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HFMAAugust 23, 2018

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TRANSFORMINGHEALTHCARE

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ABCBS Vision & MissionVision

A health care system that providers affordable and safe care for all citizens.

Mission

Improve the health, financial security and peace of mind of the communities we serve.

• Not-for-profit mutual insurance company • No dividends to shareholders• Owned by policyholders

• All revenues go to:• Pay claims: >$2 billion/year• Cover administrative costs • Maintain reserves to pay future claims

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Growth in Premiums

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Arkansas Blue Cross and Blue Shield (ABCBS)Group inflation versus wage inflation

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Why does healthcare costso much? Many reasons, not limited to:

• Patient accountability/responsibility.• Malpractice risks.• Pharmacy inflation.• Increased overhead / excess administrative costs.• Redundancy, waste and lack of coordination (inefficiency).• Low-value or unnecessary services that don’t help us get better.• Significant variation in treatment approaches to achieve similar

outcomes.• Fee-for-service is the current reward system and does not incent

the efficient use of healthcare resources.

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We’re working to create a new healthcare payment model intended to improve affordability and increase sustainability by creating financial incentives that aren’t 100% volume based.

Value-Based Compensation Initiative

A partial shift from fee-for-service to

value-based compensation

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Is a continued evolution of other value-based programs.

Is intended to reward value not just volume – the provision of high-value care and the reduction of low-value care.

Value-Based Compensation Initiative (VBCI):

Is a hybrid payment model that incorporates a value-based component.

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How do you define value?

What is low- vs. high- value, and how do you compensate differently for the two?

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Identifying and paying for value

All contents are proprietary to RowdMap, Inc. and are being provided on a confidential basis.

Any use, reproduction or distribution of this information, in whole or in part, or the disclosure of any of its contents

without the prior written consent of the Company, is prohibited.

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All contents are proprietary to RowdMap, Inc. and are being provided on a confidential basis.

Any use, reproduction or distribution of this information, in whole or in part, or the disclosure of any of its contents

without the prior written consent of the Company, is prohibited.13

Risk-Readiness® ScoringHow Scores Are Created: An Overview

Open DataOpen Methods

Define physician specialty and generate peer cohort

Apply specialty-specific measures

Apply risk-adjustment

Create benchmarks and scoring tiers

RowdMap uses providers claims and publicly available

data and methods to reduce the administrative

burden on physicians and their staff.

RowdMap uses an algorithmic approach to identify

specialties and create peer cohorts based on specialty

and geography

RowdMap uses specialty-specific metrics to measure

clinical quality and medical economic outcomes.

Measures are risk-adjusted based on the provider’s

patient panel.

Providers are scored in each measure based on their

relative performance within their peer cohorts.

In a Nut Shell

RowdMap uses the Dartmouth Atlas, Choosing Wisely, and academic research to define high and low

value practice patterns and mines ABCBS claims data to find evidence of these patterns and identify

practitioners who are likely to succeed in risk-based arrangements.

ABCBS Data

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All contents are proprietary to RowdMap, Inc. and are being

provided on a confidential basis. Any use, reproduction or

distribution of this information in whole or in part, or the

disclosure of any of its contents without the prior written

consent of the Company, is prohibited.

Low Performing

Overall Value Score = 5High Performing

Overall Value Score = 1

Green dot providers exhibit practice patterns that align with pay-for-value models and make money for whoever owns the risk.

Red dot providers exhibit practice patterns that may be clinically appropriate, but optimized around a FFS economic model.

5 4 3 2 1

Methodology Review

Measuring Value with Clinical Relevancy

Proceduremeasures, compared to

peers, cost effectiveness and intensity of how a

doctor practices medicine. Does he/she jump immediately to high

intensity treatments or start with conservative

treatments?

Referralmeasures,

compared to

peers, the number,

performance, and appropriateness of the providers

downstream referral

destinations.

Pharmacymeasures, compared

to peers, how a doctor prescribes medications. How

often, how much and what kind of

prescriptions are common with this

provider?

Visit measures, compared

to peers, intensity of practice patterns

within a visit and how quickly a visit escalates into

additional services like procedures,

images, tests and eventually surgery.

Overall

Value Scoreaverages the four domains into an overall

composite score.

Provider profiles can be shown at physician level or rolled up in a variety of ways.

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All contents are proprietary to RowdMap, Inc. and are being provided on a confidential basis.

Any use, reproduction or distribution of this information, in whole or in part, or the disclosure of any of its contents

without the prior written consent of the Company, is prohibited.1515

All contents are proprietary to RowdMap, Inc. and are being provided on a confidential basis.

Any use, reproduction or distribution of this information, in whole or in part, or the disclosure of any of its contents

without the prior written consent of the Company, is prohibited.

A high performer exhibits patterns that align with

pay for value models. They create value for

whoever owns the risk.

A lower performing outlier has optimized practice patterns around a

specific economic model, FFS. This does not mean this provider is a poor

clinician. In pay for value, these outliers may add additional risk.

This is how CMS views providers, but

occasionally there are outliers with

legitimate aberrational patterns. RowdMap

will help you drill into this to explain why.

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Background and Context

What is Risk-Readiness®?

• Important for claims submissions to be:• Timely• Complete• Accurate• Use the most detailed procedure and ICD 10

diagnosis coding

Use information on AHIN to help with claims submissions for member eligibility, benefits, Provider News, Alerts, etc.

mely

Acc

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VBCI Scores: Risk Adjusted & Based on Provider Submitted Claims

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Value-Based Compensation

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Value-Based Compensation Initiative

2018 2019 2020 2021 2022

Total Compensation

Primary Care

Specialist5%

10%15%

25%100% of Medicare

Fee-for-Service Reimbursement

HospitalSh

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ow

Re

po

rtin

g

Re

lea

sed

Va

lue

Po

ol C

on

trib

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Be

gin

s

12 Months12 Months

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Value pool distribution

Each quarter, providers will receive a distribution from the value pool based on a percentage of their contribution.

2 3 4 5

0% Return

1

FeeFor

Service

Fee For

Service

Fee For

Service

FeeFor

Service

Fee for

Service

Average total

compensation

RowdMap

score

50% Return 100% Return

150% Return 200% Return

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Next steps

Continued communications with providers and other stakeholders

Continued review/QA of Measures

Continued review/QA of Value Scores using ABCBS claims data / validation of provider peer group

Continued stakeholder feedback

Shadow reporting – “triggers” 12-month shadow reporting period

First Value Pool Contributions – 12 months after “trigger” date

Change is going to happen

If not this, then what?

If not now, then when?

If not us, then who?

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