GHG Forum
“Innovate or Disintegrate”
April 19th, 2016
1-1:55 PM
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Urgency in the Market
With the magnitude of financial incentives
linked to risk- and quality-based payments,
health plans and providers that do not continually track
and monitor performance will be financially
disadvantaged compared to their peers
2
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Urgency in the Market – Risk Adjustment
Risk adjustment transfer payments can generate a significant impact on a
health plan’s performance:
3
•
The expansion of insurance coverage to higher-risk demographics through exchanges
and Medicaid has created the potential for adverse selection by way of health plans
targeting specific categories of enrollees
•
In an attempt to avoid risk selection, ACA established a transfer payment mechanism
to ensure that a health plan’s premiums are commensurate with the underlying risk
of its member population; as a result, plans servicing higher-risk populations will
receive payments from those servicing lower-risk populations
•
The transfer payment methodology results in transfers between health plans on a
zero-sum basis; plans that do not accurately collect and report member data are
effectively at risk of “paying” their competitors
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The Wide Disparity in ACA Transfer Payments
2015 Amount
Received
Plan
$262M
$237M
$108M
2015 Amount
Transferred
Plan
($335M)
($190M)
($123M)
4
.
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Urgency in the Market – Quality Bonuses
The magnitude of quality payments has generated increased focus:
5
•
Quality initiatives have evolved from providing performance transparency to an
incentive-based program that rewards health plans that deliver high-quality care
•
CMS quality programs, notably 5-Star, have had an enormous impact on both the
quality of care and the bottom line of managed care plans, with 2014 Star Ratings
bonuses expected to exceed $2 billion for the large, public MCOs
•
Payor/Provider collaboration and the emergence of ACOs create new challenges for
compliance and the next generation of HEDIS® and quality reporting
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The Wide Disparity in 5-Star Bonuses
Plan
>4 Star
Enrollment
Bonus
595,987
$352M
170,383
$124M
191,388
$107M
1,369,045
$819M
733,757
$528M
76,839
$47M
58,065
$41M
Total
6
$2,018M
.
© 2016 Pulse8 Inc. Confidential and Proprietary. All Rights Reserved.
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Urgency in the Market
With the magnitude of financial incentives linked to risk- and quality-based payments, health plans that do not continually track and
monitor plan performance will be financially disadvantaged compared to their peers
Risk Adjustment – Transfer Payments Example



2015 Amount
Received
Plan
Risk adjustment transfer payments can lead to significant impact on a health plan’s performance
$262M
The expansion of insurance coverage to higher-risk demographics through Exchanges and Medicaid has
created the potential for adverse selection by way of health plans targeting specific categories of enrollees
$237M
$108M
In an attempt to avoid risk selection, ACA established a transfer payment mechanism to ensure that a
health plan’s premiums are commensurate with the underlying risk of its member population; as a result,
plans servicing higher-risk populations will receive payments from those servicing lower-risk populations
2015 Amount
Transferred
Plan
($335M)
($190M)
The transfer payment methodology results in transfers between health plans on a zero-sum basis; plans
that do not accurately collect and report member data are effectively at risk of “paying” their competitors
($123M)
Quality Initiatives – Medicare Star Ratings Example
The magnitude of quality payments has been an increasing focus area for health plans

Quality initiatives have evolved from providing performance transparency to an incentive-based program
that rewards health plans for delivering high-quality care

CMS quality programs, notably 5-Star, have had an enormous impact on both the quality of care and the
bottom line of managed care plans, with 2014 Star Ratings bonuses expected to exceed $2 billion for the
large, public MCOs

7
Payor/Provider collaboration and emergence of ACOs create new challenges for compliance and the next
generation of HEDIS® and quality reporting
.
Plan
Total
>4 Star
Enrollment
Bonus
595,987
$352M
170,383
$124M
191,388
$107M
1,369,045
$819M
733,757
$528M
76,839
$47M
58,065
$41M
$2,018M
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Intended For Internal Use of Recipients Only. Do Not Distribute or Reproduce.
Infrastructure can’t support the Shift
Market dynamics have created an immediate need for innovative revenue optimization and
member surveillance solutions that can help address the complex, multi-faceted, and evolving
needs of the payor landscape
Current Technology Infrastructure is Woefully Inadequate

Payment drivers for risk- or quality-based payment models are
fundamentally different than the fee-for-service paradigm, rendering legacy
systems and workflows inadequately prepared to help health plans thrive

Existing infrastructure lacks the transparency and reporting capabilities that
provide real-time visibility and allow health plans to better manage care
and ensure accurate risk- and quality-based reimbursement

An increasingly complex regulatory environment, coupled with the need to
collect data across the care continuum, requires workflow automation and
auditing solutions that allow for timely submissions and regulatory
compliance
Problems
8
.
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The Transformation of Managed Care
The Business of Managing Care is Undergoing a Fundamental Transformation
Expansion of government-funded healthcare and the shift to valuebased reimbursement are driving an operational and strategic shift in
the way health plans manage their member populations:

Historically, plans have been primarily focused on managing costs
through utilization and medical management activities to enhance
margins

Today, the expansion of risk-adjusted reimbursement and quality
initiatives across Medicare Advantage, Managed Medicaid, and
Commercial markets has created additional demands to manage
revenue

Revenue
Management
MACRA: Value-Based Care
Risk Adjustment: ACA
STAR: Medicare
Risk Adjustment: Medicare and
Medicaid
HEDIS® / Pay for
Performance
Premium
Margin
Cost
Utilization Management
As the industry continues its shift to value-based payment models,
plans are faced with the dual requirement to manage revenue and
costs in an integrated manner while ensuring regulatory compliance
Case Management
Disease Management

This transition requires an ability to aggregate and monitor membercentric data to identify opportunities for intervention, close gaps in
care, and reduce cost through care optimization
Cost
Management
Medication Therapy Management
Utilization Reporting
In order to compete in today’s environment, health plans and other risk-bearing entities must continually monitor and stratify member populations to
identify cost-effective intervention opportunities that properly manage revenue while minimizing waste
9
.
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MACRA – Redefining Payment
Track One: Merit-based Incentive Payment System (MIPS)
•
•
•
•
This is the default track; participants must qualify for and opt into the APM track
Participants include physicians and mid-levels, but not hospitals
This is a budget-neutral model: losers will pay the winners
Payment adjustments (positive and negative) increase from a maximum of 4% in 2019 to a
maximum of 9% from 2020 forward
• Exceptional performers are eligible for bonus payments
• The MIPS score will aggregate quality, resource use/cost, clinical practice improvement, and
meaningful use measures
=> This track decreases the control that participants have over their final reimbursement
Track Two: Alternative Payment Models (APMs)
•
•
•
•
To participate, a threshold percentage of reimbursement must be placed at risk
The risk must be more than a nominal financial risk
CMS will determine on a yearly basis which programs qualify as APMs
Eligible Patient-Centered Medical Home (PCMH) models will be considered APMs and do not
require financial risk
• Qualifying providers participating in special “eligible” APM tracks will receive a yearly 5% bonus
=> This track increases the control that participants have over their final reimbursement
10
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Infrastructure can’t support the Shift
Market dynamics have created an immediate need for innovative revenue optimization and member surveillance solutions that can help
address the complex, multi-faceted, and evolving needs of the payor landscape
Current Technology Infrastructure is Woefully Inadequate
Problems
Requirements

Payment drivers for risk- or quality-based payment models are fundamentally different than the fee-for-service
paradigm, rendering legacy systems and workflows inadequately prepared to help health plans thrive

Existing infrastructure lacks the transparency and reporting capabilities that provide real-time visibility and allow
health plans to better manage care and ensure accurate risk- and quality-based reimbursement

An increasing complex regulatory environment, coupled with the need to collect data across the care continuum,
requires workflow automation and auditing solutions that allow for timely submissions and regulatory compliance

Proactive identification of care gaps

Targeted, timely interventions to help reduce avoidable costs

Maximized revenue through sophisticated risk adjustment protocols

Minimization of administration costs and wasteful services
Solution Specifications Designed to Address Today’s Market Needs

11
Advanced Risk Adjustment
and Quality Analytics to
Optimize Revenue and
Reduce Administrative Spend

Scalable Data Management
to Aggregate Member-Centric
Data across Multiple,
Disparate Sources
.

Provider and Member
Engagement to Identify and
Close Care and Data Gaps

Integrated, Cross-functional
Processes to Enable Real-time
Reporting and Ensure
Regulatory Compliance
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Success Requires
Innovation
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Success Requires Innovation
Alignment Across Company
Risk Adjustment Initiatives need to be aligned with:
• Quality, Case Management
• Claim Experts, IT (RAPS vs EDPS)
• Provider Contracting / Providers
The Strategy at Pulse8
• Financial & Quality Analytics
• Pragmatic, ROI-driven Approach
• Innovative Gap Closure Strategies
13
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Coordinating Risk Adjustment and Quality Gap Closure
Health Plans need to employ a data-driven triad of gap identification,
strategic intervention, and dynamic recalibration:
• Integrate efforts to close Quality Gaps with those aimed at Documentation & Coding
• Assign confidence levels to the likelihood of closing each gap at the individual
provider- and member-level
• Assign priority scores to the revenue impact of addressing each quality metric
• Assign grades for both clinical performance and coding efficacy to providers and
medical groups
• Utilize Dynamic Intervention Planning to tailor the intensity, timing, and type of
intervention in accordance with the characteristics of each particular opportunity
• Deploy an integrated analytic solution, such as Qualit8™, as the “Command Center”
from which to orchestrate your Quality Management endeavors
14
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Integrating Risk Adjustment and Quality Teams
Aligning your Resources and Goals is Key:
• Identify groups in your organization that work in Silos
• Begin collaborating
• Identify shared opportunities and prioritize your focus
• Engage providers/members and internal clinical teams
• Evaluate performance using data, analytics, and reporting
15
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RAPS vs. EDPS
RAPS
EDPS
• Understand each of these buckets and the patterns that exist within
• Understand the financial impact at the member level
• You should have already started working on a plan to mitigate some of the
financial impact
16
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RAPS vs. EDPS
Get the right people at the table:
• Claim Experts
• Case Management
• IT / Developers
• Quality
• Actuarial
=> Key players from across the company need have a basic understanding of
Risk Adjustment and the potential financial impact
17
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EMR Integration and Electronic Chart Transfers
Pulse8 is working with leading Electronic Medical Records (EMR) vendors to:
• Leverage their expansive data sets;
• Reduce the number of manual chart reviews (Retrospective Risk Adjustment); and
• Facilitate Payor/Provider Collaboration through the bi-directional exchange of data:
o Extracting patient/member data from the Provider’s EMR and
o Returning Gaps in Documentation, Coding, and/or Quality to the EMR
Just as our finely-tuned Risk Adjustment Algorithms produce the
most efficient Intervention Strategy,
Pulse8 is always striving to incorporate additional data sets and
adopt innovative Data Acquisition Methodologies
18
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EMR Integration: Integr8 Generates Value
EMR Integration will create value in multiple ways:
•
•
•
•
•
Close HCC Gaps that otherwise would remain open –> incremental revenue
Less costly and more efficient than other gap closure interventions –> administrative savings
Validate that Medical Record documentation exists –> mitigate RADV audit risk
Address Quality Gaps at the Point of Care to improve Star Ratings –> secure Quality bonuses
Supports treatment of conditions by network providers –> align with CMS initiative
Critical Success Factors:
•
•
•
•
•
Strong data analytics – providing gaps that providers would not otherwise address
Data presented as part of the provider workflow to address gaps at the Point of Care
Provider engagement to act upon presented gaps
Timely feedback after the encounter to ensure gaps have been addressed and closed
Real-time confirmation (or nearly real-time)
Pulse8 is currently working with the largest EMR Vendors:
•
•
•
19
Allscripts
GE Centricity
EPIC
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Analytic Insight
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Financial Projections
21
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Pragmatic, ROI-driven
Approach
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Responsive, Integrated Approach
Spanning traditional to unusual sources and types of incoming data
Providers
Care Mgt Systems
Disease Registries
Benefits
HCPC Rx
EMR APIs
Enrollment
DME, Supplies
Lifestyle, Attitudes
Claims
Lab Results
Semi-structured Data
Authoritative Sources
Disease Groupers:
HCCs, CDPS, CRGs etc.
Quality Metric Definitions:
HEDIS, 5Star, QRS, etc.
Standards of Care
Confirm Conditions,
Close Gaps
Identify Opportunities
Nomenclatures
Rank Opportunities
Chart
Review
Results
Proprietary
Mining,
Modeling,
Scoring
Vendors
Status
Updates
Assign Intervention Type
Update Intervention Status
Activate Interventions
Chase
Listings
Update YTD Closures, ROI
Update
Dashboards
23
Update Output
Files
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Distinctive Aspects of This Approach
Integrated framework has many advantages over standalone solutions
•
Focus: All care/condition “gaps” in one place for comprehensive view by member, provider
•
Completeness: Relevant data from broad array of sources in one place at member level
•
Consistency: Within/across data sources, for more accurate findings, single source of truth
•
Precision: Comprehensive view highlights right members/providers for all gaps
•
Effectiveness: Timely interventions with focused credible data and compelling visuals that foster action
•
Efficiency: Many/most “potential” risk-adjustable conditions also correspond to quality of care metrics
•
Empowerment: Client tailors interventions to their strategies, risk tolerance, budget driven by our ranking analytics
Find potential medical conditions sooner and more precisely
•
Sooner is far, far better: earlier detection often means better prognosis, more time to rectify gaps, to prove compliance
•
With newer federal programs – ACA Commercial, MA, Managed Medicaid – confirming potential diagnoses – that is,
“risk adjustment” -- yields increased revenue
•
Multivariate models assess “confidence” of the condition, hence expected value, to target interventions precisely
Track record of effectiveness
• Recommended thousands fewer interventions that yielded higher total financial return, hence far higher ROI, than other
vendors who analyzed the same data
• Independent “referee”: We don’t do interventions ourselves, thus we lack the perverse incentive to do more of them in
order to boost our revenues at the expense of client’s budget and ROI
24
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Innovative
Gap Closure Strategies
© 2016 Pulse8, Inc. – Proprietary and Confidential – All Rights Reserved
Innovative Gap Closure Strategies
• EMR Integration: Bi-directional integration of Analytics and Gap Closure Efforts by
embedding analytics into the provider’s workflow at the Point of Care and extracting
CCD/medical record information from the EMR, thereby improving gap closure rates
and reducing the number of costly interventions.
• Dynamic Intervention Planning: Deploying the right intervention with the right
providers for the right patient at the right time.
• Coding Technology with advanced features, such as Optical Character Recognition,
Computer-aided Coding, and an Intuitive Interface with error-proofing.
• Capturing “off-the-data-grid” Diagnoses: Pulse8 has designed analytics that address
blind spots, especially in LIS populations, in order to identify the outliers to target.
• Telehealth: Leveraging the increased acceptance of remote clinical visits to speed up
the member’s access to care, along with the payor’s access to diagnostic information.
26
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EMR Integration: Integr8™ Process Flow
• Year-round, continuous
process
• Leverage the Pulse8
analytics by presenting
“the opportunity” to
providers
• Persistent and Suspected
HCC gaps and Quality gaps
are presented
Extracts of Clinical
Data from EMR to
Pulse8/Health Plan
Clinical
Documentation
entered into the
EMR
Pulse8 Analytics
identify HCC and
Quality Gaps
• EMR Extracts enable
real/near-time receipt of
clinical data to validate
conditions
• Clinical data will inform
member-level analytics
27
Providers see Gaps
in the EMR at the
Point of Care
HCC and Quality
Gaps are Pushed to
the EMR
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Summary: Innovative Analytics are Essential
•
28
Deep understanding of each source of revenue lift for each line of business and timing
o
ACA’s 3 Rs: Reinsurance, Risk Transfer Payments, Risk Corridors
o
MA: Premium adjustments by sweeps periods, Mid- and Final-Year Adjustments
o
Medicaid: State-specific Risk-adjustment, increasingly a blend of MA’s moving sweeps with ACA’s “transfer
premiums”
•
Client-specific intervention analytics reflecting strategy, risk-tolerance, timing, ROI targets, and
incentives
•
Clear line-of-sight throughout the year at progress towards goals for risk adjustment, quality scores,
intervention budgets, and ROI
•
Can statistically model, hence measure, the incremental contributions of interventions while
controlling for factors that otherwise would over/understate the ROI:
o
Reminders: Multiple instances of the same intervention type (e.g. reminder alerts)
o
Escalations to more intensive, hence costly interventions
o
Complementary activities such as webinars or site visits for those providers with pending alerts
o
Natural gap closure – the single-largest contributor to gap closing in most every population
•
Yield, lift, and ROI estimation by vendor and type of intervention that is transparent, hence credible
•
Ability to link intervention results to anticipated revenues: ACA transfer payments, MA Stars
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Reminder
Confidential and Proprietary
Information Prepared by Pulse8 for GHG Forum:
Internal Use and Distribution Only
This document is intended for the internal use of recipients only
and may not be distributed externally or reproduced for distribution in any form
without express written permission of Pulse8 Inc.
29
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Reserved.
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John Criswell
443-223-2271
John.Criswell@pulse8.com
Eric Hedrick
231-215-0770
Eric.Hedrick@Pulse8.com
Pulse8.com
© 2016 Pulse8, Inc. – Proprietary and Confidential – All Rights Reserved