charlie Hospital Echo Hospital Alpha Medical Center
Develop fee schedule relative to market
28
Service Line Procedure CPT CodeDRG
Memorial Hospital
Beta Hosptial
Charlie Hospital
Delta Hospital
Echo Hospital
Alpha Medical Center
Arthroscopy Ligament Repair 29888 $ 5062 $ 9557 $ 5983 $ 10096 $ 7519 $ 2502 Knee Arthroscopy 29881 $ 5069 $ 4185 $ 3837 $ 3022 $ 3729 $ 2266 Upper GI Endoscopy 43239 $ 3075 $ 2539 $ 2012 $ 1132 $ 1565 $ 2240 Lap Sleeve Gastrectomy DRG 621 $ 20421 $ 20815 $ 12105 $ 13230 $ 14600 $ 17800 Colonoscopy and biopsy 45380 $ 3075 $ 3071 $ 2013 $ 1244 $ 1972 $ 859 Diagnostic Colonoscopy 45378 $ 3075 $ 2805 $ 2013 $ 1244 $ 1972 $ 859 MRI Brain w amp wo dye 70553 $ 1238 $ 1468 $ 1117 $ 967 $ 2805 $ 1052 MRI Joint of Lower Extremity wo dye 73721 $ 1238 $ 1398 $ 1042 $ 967 $ 925 $ 557 MRI Abdomen w amp wo dye 74183 $ 1238 $ 1468 $ 1106 $ 967 $ 2805 $ 836 X-ray Chest 71020 $ 115 $ 266 $ 305 $ 279 $ 375 $ 72 CT Thorax wo dye 71250 $ 882 $ 810 $ 505 $ 491 $ 579 $ 319 Ultrasound Abdomen Complete 76700 $ 397 $ 538 $ 545 $ 195 $ 190 $ 168 Mammogram Screening G0202 $ 141 $ 328 $ 431 $ 294 $ 425 $ 168 Computer Detection Add-on 77052 $ 112 $ 99 $ 41 $ 15 $ 45 $ 23 Comp Metabolic Panel 80053 $ 56 $ 15 $ 24 $ 56 $ 51 $ 25 Tissue Exam by Pathologist 88305 $ 236 $ 307 $ 80 $ 152 $ 78 $ 232 Cardiovascular Stress Test 93017 $ 383 $ 432 $ 1299 $ 907 $ 717 $ 797 TTE w Doppler 93306 $ 960 $ 1566 $ 1388 $ 1173 $ 1125 $ 1157
Obstetrics Vaginal Delivery DRG 755 7290$ 5730$ 4654$ 4607$ 5855$ 4688$
GI
Lab
Radiology
Medical Cardiology
Orthopedics
KEY OBSERVA TIONS bull Potential exposure on GI bull Opportunity to align price and acuity in MRI bull Opportunity to raise rates on chest x-ray and mammogram
Percentile Bands Emory Allowables Heatmap TEC ASC Heatmap Allowable Comp Analysis Portal Pricing Sheet1 image1png A few words on Bundled Payments bull Bundled payments are growing as a type of direct contracting bull In some cases third parties match-make between employers
and providers bull Contracts may vary in definitions prepost admission
coverage duration readmission cause (ie all-cause vs medically related) outlier provisions LOS caps andor per diems
bull Providers need to be strategic in pricing to enable profitable growth of market share
29
Considerations in Offering Development bull Network Development
bull Build off existing structure eg health system employee plan network bull How does this fit into your broader value based care strategy bull Employed and independent physicians bull How do you want to approach the buildout of high performance
network bull Quality focus bull Cost efficiency
bull Integrated behavioral health bull Wrap network for other markets
30
Considerations in Offering Development bull Target Market
bull Consideration of employer profile in market bull Fully-insured vs ASO bull Total cost of care vs bundled services
bull Distribution bull Direct marketing bull Brokerconsultant community
bull Plan designs bull Standard designs vs flexible ndash Dependent on target market
bull Claims administration bull Data sharing amp analytics
31
Considerations in Offering Development bull Other components of comprehensive offering
bull Pharmacy bull Preventive health bull Onsite clinics bull Wellness programs bull Technology platform
32
Sample Bundle Analysis
33
Cover page Dotson Hazelrigs Nation Mainly of charge of fixed Cardiovascular stress test TTE wDoppler complete Colonoscopy and biopsy (Combined) Diagnostic colonoscopy (Combined) Upper gi endoscopy biopsy (Combined) Knee Arthroscopy (Combined) Arthroscopy Ligament Repair Comp Metabolic Panel Surgical Path Tissue Exam MRI Abdomen MRI Brain MRI Joint Lower Extremity CT Thorax wo contrast X-ray Chest Screening mammography Mammo Computer Aided US Abdomen Complete Officeoutpatient visit new pt 30 min Vaginal delivery Lap Sleeve Gastrectomy
Piedmont Piedmont Piedmont Piedmont Northside Northside Northside Northside Gwinnett Gwinnett Gwinnett Gwinnett WellStar WellStar WellStar WellStar AMC - Tenet AMC - Tenet AMC - Tenet AMC - Tenet CPT Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing 29881 $11312 $10872 NA NA $7476 $9338 NA $23655 $11856 $3668 NA $17871 $12253 NA NA $15645 $5490 NA NA $23039 29888 NA NA NA NA NA NA NA $23784 NA $8261 NA $18000 NA NA NA $15774 NA NA NA $23168 43239 NA $4408 NA NA NA NA $5997 $8852 NA $3304 NA $7424 $1267 NA NA $9230 NA $2458 NA $8274 43644 $26468 NA NA NA $3382 $12050 NA $1861 NA NA NA $1316 $7841 NA NA $3444 $18892 $27950 NA $979 43775 NA NA NA NA NA NA NA $352 NA NA NA $302 NA NA NA $413 NA NA NA $83 45378 $2705 $2530 NA NA $4381 $3676 $4496 $1022 $2938 $2138 NA $695 $5504 NA NA $2036 NA NA NA $372 45380 $3075 $2600 NA NA $4723 $3527 $3012 $1757 $4215 $2285 NA NA $5298 NA NA $3268 NA NA NA $627 59400 $6160 NA NA NA NA $5100 NA $1851 NA NA NA $1304 $9035 NA NA $3427 $9116 $5150 NA $966 70553 $2985 NA $1153 NA $2182 NA $1192 $492 NA NA $803 $489 $1512 NA $985 $1187 NA NA NA $197 71020 $61 $69 $43 NA $113 $319 $307 NA $183 $59 $32 NA $213 $66 $40 NA $83 $53 NA NA 71250 $1837 $621 $989 NA $1490 $931 $755 NA NA $745 $401 NA $1067 $982 $616 NA NA $304 NA NA 73721 NA $1098 $1153 NA $2042 $1065 $1192 NA NA $998 $803 NA NA $1275 $985 NA NA $644 NA $178 74183 $2971 $1144 NA NA NA $1092 $1192 $6884 NA $1098 $803 NA $2960 $1197 $985 $5454 NA NA NA $7607 76700 $364 $247 $207 NA $427 $708 $614 $13267 $428 $214 $152 NA $747 $263 $189 $9139 NA $235 NA NA 77052 NA NA NA NA NA NA NA $4744 NA NA NA NA NA NA NA $3070 NA NA NA $5611 93306 $1220 $1117 NA NA $1877 $1657 $2100 $4605 $1433 $413 $945 NA $1336 $1434 $1951 $2931 NA $2399 NA $5472 G0202 $262 $187 NA NA $431 NA NA $4605 $292 NA NA NA $530 $281 NA $2931 $327 NA NA $5472
Provider Group 29881_6 29888_6 43239_6 43644_1 43775_1 45378_6 45380_6 59400_1 70553_2 71020_2 71250_2 73721_2 74183_2 76700_2 77052_2 77052_5 80053_8 88305_8 93306_2 99203_4 G0202_2 G0202_5 93017_2 Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Atlanta Gastroenterology Associates $2399 $536 348 $1628 $536 204 $2400 $536 348 Atlanta Medical Center $24889 $2266 999 $25897 $2502 935 $11449 $2240 411 $81927 $15300 435 $75815 $17800 326 $7317 $859 752 $7317 $859 752 $12821 $4688 173 $6581 $1052 526 $645 $72 796 $3265 $319 925 $3450 $557 519 $7398 $836 785 $1576 $133 1084 $73 $23 217 $635 $25 2440 $891 $232 285 $2967 $1157 156 $344 $168 105 $1265 $797 59 Atlanta Womens Health Physicians Group $29 $14 107 $40 $13 208 $396 $188 111 $278 $118 135 $450 $231 95 Gwinnett Hospital $11941 $3022 295 $21654 $10096 114 $3551 $1132 214 $34384 $10800 218 $56472 $13230 327 $3003 $1244 141 $3533 $1244 184 $8984 $4607 95 $3901 $967 303 $417 $279 49 $2247 $491 358 $4000 $967 314 $3755 $967 288 $1593 $195 717 $50 $15 233 $186 $56 233 $505 $152 233 $1750 $1173 49 $418 $294 42 $1396 $907 54 Northside Hospital $15482 $4185 270 $21651 $9557 127 $4885 $2539 92 $35176 $17000 107 $35233 $20815 69 $3883 $2805 38 $5256 $3071 71 $10911 $5730 90 $4856 $1468 231 $443 $266 67 $2379 $810 194 $3776 $1398 170 $5105 $1468 248 $942 $538 75 $167 $99 69 $379 $15 2427 $433 $307 41 $2252 $1566 44 $459 $328 40 $576 $432 33 Piedmont Hospital $14772 $3837 285 $35493 $5983 493 $5069 $2012 152 $38320 $17750 116 $37125 $12105 207 $3485 $2013 73 $4993 $2013 148 $10143 $4654 118 $5939 $1117 432 $542 $305 78 $2983 $505 491 $3410 $1042 227 $6067 $1106 449 $1364 $545 150 $75 $41 85 $231 $24 863 $657 $80 721 $2041 $1388 47 $490 $431 14 $1780 $1299 37 Piedmont Physicians Group $42 $22 87 $318 $179 78 $239 $159 50 Resurgens $8558 $2036 320 $9293 $2258 312 $4638 $2067 124 $4039 $2164 87 $4392 $2164 103 $2252 $1371 64 $459 $330 39 Wellstar Hospital $9330 $3729 150 $17479 $7519 132 $5261 $1565 236 $35794 $18200 97 $46780 $14600 220 $3707 $1972 88 $4928 $1972 150 $13549 $5855 131 $5054 $2805 80 $528 $375 41 $3222 $579 457 $3694 $925 299 $5495 $2805 96 $1355 $190 615 $66 $45 46 $73 $51 43 $133 $78 71 $1785 $1125 59 $599 $425 41 $1010 $717 41 Avg Mark UpProcedure Atlanta Medical Center 634 Gwinnett Hospital 223 Northside Hospital 233 Piedmont Hospital 259 Wellstar Hospital 155 Emory 105
Atlanta Gastroenterology Associates Atlanta Medical Center Atlanta Womens Health Gwinnett Hospital Northside Hospital Piedmont Hospital Piedmont Physicians Group Resurgens Wellstar Hospital CPT Code CPT Proc Cat Comp Avg Allow Allow Allow Allow Allow Allow Allow Allow Allow 29881 KNEE ARTHROSCOPYSURGERY 6 $3179 $2266 $3022 $4185 $3837 $2036 $3729 29888 KNEE ARTHROSCOPYSURGERY 6 $6319 $2502 $10096 $9557 $5983 $2258 $7519 43239 UPPER GI ENDOSCOPY BIOPSY 6 $1727 $536 $2240 $1132 $2539 $2012 $2067 $1565 43644 LAP GASTRIC BYPASSROUX-EN-Y 1 $15810 $15300 $10800 $17000 $17750 $18200 43775 LAP SLEEVE GASTRECTOMY 1 $17800 $13230 $20815 $12105 $14600 45378 DIAGNOSTIC COLONOSCOPY 6 $1656 $536 $859 $1244 $2805 $2013 $2164 $1972 45380 COLONOSCOPY AND BIOPSY 6 $1694 $536 $859 $1244 $3071 $2013 $2164 $1972 59400 OBSTETRICAL CARE 1 $5107 $4688 $4607 $5730 $4654 $5855 70553 MRI BRAIN WO amp WDYE 2 $1482 $1052 $967 $1468 $1117 $2805 71020 CHEST X-RAY 2 $259 $72 $279 $266 $305 $375 71250 CT THORAX WO DYE 2 $541 $319 $491 $810 $505 $579 73721 MRI JNT OF LWR EXTRE WO DYE 2 $978 $557 $967 $1398 $1042 $925 74183 MRI ABDOMEN WO amp WDYE 2 $1436 $836 $967 $1468 $1106 $2805 76700 US EXAM ABDOM COMPLETE 2 $320 $133 $195 $538 $545 $190 77052 COMP SCREEN MAMMOGRAM ADD-ON 2 $45 $23 $15 $99 $41 $45 77052 COMP SCREEN MAMMOGRAM ADD-ON 5 $14 $14 80053 COMPREHEN METABOLIC PANEL 8 $29 $25 $13 $56 $15 $24 $22 $51 88305 TISSUE EXAM BY PATHOLOGIST 8 $174 $232 $188 $152 $307 $80 $179 $78 93306 TTE WDOPPLER COMPLETE 2 $1297 $1157 $1173 $1566 $1388 $1371 $1125 93017 STRESS TEST 5 $830 $797 $907 $432 $1299 $717 99203 OFFICEOUTPATIENT VISIT NEW 4 $139 $118 $159 G0202 Screeningmammographydigital 2 $329 $168 $294 $328 $431 $330 $425 G0202 Screeningmammographydigital 5 $231 $231
Service Line Procedure CPT Code Emory Atlanta Gastroenterology Associates Resurgens Atlanta Womens Health Piedmont Physicians Group Orthopedics (ASC) Knee Arthroscopy 29881 $3467 $2036 Arthroscopy Ligament Repair 29888 $3386 $2258 GI (ASC) Upper GI Endoscopy 43239 $2758 $536 Diagnostic Colonoscopy 45378 $2348 $536 Colonoscopy and biopsy 45380 $2181 $536 Radiology Mammogram Screening G0202 $164 $231 Computer Detection Add-on 77052 $93 $14 Lab Comp Metabolic Panel 80053 $53 $13 $22 Tissue Exam by Pathologist 88305 $277 $188 $179 EampM (TEC) Office Visit new pt 99203 $269 $118 $159
Service Line Procedure CPT CodeDRG Memorial Hospital Beta Hosptial Charlie Hospital Delta Hospital Echo Hospital Alpha Medical Center Atlanta Gastroenterology Associates Resurgens Atlanta Womens Health Piedmont Physicians Group Market Avg Emory abovebelow Orthopedics Arthroscopy Ligament Repair 29888 $ 5062 $ 9557 $ 5983 $ 10096 $ 7519 $ 2502 $ 2258 $ 6319 -20 Knee Arthroscopy 29881 6 $ 5069 $ 4185 $ 3837 $ 3022 $ 3729 $ 2266 $ 2036 $ 3179 59 GI Upper GI Endoscopy 43239 6 $ 3075 $ 2539 $ 2012 $ 1132 $ 1565 $ 2240 $ 536 $ 1671 84 Lap Sleeve Gastrectomy DRG 621 $ 20421 $ 20815 $ 12105 $ 13230 $ 14600 $ 17800 $ 15710 30 Colonoscopy and biopsy 45380 $ 3075 $ 3071 $ 2013 $ 1244 $ 1972 $ 859 $ 536 $ 1616 90 Diagnostic Colonoscopy 45378 6 $ 3075 $ 2805 $ 2013 $ 1244 $ 1972 $ 859 $ 536 $ 1572 96 Radiology MRI Brain w amp wo dye 70553 2 $ 1238 $ 1468 $ 1117 $ 967 $ 2805 $ 1052 $ 1482 -16 MRI Joint of Lower Extremity wo dye 73721 2 $ 1238 $ 1398 $ 1042 $ 967 $ 925 $ 557 $ 978 27 MRI Abdomen w amp wo dye 74183 2 $ 1238 $ 1468 $ 1106 $ 967 $ 2805 $ 836 $ 1436 -14 X-ray Chest 71020 $ 115 $ 266 $ 305 $ 279 $ 375 $ 72 $ 259 -56 CT Thorax wo dye 71250 $ 882 $ 810 $ 505 $ 491 $ 579 $ 319 $ 541 63 Ultrasound Abdomen Complete 76700 $ 397 $ 538 $ 545 $ 195 $ 190 $ 168 $ 327 21 Mammogram Screening G0202 2 $ 141 $ 328 $ 431 $ 294 $ 425 $ 168 $ 231 $ 313 -55 Computer Detection Add-on 77052 2 $ 112 $ 99 $ 41 $ 15 $ 45 $ 23 $ 14 $ 39 183 Lab Comp Metabolic Panel 80053 8 $ 56 $ 15 $ 24 $ 56 $ 51 $ 25 $ 13 $ 22 $ 29 88 Tissue Exam by Pathologist 88305 8 $ 236 $ 307 $ 80 $ 152 $ 78 $ 232 $ 188 $ 179 $ 174 36 Medical Cardiology Cardiovascular Stress Test 93017 $ 383 $ 432 $ 1299 $ 907 $ 717 $ 797 $ 830 -54 TTE w Doppler 93306 2 $ 960 $ 1566 $ 1388 $ 1173 $ 1125 $ 1157 $ 1282 -25 Obstetrics Vaginal Delivery DRG 755 $ 7290 $ 5730 $ 4654 $ 4607 $ 5855 $ 4688 $ 5107 43 EampM Office Visit new pt 99203 4 $ 248 $ 118 $ 159 $ 139 78 Colonoscopy and biopsy (HOSPITAL ONLY) 45380 Surg 2530 $ 307591 Diagnostic colonoscopy (HOSPITAL ONLY) 45378 Surg 2255 $ 307591 Upper gi endoscopy biopsy (HOSPITAL ONLY) 43239 Surg 1787 $ 307591 Knee Arthroscopy (HOSPITAL ONLY) 29881 Surg 10900 $ 506893 Arthroscopy Ligament Repair (HOSPITAL ONLY) 29888 Surg 10900 $ 506200 Key 1 Facility - Inpatient 2 Facility - Imaging 3 Physician - Imaging 4 Physician 5 Global - Imaging 6 Facility - Outpatient 8 Lab 41 Physician - Primary Care 42 Physician - Specialist
Blue Cross United - EJCH EUH EUHM WW United - SJH Non Options United - SJH Options Aetna - ASC TEC (HMO) Cigna - ASC TEC (HMO) Aetna - EJCH ESJH ECHM WW Cigna - EJCH (HMO) Cigna - ESJH EUHM (HMO) List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract Description CPT Code Charge Average Final Price (all plans) Emory Mark Up Reimbursement Method ( of charge or fixed) - 1713 Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Cardiovascular stress test 93017 Cardio $543 $ 425 28 of Charge 70 $ 380 of Charge 65 $ 353 of Charge 60 $ 326 of Charge 70 $ 380 of Charge 70 $ 380 of charge 100 $ 543 of Charge 70 $ 380 of charge 100 $ 543 of charge 100 $ 543 TTE wDoppler complete 93306 Cardio $1226 $ 960 28 of Charge 70 $ 858 of Charge 65 $ 797 of Charge 60 $ 736 of Charge 70 $ 858 of Charge 70 $ 858 of charge 100 $ 1226 of Charge 70 $ 858 of charge 100 $ 1226 of charge 100 $ 1226 Colonoscopy and biopsy (HOSPITAL ONLY) 45380 Surg $2530 $ 3076 -18 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 of Charge 70 $ 1771 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Diagnostic colonoscopy (HOSPITAL ONLY) 45378 Surg $2255 $ 3076 -27 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 of Charge 70 $ 1579 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Upper gi endoscopy biopsy (HOSPITAL ONLY) 43239 Surg $1787 $ 3076 -42 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Knee Arthroscopy (HOSPITAL ONLY) 29881 Surg $10900 $ 5069 115 Fixed Rate SC 4 $ 3865 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 449300 $ 4493 Fixed Rate $ 654700 $ 6547 of Charge 70 $ 7630 Fixed Rate $ 401000 $ 4010 of Charge 70 $ 7630 Fixed Rate $ 398300 $ 3983 Fixed Rate $ 398100 $ 3981 Arthroscopy Ligament Repair (HOSPITAL ONLY) 29888 Surg $10900 $ 5062 115 Fixed Rate SC 3 $ 3121 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 556900 $ 5569 Fixed Rate $ 770100 $ 7701 of Charge 70 $ 7630 Fixed Rate $ 323900 $ 3239 of Charge 70 $ 7630 Fixed Rate $ 321700 $ 3217 Fixed Rate $ 321400 $ 3214 Comp Metabolic Panel 80053 Lab $132 $ 56 138 RBRVS Fee (100) $ 1437 of Charge 65 $ 86 of Charge 65 $ 86 of Charge 65 $ 86 of Charge 70 $ 92 RBRVS Fee (100) $ 1437 $ 14 of Charge 70 $ 92 RBRVS Fee (100) $ 1437 $ 14 RBRVS Fee (100) $ 1437 $ 14 Surgical Path Tissue Exam 88305 Lab $326 $ 236 38 of Charge 150 $ 51 of Charge 65 $ 212 of Charge 65 $ 212 of Charge 65 $ 212 of Charge 70 $ 228 of charge 100 $ 326 of Charge 70 $ 228 of charge 100 $ 326 of charge 100 $ 326 MRI Abdomen 74183 Radiology $6960 $ 1238 462 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 MRI Brain 70553 Radiology $6804 $ 1238 450 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 MRI Joint Lower Extremity 73721 Radiology $3067 $ 1238 148 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 CT Thorax wo contrast 71250 Radiology $2199 $ 882 149 Fixed Rate $ 771 Fixed Rate $ 47100 $ 471 Fixed Rate $ 81700 $ 817 Fixed Rate $ 116000 $ 1160 of Charge 70 $ 1539 Fixed Rate $ 80100 $ 801 Fixed Rate $ 79200 $ 792 Fixed Rate $ 79300 $ 793 Fixed Rate $ 79500 $ 795 X-ray Chest 71020 Radiology $280 $ 115 142 of Charge 150 $ 25 of Charge 65 $ 182 of Charge 60 $ 168 of Charge 70 $ 196 of Charge 70 $ 196 RBRVS Fee (150) $ 2534 $ 25 of Charge 70 $ 196 RBRVS Fee (150) $ 2534 $ 25 RBRVS Fee (150) $ 2534 $ 25 Screening mammography G0202 Radiology $279 $ 141 98 Fixed Rate $ 128 Fixed Rate $ 13100 $ 131 Fixed Rate $ 14300 $ 143 Fixed Rate $ 16100 $ 161 of Charge 70 $ 195 Fixed Rate $ 13300 $ 133 Fixed Rate $ 13500 $ 135 Fixed Rate $ 13000 $ 130 Fixed Rate $ 11200 $ 112 Mammo Computer Aided 77052 Radiology $75 $ 112 -33 Fixed Rate $ 9 Fixed Rate $ 13100 $ 131 Fixed Rate $ 14300 $ 143 Fixed Rate $ 16100 $ 161 of Charge 70 $ 53 Fixed Rate $ 13300 $ 133 Fixed Rate $ 13500 $ 135 Fixed Rate $ 13000 $ 130 Fixed Rate $ 11200 $ 112 US Abdomen Complete 76700 Radiology $917 $ 397 131 of Charge 150 $ 125 of Charge 65 $ 596 of Charge 60 $ 550 of Charge 70 $ 642 of Charge 70 $ 642 RBRVS Fee (150) $ 12519 $ 125 of Charge 70 $ 642 RBRVS Fee (150) $ 12519 $ 125 RBRVS Fee (150) $ 12519 $ 125 Officeoutpatient visit new pt 30 min (TEC) 99203 EampM $316 $ 248 28 of Charge 70 $ 221 of Charge 65 $ 205 of Charge 60 $ 190 of Charge 70 $ 221 of Charge 70 $ 221 of charge 100 $ 316 of Charge 70 $ 221 of charge 100 $ 316 of charge 100 $ 316 Vaginal delivery 59409 Surg $14484 $ 7290 99 Fixed Rate DRG - 775 $ 5437 2 Day Case Rate + LOC 561700 $ 5617 BaseCMS Weight 584741 $ 5847 BaseCMS Weight 726146 $ 7261 No IP Terms $ - 0 No IP BaseCMS Weight 659343 $ 6593 BaseContract Weight 479451 100 $ 14484 BaseCMS Weight 579110 $ 5791 Lap Sleeve Gastrectomy 43775 Surg $29961 $ 20421 47 Fixed Rate DRG - 621 $ 14872 BaseCMS Weight 1810697 $ 18107 BaseCMS Weight 1835178 $ 18352 BaseCMS Weight 2278911 $ 22789 No IP Terms $ - 0 No IP BaseCMS Weight 2069315 $ 20693 BaseCMS Weight 1730442 100 $ 29961 BaseCMS Weight 1817507 $ 18175 105 Colonoscopy and biopsy (ASC ONLY) Surg $ 219200 $ 2181 Diagnostic colonoscopy (ASC ONLY) Surg $ 267100 $ 2348 Upper gi endoscopy biopsy (ASC ONLY) Surg $ 207500 $ 2758 Knee Arthroscopy (ASC ONLY) Surg $ 417900 $ 3467 Arthroscopy Ligament Repair (ASC ONLY) Surg $ 504800 $ 3386
Cpt Code CPT Description Procedure Category Claims Min 25thNtile 50thNtile Emorys Rates 75thNtile 90thNtile Max 20 Below 50th Ntile 20 Above 50th Ntile 93017 CARDIOVASCULAR STRESS TEST 5 82 $80 $125 $321 $382 $568 $791 $930 $257 $386 71020 CHEST X-RAY 2 2638 $11 $45 $152 $115 $289 $373 $585 $122 $182 71020 CHEST X-RAY 5 8106 $25 $34 $38 $54 $57 $69 $30 $46 45380 COLONOSCOPY AND BIOPSY 6 1256 $541 $560 $572 $2877 $1000 $2024 $3289 $458 $686 77052 COMP SCREEN MAMMOGRAM ADD-ON 2 194 $13 $15 $25 $38 $47 $134 $20 $30 77052 COMP SCREEN MAMMOGRAM ADD-ON 5 2411 $13 $16 $20 $23 $26 $28 $16 $24 80053 COMPREHEN METABOLIC PANEL 8 13019 $9 $19 $23 $55 $24 $25 $69 $19 $28 71250 CT THORAX WO DYE 2 302 $165 $372 $545 $878 $1658 $2067 $436 $654 71250 CT THORAX WO DYE 5 209 $53 $127 $203 $289 $419 $534 $162 $244 45378 DIAGNOSTIC COLONOSCOPY 6 1479 $484 $515 $536 $2914 $831 $1971 $2828 $428 $643 29881 KNEE ARTHROSCOPYSURGERY 6 152 $1650 $1826 $2036 $5235 $3054 $4216 $6461 $1629 $2443 29888 KNEE ARTHROSCOPYSURGERY 6 82 $1682 $3615 $5081 $5145 $7553 $12924 $18532 $4065 $6097 43644 LAP GASTRIC BYPASSROUX-EN-Y 1 21 $11821 $13873 $17050 $18391 $25029 $31079 $13640 $20460 43775 LAP SLEEVE GASTRECTOMY 1 38 $4215 $8250 $13253 $20421 $19197 $21509 $24260 $10602 $15903 74183 MRI ABDOMEN WO amp WDYE 2 120 $919 $987 $1015 $1237 $1252 $2534 $3177 $812 $1218 74183 MRI ABDOMEN WO amp WDYE 5 112 $475 $490 $521 $1154 $1337 $1696 $417 $625 70553 MRI BRAIN WO amp WDYE 2 324 $633 $987 $1142 $1237 $1706 $2805 $3331 $914 $1370 70553 MRI BRAIN WO amp WDYE 5 467 $280 $539 $1023 $1277 $1363 $1726 $818 $1228 73721 MRI JNT OF LWR EXTRE WO DYE 2 304 $804 $859 $967 $1237 $1063 $1598 $2485 $774 $1160 73721 MRI JNT OF LWR EXTRE WO DYE 5 1130 $500 $520 $530 $628 $679 $859 $424 $636 59400 OBSTETRICAL CARE 1 494 $3699 $4402 $4969 $6655 $7307 $8613 $3975 $5963 99203 OFFICEOUTPATIENT VISIT NEW 4 6776 $88 $101 $112 $138 $155 $169 $90 $134 G0202 Screeningmammographydigital 2 7444 $123 $206 $285 $380 $425 $479 $228 $342 G0202 Screeningmammographydigital 5 2754 $117 $165 $195 $230 $247 $252 $156 $234 88305 TISSUE EXAM BY PATHOLOGIST 8 20834 $51 $74 $112 $235 $168 $261 $478 $90 $134 93306 TTE WDOPPLER COMPLETE 2 931 $194 $377 $739 $960 $1267 $1480 $1849 $591 $887 93306 TTE WDOPPLER COMPLETE 5 2299 $151 $296 $373 $538 $573 $834 $298 $448 43239 UPPER GI ENDOSCOPY BIOPSY 6 1264 $424 $514 $550 $800 $1838 $2833 $440 $660 76700 US EXAM ABDOM COMPLETE 2 321 $96 $165 $271 $509 $584 $857 $217 $325 76700 US EXAM ABDOM COMPLETE 5 444 $111 $129 $147 $156 $220 $279 $118 $176 Key 1 Facility - Inpatient 2 Facility - Imaging 3 Physician - Imaging 4 Physician 5 Global - Imaging 6 Facility - Outpatient 8 Lab 41 Physician - Primary Care 42 Physician - Specialist Cardiovascular stress test $ 38279 TTE wDoppler complete $ 96037 Colonoscopy and biopsy $ 287709 Diagnostic colonoscopy $ 291434 Upper gi endoscopy biopsy $ 300526 Knee Arthroscopy $ 523584 Arthroscopy Ligament Repair $ 514501 Comp Metabolic Panel $ 5552 Surgical Path Tissue Exam $ 23570 MRI Abdomen $ 123786 MRI Brain $ 123786 MRI Joint Lower Extremity $ 123786 CT Thorax wo contrast $ 88213 X-ray Chest $ 11548 Screening mammography $ 14098 Mammo Computer Aided $ 11179 US Abdomen Complete $ 39695 Officeoutpatient visit new pt 30 min $ 24753 Vaginal delivery $ 729025 Lap Sleeve Gastrectomy $ 2042124
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Develop fee schedule relative to market
28
Service Line Procedure CPT CodeDRG
Memorial Hospital
Beta Hosptial
Charlie Hospital
Delta Hospital
Echo Hospital
Alpha Medical Center
Arthroscopy Ligament Repair 29888 $ 5062 $ 9557 $ 5983 $ 10096 $ 7519 $ 2502 Knee Arthroscopy 29881 $ 5069 $ 4185 $ 3837 $ 3022 $ 3729 $ 2266 Upper GI Endoscopy 43239 $ 3075 $ 2539 $ 2012 $ 1132 $ 1565 $ 2240 Lap Sleeve Gastrectomy DRG 621 $ 20421 $ 20815 $ 12105 $ 13230 $ 14600 $ 17800 Colonoscopy and biopsy 45380 $ 3075 $ 3071 $ 2013 $ 1244 $ 1972 $ 859 Diagnostic Colonoscopy 45378 $ 3075 $ 2805 $ 2013 $ 1244 $ 1972 $ 859 MRI Brain w amp wo dye 70553 $ 1238 $ 1468 $ 1117 $ 967 $ 2805 $ 1052 MRI Joint of Lower Extremity wo dye 73721 $ 1238 $ 1398 $ 1042 $ 967 $ 925 $ 557 MRI Abdomen w amp wo dye 74183 $ 1238 $ 1468 $ 1106 $ 967 $ 2805 $ 836 X-ray Chest 71020 $ 115 $ 266 $ 305 $ 279 $ 375 $ 72 CT Thorax wo dye 71250 $ 882 $ 810 $ 505 $ 491 $ 579 $ 319 Ultrasound Abdomen Complete 76700 $ 397 $ 538 $ 545 $ 195 $ 190 $ 168 Mammogram Screening G0202 $ 141 $ 328 $ 431 $ 294 $ 425 $ 168 Computer Detection Add-on 77052 $ 112 $ 99 $ 41 $ 15 $ 45 $ 23 Comp Metabolic Panel 80053 $ 56 $ 15 $ 24 $ 56 $ 51 $ 25 Tissue Exam by Pathologist 88305 $ 236 $ 307 $ 80 $ 152 $ 78 $ 232 Cardiovascular Stress Test 93017 $ 383 $ 432 $ 1299 $ 907 $ 717 $ 797 TTE w Doppler 93306 $ 960 $ 1566 $ 1388 $ 1173 $ 1125 $ 1157
Obstetrics Vaginal Delivery DRG 755 7290$ 5730$ 4654$ 4607$ 5855$ 4688$
GI
Lab
Radiology
Medical Cardiology
Orthopedics
KEY OBSERVA TIONS bull Potential exposure on GI bull Opportunity to align price and acuity in MRI bull Opportunity to raise rates on chest x-ray and mammogram
Percentile Bands Emory Allowables Heatmap TEC ASC Heatmap Allowable Comp Analysis Portal Pricing Sheet1 image1png A few words on Bundled Payments bull Bundled payments are growing as a type of direct contracting bull In some cases third parties match-make between employers
and providers bull Contracts may vary in definitions prepost admission
coverage duration readmission cause (ie all-cause vs medically related) outlier provisions LOS caps andor per diems
bull Providers need to be strategic in pricing to enable profitable growth of market share
29
Considerations in Offering Development bull Network Development
bull Build off existing structure eg health system employee plan network bull How does this fit into your broader value based care strategy bull Employed and independent physicians bull How do you want to approach the buildout of high performance
network bull Quality focus bull Cost efficiency
bull Integrated behavioral health bull Wrap network for other markets
30
Considerations in Offering Development bull Target Market
bull Consideration of employer profile in market bull Fully-insured vs ASO bull Total cost of care vs bundled services
bull Distribution bull Direct marketing bull Brokerconsultant community
bull Plan designs bull Standard designs vs flexible ndash Dependent on target market
bull Claims administration bull Data sharing amp analytics
31
Considerations in Offering Development bull Other components of comprehensive offering
bull Pharmacy bull Preventive health bull Onsite clinics bull Wellness programs bull Technology platform
32
Sample Bundle Analysis
33
Cover page Dotson Hazelrigs Nation Mainly of charge of fixed Cardiovascular stress test TTE wDoppler complete Colonoscopy and biopsy (Combined) Diagnostic colonoscopy (Combined) Upper gi endoscopy biopsy (Combined) Knee Arthroscopy (Combined) Arthroscopy Ligament Repair Comp Metabolic Panel Surgical Path Tissue Exam MRI Abdomen MRI Brain MRI Joint Lower Extremity CT Thorax wo contrast X-ray Chest Screening mammography Mammo Computer Aided US Abdomen Complete Officeoutpatient visit new pt 30 min Vaginal delivery Lap Sleeve Gastrectomy
Piedmont Piedmont Piedmont Piedmont Northside Northside Northside Northside Gwinnett Gwinnett Gwinnett Gwinnett WellStar WellStar WellStar WellStar AMC - Tenet AMC - Tenet AMC - Tenet AMC - Tenet CPT Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing Anthem Pricing Cigna Pricing Aetnat Pricing UHC Pricing 29881 $11312 $10872 NA NA $7476 $9338 NA $23655 $11856 $3668 NA $17871 $12253 NA NA $15645 $5490 NA NA $23039 29888 NA NA NA NA NA NA NA $23784 NA $8261 NA $18000 NA NA NA $15774 NA NA NA $23168 43239 NA $4408 NA NA NA NA $5997 $8852 NA $3304 NA $7424 $1267 NA NA $9230 NA $2458 NA $8274 43644 $26468 NA NA NA $3382 $12050 NA $1861 NA NA NA $1316 $7841 NA NA $3444 $18892 $27950 NA $979 43775 NA NA NA NA NA NA NA $352 NA NA NA $302 NA NA NA $413 NA NA NA $83 45378 $2705 $2530 NA NA $4381 $3676 $4496 $1022 $2938 $2138 NA $695 $5504 NA NA $2036 NA NA NA $372 45380 $3075 $2600 NA NA $4723 $3527 $3012 $1757 $4215 $2285 NA NA $5298 NA NA $3268 NA NA NA $627 59400 $6160 NA NA NA NA $5100 NA $1851 NA NA NA $1304 $9035 NA NA $3427 $9116 $5150 NA $966 70553 $2985 NA $1153 NA $2182 NA $1192 $492 NA NA $803 $489 $1512 NA $985 $1187 NA NA NA $197 71020 $61 $69 $43 NA $113 $319 $307 NA $183 $59 $32 NA $213 $66 $40 NA $83 $53 NA NA 71250 $1837 $621 $989 NA $1490 $931 $755 NA NA $745 $401 NA $1067 $982 $616 NA NA $304 NA NA 73721 NA $1098 $1153 NA $2042 $1065 $1192 NA NA $998 $803 NA NA $1275 $985 NA NA $644 NA $178 74183 $2971 $1144 NA NA NA $1092 $1192 $6884 NA $1098 $803 NA $2960 $1197 $985 $5454 NA NA NA $7607 76700 $364 $247 $207 NA $427 $708 $614 $13267 $428 $214 $152 NA $747 $263 $189 $9139 NA $235 NA NA 77052 NA NA NA NA NA NA NA $4744 NA NA NA NA NA NA NA $3070 NA NA NA $5611 93306 $1220 $1117 NA NA $1877 $1657 $2100 $4605 $1433 $413 $945 NA $1336 $1434 $1951 $2931 NA $2399 NA $5472 G0202 $262 $187 NA NA $431 NA NA $4605 $292 NA NA NA $530 $281 NA $2931 $327 NA NA $5472
Provider Group 29881_6 29888_6 43239_6 43644_1 43775_1 45378_6 45380_6 59400_1 70553_2 71020_2 71250_2 73721_2 74183_2 76700_2 77052_2 77052_5 80053_8 88305_8 93306_2 99203_4 G0202_2 G0202_5 93017_2 Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Submit Allow Markup Atlanta Gastroenterology Associates $2399 $536 348 $1628 $536 204 $2400 $536 348 Atlanta Medical Center $24889 $2266 999 $25897 $2502 935 $11449 $2240 411 $81927 $15300 435 $75815 $17800 326 $7317 $859 752 $7317 $859 752 $12821 $4688 173 $6581 $1052 526 $645 $72 796 $3265 $319 925 $3450 $557 519 $7398 $836 785 $1576 $133 1084 $73 $23 217 $635 $25 2440 $891 $232 285 $2967 $1157 156 $344 $168 105 $1265 $797 59 Atlanta Womens Health Physicians Group $29 $14 107 $40 $13 208 $396 $188 111 $278 $118 135 $450 $231 95 Gwinnett Hospital $11941 $3022 295 $21654 $10096 114 $3551 $1132 214 $34384 $10800 218 $56472 $13230 327 $3003 $1244 141 $3533 $1244 184 $8984 $4607 95 $3901 $967 303 $417 $279 49 $2247 $491 358 $4000 $967 314 $3755 $967 288 $1593 $195 717 $50 $15 233 $186 $56 233 $505 $152 233 $1750 $1173 49 $418 $294 42 $1396 $907 54 Northside Hospital $15482 $4185 270 $21651 $9557 127 $4885 $2539 92 $35176 $17000 107 $35233 $20815 69 $3883 $2805 38 $5256 $3071 71 $10911 $5730 90 $4856 $1468 231 $443 $266 67 $2379 $810 194 $3776 $1398 170 $5105 $1468 248 $942 $538 75 $167 $99 69 $379 $15 2427 $433 $307 41 $2252 $1566 44 $459 $328 40 $576 $432 33 Piedmont Hospital $14772 $3837 285 $35493 $5983 493 $5069 $2012 152 $38320 $17750 116 $37125 $12105 207 $3485 $2013 73 $4993 $2013 148 $10143 $4654 118 $5939 $1117 432 $542 $305 78 $2983 $505 491 $3410 $1042 227 $6067 $1106 449 $1364 $545 150 $75 $41 85 $231 $24 863 $657 $80 721 $2041 $1388 47 $490 $431 14 $1780 $1299 37 Piedmont Physicians Group $42 $22 87 $318 $179 78 $239 $159 50 Resurgens $8558 $2036 320 $9293 $2258 312 $4638 $2067 124 $4039 $2164 87 $4392 $2164 103 $2252 $1371 64 $459 $330 39 Wellstar Hospital $9330 $3729 150 $17479 $7519 132 $5261 $1565 236 $35794 $18200 97 $46780 $14600 220 $3707 $1972 88 $4928 $1972 150 $13549 $5855 131 $5054 $2805 80 $528 $375 41 $3222 $579 457 $3694 $925 299 $5495 $2805 96 $1355 $190 615 $66 $45 46 $73 $51 43 $133 $78 71 $1785 $1125 59 $599 $425 41 $1010 $717 41 Avg Mark UpProcedure Atlanta Medical Center 634 Gwinnett Hospital 223 Northside Hospital 233 Piedmont Hospital 259 Wellstar Hospital 155 Emory 105
Atlanta Gastroenterology Associates Atlanta Medical Center Atlanta Womens Health Gwinnett Hospital Northside Hospital Piedmont Hospital Piedmont Physicians Group Resurgens Wellstar Hospital CPT Code CPT Proc Cat Comp Avg Allow Allow Allow Allow Allow Allow Allow Allow Allow 29881 KNEE ARTHROSCOPYSURGERY 6 $3179 $2266 $3022 $4185 $3837 $2036 $3729 29888 KNEE ARTHROSCOPYSURGERY 6 $6319 $2502 $10096 $9557 $5983 $2258 $7519 43239 UPPER GI ENDOSCOPY BIOPSY 6 $1727 $536 $2240 $1132 $2539 $2012 $2067 $1565 43644 LAP GASTRIC BYPASSROUX-EN-Y 1 $15810 $15300 $10800 $17000 $17750 $18200 43775 LAP SLEEVE GASTRECTOMY 1 $17800 $13230 $20815 $12105 $14600 45378 DIAGNOSTIC COLONOSCOPY 6 $1656 $536 $859 $1244 $2805 $2013 $2164 $1972 45380 COLONOSCOPY AND BIOPSY 6 $1694 $536 $859 $1244 $3071 $2013 $2164 $1972 59400 OBSTETRICAL CARE 1 $5107 $4688 $4607 $5730 $4654 $5855 70553 MRI BRAIN WO amp WDYE 2 $1482 $1052 $967 $1468 $1117 $2805 71020 CHEST X-RAY 2 $259 $72 $279 $266 $305 $375 71250 CT THORAX WO DYE 2 $541 $319 $491 $810 $505 $579 73721 MRI JNT OF LWR EXTRE WO DYE 2 $978 $557 $967 $1398 $1042 $925 74183 MRI ABDOMEN WO amp WDYE 2 $1436 $836 $967 $1468 $1106 $2805 76700 US EXAM ABDOM COMPLETE 2 $320 $133 $195 $538 $545 $190 77052 COMP SCREEN MAMMOGRAM ADD-ON 2 $45 $23 $15 $99 $41 $45 77052 COMP SCREEN MAMMOGRAM ADD-ON 5 $14 $14 80053 COMPREHEN METABOLIC PANEL 8 $29 $25 $13 $56 $15 $24 $22 $51 88305 TISSUE EXAM BY PATHOLOGIST 8 $174 $232 $188 $152 $307 $80 $179 $78 93306 TTE WDOPPLER COMPLETE 2 $1297 $1157 $1173 $1566 $1388 $1371 $1125 93017 STRESS TEST 5 $830 $797 $907 $432 $1299 $717 99203 OFFICEOUTPATIENT VISIT NEW 4 $139 $118 $159 G0202 Screeningmammographydigital 2 $329 $168 $294 $328 $431 $330 $425 G0202 Screeningmammographydigital 5 $231 $231
Service Line Procedure CPT Code Emory Atlanta Gastroenterology Associates Resurgens Atlanta Womens Health Piedmont Physicians Group Orthopedics (ASC) Knee Arthroscopy 29881 $3467 $2036 Arthroscopy Ligament Repair 29888 $3386 $2258 GI (ASC) Upper GI Endoscopy 43239 $2758 $536 Diagnostic Colonoscopy 45378 $2348 $536 Colonoscopy and biopsy 45380 $2181 $536 Radiology Mammogram Screening G0202 $164 $231 Computer Detection Add-on 77052 $93 $14 Lab Comp Metabolic Panel 80053 $53 $13 $22 Tissue Exam by Pathologist 88305 $277 $188 $179 EampM (TEC) Office Visit new pt 99203 $269 $118 $159
Service Line Procedure CPT CodeDRG Memorial Hospital Beta Hosptial Charlie Hospital Delta Hospital Echo Hospital Alpha Medical Center Atlanta Gastroenterology Associates Resurgens Atlanta Womens Health Piedmont Physicians Group Market Avg Emory abovebelow Orthopedics Arthroscopy Ligament Repair 29888 $ 5062 $ 9557 $ 5983 $ 10096 $ 7519 $ 2502 $ 2258 $ 6319 -20 Knee Arthroscopy 29881 6 $ 5069 $ 4185 $ 3837 $ 3022 $ 3729 $ 2266 $ 2036 $ 3179 59 GI Upper GI Endoscopy 43239 6 $ 3075 $ 2539 $ 2012 $ 1132 $ 1565 $ 2240 $ 536 $ 1671 84 Lap Sleeve Gastrectomy DRG 621 $ 20421 $ 20815 $ 12105 $ 13230 $ 14600 $ 17800 $ 15710 30 Colonoscopy and biopsy 45380 $ 3075 $ 3071 $ 2013 $ 1244 $ 1972 $ 859 $ 536 $ 1616 90 Diagnostic Colonoscopy 45378 6 $ 3075 $ 2805 $ 2013 $ 1244 $ 1972 $ 859 $ 536 $ 1572 96 Radiology MRI Brain w amp wo dye 70553 2 $ 1238 $ 1468 $ 1117 $ 967 $ 2805 $ 1052 $ 1482 -16 MRI Joint of Lower Extremity wo dye 73721 2 $ 1238 $ 1398 $ 1042 $ 967 $ 925 $ 557 $ 978 27 MRI Abdomen w amp wo dye 74183 2 $ 1238 $ 1468 $ 1106 $ 967 $ 2805 $ 836 $ 1436 -14 X-ray Chest 71020 $ 115 $ 266 $ 305 $ 279 $ 375 $ 72 $ 259 -56 CT Thorax wo dye 71250 $ 882 $ 810 $ 505 $ 491 $ 579 $ 319 $ 541 63 Ultrasound Abdomen Complete 76700 $ 397 $ 538 $ 545 $ 195 $ 190 $ 168 $ 327 21 Mammogram Screening G0202 2 $ 141 $ 328 $ 431 $ 294 $ 425 $ 168 $ 231 $ 313 -55 Computer Detection Add-on 77052 2 $ 112 $ 99 $ 41 $ 15 $ 45 $ 23 $ 14 $ 39 183 Lab Comp Metabolic Panel 80053 8 $ 56 $ 15 $ 24 $ 56 $ 51 $ 25 $ 13 $ 22 $ 29 88 Tissue Exam by Pathologist 88305 8 $ 236 $ 307 $ 80 $ 152 $ 78 $ 232 $ 188 $ 179 $ 174 36 Medical Cardiology Cardiovascular Stress Test 93017 $ 383 $ 432 $ 1299 $ 907 $ 717 $ 797 $ 830 -54 TTE w Doppler 93306 2 $ 960 $ 1566 $ 1388 $ 1173 $ 1125 $ 1157 $ 1282 -25 Obstetrics Vaginal Delivery DRG 755 $ 7290 $ 5730 $ 4654 $ 4607 $ 5855 $ 4688 $ 5107 43 EampM Office Visit new pt 99203 4 $ 248 $ 118 $ 159 $ 139 78 Colonoscopy and biopsy (HOSPITAL ONLY) 45380 Surg 2530 $ 307591 Diagnostic colonoscopy (HOSPITAL ONLY) 45378 Surg 2255 $ 307591 Upper gi endoscopy biopsy (HOSPITAL ONLY) 43239 Surg 1787 $ 307591 Knee Arthroscopy (HOSPITAL ONLY) 29881 Surg 10900 $ 506893 Arthroscopy Ligament Repair (HOSPITAL ONLY) 29888 Surg 10900 $ 506200 Key 1 Facility - Inpatient 2 Facility - Imaging 3 Physician - Imaging 4 Physician 5 Global - Imaging 6 Facility - Outpatient 8 Lab 41 Physician - Primary Care 42 Physician - Specialist
Blue Cross United - EJCH EUH EUHM WW United - SJH Non Options United - SJH Options Aetna - ASC TEC (HMO) Cigna - ASC TEC (HMO) Aetna - EJCH ESJH ECHM WW Cigna - EJCH (HMO) Cigna - ESJH EUHM (HMO) List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract List Hospital(s) Covered Under Contract Description CPT Code Charge Average Final Price (all plans) Emory Mark Up Reimbursement Method ( of charge or fixed) - 1713 Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Reimbursement Method ( of charge or fixed) Allowed Rate (if fixed) of charge rate Final Price Cardiovascular stress test 93017 Cardio $543 $ 425 28 of Charge 70 $ 380 of Charge 65 $ 353 of Charge 60 $ 326 of Charge 70 $ 380 of Charge 70 $ 380 of charge 100 $ 543 of Charge 70 $ 380 of charge 100 $ 543 of charge 100 $ 543 TTE wDoppler complete 93306 Cardio $1226 $ 960 28 of Charge 70 $ 858 of Charge 65 $ 797 of Charge 60 $ 736 of Charge 70 $ 858 of Charge 70 $ 858 of charge 100 $ 1226 of Charge 70 $ 858 of charge 100 $ 1226 of charge 100 $ 1226 Colonoscopy and biopsy (HOSPITAL ONLY) 45380 Surg $2530 $ 3076 -18 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 of Charge 70 $ 1771 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Diagnostic colonoscopy (HOSPITAL ONLY) 45378 Surg $2255 $ 3076 -27 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 of Charge 70 $ 1579 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Upper gi endoscopy biopsy (HOSPITAL ONLY) 43239 Surg $1787 $ 3076 -42 Fixed Rate SC 2 $ 2725 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 198600 $ 1986 Fixed Rate $ 349600 $ 3496 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 282800 $ 2828 Fixed Rate $ 268800 $ 2688 Fixed Rate $ 280900 $ 2809 Fixed Rate $ 284300 $ 2843 Knee Arthroscopy (HOSPITAL ONLY) 29881 Surg $10900 $ 5069 115 Fixed Rate SC 4 $ 3865 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 449300 $ 4493 Fixed Rate $ 654700 $ 6547 of Charge 70 $ 7630 Fixed Rate $ 401000 $ 4010 of Charge 70 $ 7630 Fixed Rate $ 398300 $ 3983 Fixed Rate $ 398100 $ 3981 Arthroscopy Ligament Repair (HOSPITAL ONLY) 29888 Surg $10900 $ 5062 115 Fixed Rate SC 3 $ 3121 Fixed Rate $ 498400 $ 4984 Fixed Rate $ 556900 $ 5569 Fixed Rate $ 770100 $ 7701 of Charge 70 $ 7630 Fixed Rate $ 323900 $ 3239 of Charge 70 $ 7630 Fixed Rate $ 321700 $ 3217 Fixed Rate $ 321400 $ 3214 Comp Metabolic Panel 80053 Lab $132 $ 56 138 RBRVS Fee (100) $ 1437 of Charge 65 $ 86 of Charge 65 $ 86 of Charge 65 $ 86 of Charge 70 $ 92 RBRVS Fee (100) $ 1437 $ 14 of Charge 70 $ 92 RBRVS Fee (100) $ 1437 $ 14 RBRVS Fee (100) $ 1437 $ 14 Surgical Path Tissue Exam 88305 Lab $326 $ 236 38 of Charge 150 $ 51 of Charge 65 $ 212 of Charge 65 $ 212 of Charge 65 $ 212 of Charge 70 $ 228 of charge 100 $ 326 of Charge 70 $ 228 of charge 100 $ 326 of charge 100 $ 326 MRI Abdomen 74183 Radiology $6960 $ 1238 462 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 MRI Brain 70553 Radiology $6804 $ 1238 450 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 MRI Joint Lower Extremity 73721 Radiology $3067 $ 1238 148 Fixed Rate $ 1165 Fixed Rate $ 112900 $ 1129 Fixed Rate $ 138800 $ 1388 Fixed Rate $ 150100 $ 1501 of Charge 70 Fixed Rate $ 120900 $ 1209 Fixed Rate $ 111300 $ 1113 Fixed Rate $ 120000 $ 1200 Fixed Rate $ 119800 $ 1198 CT Thorax wo contrast 71250 Radiology $2199 $ 882 149 Fixed Rate $ 771 Fixed Rate $ 47100 $ 471 Fixed Rate $ 81700 $ 817 Fixed Rate $ 116000 $ 1160 of Charge 70 $ 1539 Fixed Rate $ 80100 $ 801 Fixed Rate $ 79200 $ 792 Fixed Rate $ 79300 $ 793 Fixed Rate $ 79500 $ 795 X-ray Chest 71020 Radiology $280 $ 115 142 of Charge 150 $ 25 of Charge 65 $ 182 of Charge 60 $ 168 of Charge 70 $ 196 of Charge 70 $ 196 RBRVS Fee (150) $ 2534 $ 25 of Charge 70 $ 196 RBRVS Fee (150) $ 2534 $ 25 RBRVS Fee (150) $ 2534 $ 25 Screening mammography G0202 Radiology $279 $ 141 98 Fixed Rate $ 128 Fixed Rate $ 13100 $ 131 Fixed Rate $ 14300 $ 143 Fixed Rate $ 16100 $ 161 of Charge 70 $ 195 Fixed Rate $ 13300 $ 133 Fixed Rate $ 13500 $ 135 Fixed Rate $ 13000 $ 130 Fixed Rate $ 11200 $ 112 Mammo Computer Aided 77052 Radiology $75 $ 112 -33 Fixed Rate $ 9 Fixed Rate $ 13100 $ 131 Fixed Rate $ 14300 $ 143 Fixed Rate $ 16100 $ 161 of Charge 70 $ 53 Fixed Rate $ 13300 $ 133 Fixed Rate $ 13500 $ 135 Fixed Rate $ 13000 $ 130 Fixed Rate $ 11200 $ 112 US Abdomen Complete 76700 Radiology $917 $ 397 131 of Charge 150 $ 125 of Charge 65 $ 596 of Charge 60 $ 550 of Charge 70 $ 642 of Charge 70 $ 642 RBRVS Fee (150) $ 12519 $ 125 of Charge 70 $ 642 RBRVS Fee (150) $ 12519 $ 125 RBRVS Fee (150) $ 12519 $ 125 Officeoutpatient visit new pt 30 min (TEC) 99203 EampM $316 $ 248 28 of Charge 70 $ 221 of Charge 65 $ 205 of Charge 60 $ 190 of Charge 70 $ 221 of Charge 70 $ 221 of charge 100 $ 316 of Charge 70 $ 221 of charge 100 $ 316 of charge 100 $ 316 Vaginal delivery 59409 Surg $14484 $ 7290 99 Fixed Rate DRG - 775 $ 5437 2 Day Case Rate + LOC 561700 $ 5617 BaseCMS Weight 584741 $ 5847 BaseCMS Weight 726146 $ 7261 No IP Terms $ - 0 No IP BaseCMS Weight 659343 $ 6593 BaseContract Weight 479451 100 $ 14484 BaseCMS Weight 579110 $ 5791 Lap Sleeve Gastrectomy 43775 Surg $29961 $ 20421 47 Fixed Rate DRG - 621 $ 14872 BaseCMS Weight 1810697 $ 18107 BaseCMS Weight 1835178 $ 18352 BaseCMS Weight 2278911 $ 22789 No IP Terms $ - 0 No IP BaseCMS Weight 2069315 $ 20693 BaseCMS Weight 1730442 100 $ 29961 BaseCMS Weight 1817507 $ 18175 105 Colonoscopy and biopsy (ASC ONLY) Surg $ 219200 $ 2181 Diagnostic colonoscopy (ASC ONLY) Surg $ 267100 $ 2348 Upper gi endoscopy biopsy (ASC ONLY) Surg $ 207500 $ 2758 Knee Arthroscopy (ASC ONLY) Surg $ 417900 $ 3467 Arthroscopy Ligament Repair (ASC ONLY) Surg $ 504800 $ 3386
Cpt Code CPT Description Procedure Category Claims Min 25thNtile 50thNtile Emorys Rates 75thNtile 90thNtile Max 20 Below 50th Ntile 20 Above 50th Ntile 93017 CARDIOVASCULAR STRESS TEST 5 82 $80 $125 $321 $382 $568 $791 $930 $257 $386 71020 CHEST X-RAY 2 2638 $11 $45 $152 $115 $289 $373 $585 $122 $182 71020 CHEST X-RAY 5 8106 $25 $34 $38 $54 $57 $69 $30 $46 45380 COLONOSCOPY AND BIOPSY 6 1256 $541 $560 $572 $2877 $1000 $2024 $3289 $458 $686 77052 COMP SCREEN MAMMOGRAM ADD-ON 2 194 $13 $15 $25 $38 $47 $134 $20 $30 77052 COMP SCREEN MAMMOGRAM ADD-ON 5 2411 $13 $16 $20 $23 $26 $28 $16 $24 80053 COMPREHEN METABOLIC PANEL 8 13019 $9 $19 $23 $55 $24 $25 $69 $19 $28 71250 CT THORAX WO DYE 2 302 $165 $372 $545 $878 $1658 $2067 $436 $654 71250 CT THORAX WO DYE 5 209 $53 $127 $203 $289 $419 $534 $162 $244 45378 DIAGNOSTIC COLONOSCOPY 6 1479 $484 $515 $536 $2914 $831 $1971 $2828 $428 $643 29881 KNEE ARTHROSCOPYSURGERY 6 152 $1650 $1826 $2036 $5235 $3054 $4216 $6461 $1629 $2443 29888 KNEE ARTHROSCOPYSURGERY 6 82 $1682 $3615 $5081 $5145 $7553 $12924 $18532 $4065 $6097 43644 LAP GASTRIC BYPASSROUX-EN-Y 1 21 $11821 $13873 $17050 $18391 $25029 $31079 $13640 $20460 43775 LAP SLEEVE GASTRECTOMY 1 38 $4215 $8250 $13253 $20421 $19197 $21509 $24260 $10602 $15903 74183 MRI ABDOMEN WO amp WDYE 2 120 $919 $987 $1015 $1237 $1252 $2534 $3177 $812 $1218 74183 MRI ABDOMEN WO amp WDYE 5 112 $475 $490 $521 $1154 $1337 $1696 $417 $625 70553 MRI BRAIN WO amp WDYE 2 324 $633 $987 $1142 $1237 $1706 $2805 $3331 $914 $1370 70553 MRI BRAIN WO amp WDYE 5 467 $280 $539 $1023 $1277 $1363 $1726 $818 $1228 73721 MRI JNT OF LWR EXTRE WO DYE 2 304 $804 $859 $967 $1237 $1063 $1598 $2485 $774 $1160 73721 MRI JNT OF LWR EXTRE WO DYE 5 1130 $500 $520 $530 $628 $679 $859 $424 $636 59400 OBSTETRICAL CARE 1 494 $3699 $4402 $4969 $6655 $7307 $8613 $3975 $5963 99203 OFFICEOUTPATIENT VISIT NEW 4 6776 $88 $101 $112 $138 $155 $169 $90 $134 G0202 Screeningmammographydigital 2 7444 $123 $206 $285 $380 $425 $479 $228 $342 G0202 Screeningmammographydigital 5 2754 $117 $165 $195 $230 $247 $252 $156 $234 88305 TISSUE EXAM BY PATHOLOGIST 8 20834 $51 $74 $112 $235 $168 $261 $478 $90 $134 93306 TTE WDOPPLER COMPLETE 2 931 $194 $377 $739 $960 $1267 $1480 $1849 $591 $887 93306 TTE WDOPPLER COMPLETE 5 2299 $151 $296 $373 $538 $573 $834 $298 $448 43239 UPPER GI ENDOSCOPY BIOPSY 6 1264 $424 $514 $550 $800 $1838 $2833 $440 $660 76700 US EXAM ABDOM COMPLETE 2 321 $96 $165 $271 $509 $584 $857 $217 $325 76700 US EXAM ABDOM COMPLETE 5 444 $111 $129 $147 $156 $220 $279 $118 $176 Key 1 Facility - Inpatient 2 Facility - Imaging 3 Physician - Imaging 4 Physician 5 Global - Imaging 6 Facility - Outpatient 8 Lab 41 Physician - Primary Care 42 Physician - Specialist Cardiovascular stress test $ 38279 TTE wDoppler complete $ 96037 Colonoscopy and biopsy $ 287709 Diagnostic colonoscopy $ 291434 Upper gi endoscopy biopsy $ 300526 Knee Arthroscopy $ 523584 Arthroscopy Ligament Repair $ 514501 Comp Metabolic Panel $ 5552 Surgical Path Tissue Exam $ 23570 MRI Abdomen $ 123786 MRI Brain $ 123786 MRI Joint Lower Extremity $ 123786 CT Thorax wo contrast $ 88213 X-ray Chest $ 11548 Screening mammography $ 14098 Mammo Computer Aided $ 11179 US Abdomen Complete $ 39695 Officeoutpatient visit new pt 30 min $ 24753 Vaginal delivery $ 729025 Lap Sleeve Gastrectomy $ 2042124
Page 30
A few words on Bundled Payments bull Bundled payments are growing as a type of direct contracting bull In some cases third parties match-make between employers
and providers bull Contracts may vary in definitions prepost admission
coverage duration readmission cause (ie all-cause vs medically related) outlier provisions LOS caps andor per diems
bull Providers need to be strategic in pricing to enable profitable growth of market share
29
Considerations in Offering Development bull Network Development
bull Build off existing structure eg health system employee plan network bull How does this fit into your broader value based care strategy bull Employed and independent physicians bull How do you want to approach the buildout of high performance
network bull Quality focus bull Cost efficiency
bull Integrated behavioral health bull Wrap network for other markets
30
Considerations in Offering Development bull Target Market
bull Consideration of employer profile in market bull Fully-insured vs ASO bull Total cost of care vs bundled services
bull Distribution bull Direct marketing bull Brokerconsultant community
bull Plan designs bull Standard designs vs flexible ndash Dependent on target market
bull Claims administration bull Data sharing amp analytics
31
Considerations in Offering Development bull Other components of comprehensive offering
bull Pharmacy bull Preventive health bull Onsite clinics bull Wellness programs bull Technology platform
32
Sample Bundle Analysis
33
Cover page Dotson Hazelrigs Nation Page 31
Considerations in Offering Development bull Network Development
bull Build off existing structure eg health system employee plan network bull How does this fit into your broader value based care strategy bull Employed and independent physicians bull How do you want to approach the buildout of high performance
network bull Quality focus bull Cost efficiency
bull Integrated behavioral health bull Wrap network for other markets
30
Considerations in Offering Development bull Target Market
bull Consideration of employer profile in market bull Fully-insured vs ASO bull Total cost of care vs bundled services
bull Distribution bull Direct marketing bull Brokerconsultant community
bull Plan designs bull Standard designs vs flexible ndash Dependent on target market
bull Claims administration bull Data sharing amp analytics
31
Considerations in Offering Development bull Other components of comprehensive offering
bull Pharmacy bull Preventive health bull Onsite clinics bull Wellness programs bull Technology platform
32
Sample Bundle Analysis
33
Cover page Dotson Hazelrigs Nation Page 32
Considerations in Offering Development bull Target Market
bull Consideration of employer profile in market bull Fully-insured vs ASO bull Total cost of care vs bundled services
bull Distribution bull Direct marketing bull Brokerconsultant community
bull Plan designs bull Standard designs vs flexible ndash Dependent on target market
bull Claims administration bull Data sharing amp analytics
31
Considerations in Offering Development bull Other components of comprehensive offering
bull Pharmacy bull Preventive health bull Onsite clinics bull Wellness programs bull Technology platform
32
Sample Bundle Analysis
33
Cover page Dotson Hazelrigs Nation Page 33
Considerations in Offering Development bull Other components of comprehensive offering
bull Pharmacy bull Preventive health bull Onsite clinics bull Wellness programs bull Technology platform
32
Sample Bundle Analysis
33
Cover page Dotson Hazelrigs Nation Page 34
Sample Bundle Analysis
33
Cover page Dotson Hazelrigs Nation Page 35
Cover page Dotson Hazelrigs Nation 
