Financial and Population Analytics for Accountable Care Organizations SEPTEMBER 20, 2012

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1 Financial and Population Analytics for Accountable Care Organizations

2 Valence Biographies Lori Fox Ward is Senior Vice President of Clinical Integration for Valence Health where her primary role involves development and execution, and marketing and sales of Valence Health s clinical integration solutions, along with management of new client installations. In this capacity, she is responsible for program design, work plan/key milestone mapping, and project management. Ms. Ward is a registered nurse with clinical experience in the fields of orthopedics, neurology and geriatrics and received a bachelor of science in nursing from the University of Iowa. She can be reached at or lfox@valencehealth.com Elizabeth Simpkin is Senior Vice President of Consulting Services for Valence Health, where she helps leaders of provider organizations improve and demonstrate quality of care and strengthen their market position. Ms. Simpkin has assisted numerous IPAs and PHOs with clinical integration and ACO program development and implementation, as well as negotiating quality-based pay-for-performance contracts. Liz has a Master s degree in Healthcare Economics from Arizona State University s W.P. Carey School of Business; and over 20 years experience working with providers, employers and payers. She can be reached at or esimpkin@valencehealth.com

3 Today s Topics Trends in ACO Development Think Like a Health Plan for ACO Financial Success Key Strategies for Population Management Questions and Discussion

4 Trends in ACO Development CMS Accountable Care models Pioneer ACOs - 32 Medicare Shared Savings Program PGP Transition Demo - 6 Advanced Payment Model million beneficiaries served by Medicare ACOs Commercial activity Brookings-Dartmouth Pilots - 5 Premier Implementation - 23 Cigna - 26 AQC - 16 in Massachusetts AMGA Collaborative 16 Other private-sector ACOs - 37 The Engelberg Center for Health Care Reform at Brookings The Dartmouth Institute

5 ACO Trends Nationally 250+ ACOs in 45 states Centered in larger population centers Multiple ACOs competing in the same market Hospitals systems predominate, but physician-led groups have seen most growth recently Non-Medicare ACOs experimenting with more diverse models

6 Roadmap to Accountable Care Integration Delivery System Improvement Accountability Create an Integrated organization Culture and capabilities to organize for and deliver coordinated care Implement programs to support efficient, effective care delivery Leadership and governance to value and deliver results Expertise and financial/management processes Monitor results; manage risk & reward

7 Accountable Care Cornerstones Clinical Integration Care Coordination ACO Information Technology Financial Management Cost U'liza'on Quality

8 Think Like a Health Plan Financial Management strategy Budget IBNR Reinsurance Be prepared to negotiate contracts Project and validate shared savings earning Analytics strategy Cost Drivers Key Indicators Benchmarks Physician Practice Variations

9 Analytics and Medical Economics Cost Drivers Key Indicators MLR Benchmarks PCP Patient Panel Focus High Risk & Cost Patient Management Reports PCP Reports Specialty Reports Pharmacy Reports Continuum of Care Focus Episodes of Care Leading Practice Patterns Type and Class of Drugs High Cost Generic usage

10 Define and Monitor Key Metrics Highest level: track Spend versus Revenue Key metrics for cost management Inpatient days per 1000 Readmissions Emergency Room utilization Imaging Out of network Pharmacy utilization

11 Trend Reports Key cost indicators

12 Sample Reports

13 Other Cost Categories DSH Report

14 Physician Performance Variation Identify cost and utilization patterns For network as a whole By specialty By practice/tin By individual physician Compare internally and with external benchmarks Apply risk adjustment to standardize performance Identify physicians for outreach and intervention

15 Physician Performance Variance Reporting Savings Opportunity Specialty Cost Profiles

16 Out of Network Utilization Identify patients to help redirect them in-network Use Care Navigators within the ACO organization for outreach Identify physicians whose patients are going out of network Share ideas from other practices to improve stickiness Offer ACO resources to do outreach Identify service gaps, explore root causes, and fill gaps as needed No or few providers of the required specialty Not the preferred providers in the market Inconvenient hours, or long wait times for appointment

17 Out-of-Network Utilization

18 Components of Accountable Care Integration Create an Integrated organization; clinical integration as the foundation Culture and capabilities to organize for and deliver coordinated care Delivery System Improvement Implement programs to support efficient, effective care delivery Leadership and governance to value and deliver results Accountability Expertise and financial/management processes Monitor results; manage risk & reward

19 Using Information to Improve Clinical Quality and Outcomes Performance reports Compliance with clinical guidelines & metrics Comparison to peers and benchmarks Identification of areas for improvement Care Coordination & Population Mgmt tools Disease registries Point of care tools Alerts & reminders Patient outreach, education and engagement Performance Improvement tactics Data identifies quality, patient safety or efficiency opportunity Transparency, info sharing, teams Root cause analysis & P-D-C-A Physician engagement, with aligned incentives

20 Approaches to Getting Data From Payors From Practice Management Systems Supplement with Hospital and vendor data feeds From Electronic Health Records (common or interfaces) Participate in Health Information Exchange Use the data you can get most readily Deliver value tools that actually help today Action list to identify and outreach

21 Physician Guideline Results : Submeasure Profile

22 Action List, Patient Profiler

23 Population Management Comprehensive patient data, viewed across service providers Clinical guidelines available to all providers Compliance reporting showing variations in care at the provider and network level Physician performance against peers and external benchmarks data transparency Disease registries and outreach tools Clinical decision support and Point of care alerts Secure mechanism for provider communication and patient engagement

24 Components of Accountable Care Integration Create an Integrated organization; clinical integration as the foundation Culture and capabilities to organize for and deliver coordinated care Delivery System Improvement Implement programs to support efficient, effective care delivery Leadership and governance to value and deliver results Accountability Expertise and financial/management processes Monitor results; manage risk & reward

25 Delivery System Improvement Care Management Clinical Integration Patient identification and outreach Case/Utilization management Patient Centered Medical Home model Population definition, clinical characteristics, and prioritized opportunities Quality & Efficiency Resource utilization analysis and dashboards Redeployment of high cost services Accountability for consistently providing efficient, evidence-based care Expectation of efficient care: what s best for the patient NOW! Outcomes and Satisfaction Decision support tools Shared decisionmaking programs and tools Culture change à build greater value consciousness/ incentives for providers Monitor performance and intervene as indicated

26 Practice Pattern Changes Translate EBM into day to day practice Reduce variation and increase reliability in care delivery Effective teamwork with comprehensive hand-offs Patient engagement ~ Shared Decision Making Access to integrated care across the continuum Outreach feedback measure improve patient experience

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28 To learn more about Valence Health s capabilities, contact: Elizabeth Simpkin at or Lori Fox Ward at