4. walsteijn.edifecs enabling value based healthcare 2015 04 09 v3

Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Healthcare

Michiel Walsteijn, Executive Vice President - International

Enabling Value Based Health Care

April 9, 2015


Software Innovator in Healthcare IT

Edifecs is the first Partnership Platform for the healthcare industry

Serving more than 215 Million lives through our 100+ Health Plan customers

Worldwide700+ Employees

LeadersIn Configurable Healthcare Data Interchange & Compliance

70+Provider Customers

MultipleFederal Agencies incl. CMS

8/9National Health Plans

25/37Blue Plans

24/52State Medicaid Programs

Pre-integrated Business Applications, e.g. Value

Based Healthcare

Enterprise Testing & Compliance

Configurable Healthcare Data

InterchangePartnership Platform

1996 2015

Since 1996, Edifecs technology has been helping healthcare insurers, providers, pharmacy benefit management companies, and other healthcare entities address key challenges to scaling partnerships.


Some Definitions

Quality (in medicine):

The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge (Institute of Medicine, 1990)

Value:

Outcomes Achieved divided by Resources Expended

Health

Cost


Understanding the Shift from

Fee-for-Volume

to

Fee-for-Value

Fee-for-Volume(Old World)

Fee-for-Value(New World)

Providers make money by negotiating higher rates and performing as many services as possible

Providers make money by not only providing services, but other results valued by the industry, such as quality, efficiency, wellness, care coordination, and prevention

Providers see every touch as revenue

Providers see every touch as an expense to be managed

Payers primarily pay providers based on claims

Payers pay providers based on claims plus many other inputs (few of which are automated)

Most providers have little regard for evidence-based medicine.

Providers care a great deal about evidence based medicine

Payers see providers as vendors Payers begin to see providers as partners


Value Based ReimbursementA Continuum of Provider Risk

Fee for Service

Fee for Service Plus P4P or

Shared Savings

Episode ofCare / Payment

Bundling

Partial Capitation

Global Capitation

Provider Sophistication

Pro

vid

er

Ris

k


Scaling Healthcare Partnerships?

Addressing 3 challenges is emerging as the key to scaling.

Information Exchange and Integration

Process Automation

CommunityCollaboration

Is information flow between partners flow seamlessly ?

Does it comply with industry & partner standards?

Is it timely, trusted and visible ?

Are there any changes to core process or workflow ?

Does the partnership model need new analytics?

Can core systems adapt to support the changes?

Is there a need for shared intelligence between partners?

Do the workflows of the partners need to be linked ?

How can best practices be harvested and propagated

Pathways to Partnerships | Bridging Connections For Valueedifecs confidential

Value Based Care Maturity model

Consume Transactional Data

Value-Based Reimbursement Agreements Align Financial Incentives with Clinical Outcomes

Combine Clinical and Claim Data into Member-centric and Population Views.

Monitor the Population, Create Clinical Intelligence, and Drive Effective Interventions

Share Intelligence and Processes Across Multiple Payers and Providers

Consume & Interpret

Integrate & Share

Intervene: Change Care

Delivery

Expand to Other Partners

Support Payment Reform


Value-Based Care Solution


Provider

EMR

Billing

Practice Management

Core Systems

EDI Gateway

Claim adjudication

Membership administration

Other applications

Core Systems

Payer

EDI Gateway

Partnership Enablement

Future

Enterprise Apps

Business Applications for

Providers

Liquid Transaction Data

Liquid Transaction Data

CommunityShared Intelligence and Workflow

Transaction Workflow Transaction Workflow

Edge-based innovation for supporting the industry initiatives. Natural advantage of timeliness and completeness of information. Filter out transactions that add downstream costs.

Edge

Transaction Hub

Admin/ Clinical Transactions

Admin/ Clinical Transactions

Healthcare Information PipeEdgeSmart

Trading(All

Initiatives)

EDI Gateway

Business Applications for

Health Insurers


Enabling Value Based Healthcare

Integrated Member Record

Workflow

PrioritizationReportingTrigger Inventions

Set Monitoring/Intervention Rules

Monitor Populations

Health Information Exchange Intervention Platform

AuthorizedCare Team

Clinical Analysts

Population Analysis

Program Targeting

Member Attribution

Savings Modeling

Model Population and Plan Value-Based Agreement

Business/ Executive Manager

Partnership Platform

Population Payment Administrator

Business/ Executive Manager

Payment Calculations

Reporting

Program Automation

Program Optimization

Tasks

Target Populations

Design Contracts

Assemble Integrated Patient Records

Coordinate Care

Measure Outcomes

Pay for ValueTarget Interventions


Population Payment


Financial Management

Edifecs’ Approach

Easily define, edit and re-use patient and provider sets

Examine costs & stratify risks, drill down by any number of variables

Asses impact of alternative reimbursement models

Perform targeted budget calculations

Leverage pre-defined templates and risk adjustment models

Compare historical and projected budgets

Design dashboards and reports for internal/provider use

Enable reporting transparency to all stakeholders

Automate program savings calculations

Reduce actuarial and regulatory risk

Employ advanced data analyses

Gauge utilization and assess saving opportunities

Provide multi-layer views of program measures

TARGETImprove targeting

DESIGNScale

ADMINISTERMinimize risk, improve experience

OPTIMIZEOptimize

Shared savings and other VBR initiatives


How are PMPM Costs changing?

What is your budget

to date performanc

e?

What savings

might you anticipate?

How is your attribution changing?

What is your

leakage?

How is your quality

performance so far?

What is your

performance against

KPIs?

What is driving your

costs?


Population Health Monitoring


Intervention Gateway

Learning Engine Studio

Observation Agent Learning Engine

Des

ign

-tim

e R

un

tim

e

1

2 3

Enables clinical analysts to define monitoring and intervention rules

Visual toolkit to model and test interventions Collaborate and share concepts and rules across

communities.

Inspect incoming data streams and extract real-time data to trigger interventions

Execute Intervention Rules against streaming data and historical data

Surface the intervention in payer and provider systems

Intervention Rules

List of Data Elements to

Extract

Message Streams Intervention Data Alerts, Inferences

Intervention platform for early detection of changes to risk thresholds, quality thresholds, morbidity patterns, behavioral patterns and protocol compliance


Story of George’s Father

January, 1991 – PCP “Need to lose some weight – BMI 38,

waist circumference 41 inches, and you need to stop smoking”

February, 1991 – Routine lab work Triglyceride 160 mg/dL HDL 30 mg/dL Glucose 100 mg/dL Total cholesterol 250 mg/dL

March, 1992 – To ER, “not feel well” “Every is ok except a bit stressed and

blood pressure borderline (145/95)”

November, 1993 Massive heart attack

EHR CCD SNOMED 162864005 LOINC 9844-2 = 41 ICD-9 278.02 ICD-9 305.1

Lab Claims LOINC 2571-8 = 160 LOINC 2085-9 = 30 LOINC 1558-6 = 100 LOINC 2093-3 = 250

ER ADT + EHR CCD ADT-A04 ICD-9 308.9 LOINC 8480-6 = 145 LOINC 8462-4 = 95

Real life Digital life Edifecs logic

Metabolic syndromeFramingham Risk

28%

clipboard

insurance

Physician-supervised weight loss

program

Health and wellness program1

point of intervention

1 Baicker et al. Workplace wellness programs can generate savings. Health Affairs. 2010 Feb 2 HCUP/AHRQ 2009 data. Accessed http://hcup-us.ahrq.gov/reports/factsandfigures/2009/exhibit4_1.jsp 2014 Sep

3 Ford et al. Prevalence and correlates of metabolic syndrome based on a harmonious definition among adults in the US. J Diabetes 2010;2(2):180-93

“Start Statin”

http://hcup-us.ahrq.gov/reports/factsandfigures/2009/exhibit4_1.jsp

100 Fastest Growing

Companies in WA

Washington’s 100 Best Places to

Work For

Inc. 5000 Fastest- Growing Private

Companies in the US

Deloitte Technology

Fast500 North America

Puget Sound Business Journal

WA Best Workplaces

Seattle Business Magazine’s Tech Impact

Award


Appendix


1990s All-at-once shift to full provider capitation

1998Physician Profiling (used for public reporting and contract rates)

2000Leading California effort for third party to collect and calculate quality-based payment

2001 Provider owned insurance companies

2003 Bonus payment for submitting quality data

2004 Bonus payment based on quality

2009 Payment based on episode of care

2011 Shared Savings based on total cost of care

2015 New forms of partial capitation

Progression of Payment Reform in US

4. walsteijn.edifecs enabling value based healthcare 2015 04 09 v3

Healthcare

healthcare industry

healthcare insurers

healthcare entities

value fee

prevention providers

revenue providers

possible providers

value based health care