tricore s value-based strategy organizations’ role...powered by tricore’s value-based strategy...
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TRICORE’SVALUE-BASEDSTRATEGY&IVDORGANIZATIONS’ROLERickVanNess,MSDirector,ProductManagementTriCoreReferenceLaboratories
InformationcontainedinthismaterialisconfidentialandproprietarytoTRICOREanditsaffiliatesandmaynotbemodified,copied,published,disclosed,distributed,displayedorexhibited,ineitherelectronicorprintedformatswithoutwrittenauthorizationofanofficerofTRICORE.
April30,2019
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• Grant/ResearchSupport:None• Salary/ConsultantFees:
– TriCoreReferenceLaboratories• Board/Committee/AdvisoryBoardMembership:
– UNMMainInstitutionalReviewBoard,CommunityScientificReviewer– NewMexicoBiotechnologyandBiomedicalAssociation,President
• Stocks/Bonds– Mozak,LLC(CEOandCo-Founder)
• HonorariumExpenses:None• IntellectualProperty/RoyaltyIncome:None
FINANCIALDISCLOSUREINFORMATION
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• Background– TriCoreReferenceLab
– ClinicalLaboratory2.0
– TriCore’sLaboratory2.0andVBPstrategy
• Laboratory2.0Study:PrenatalCareinNewMexico
• IsBeckmanalignedwiththefutureofthelab?
AGENDA
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DEMING
GALLUP
ROSWELL
ARTESIA
TRICOREREFERENCELABORATORIESServices12clinicalspecialties
2,900highlyspecializedtests11,100,00+diagnostictestsperyear
Generate~60%ofNewMexico’sclinicallaboratorydata98.6%ofalltestsareperformedinTriCorefacilities
Footprint1300+employees30courierroutesacrossNewMexico
60+drawsitesthroughoutNewMexico50+pathologistsandscientists99%patientsatisfaction
15hospitallaboratories3cancercenters
LaboratoryNationallyrecognizedHematopathologyconsultservice
Thefirstmulti-siteCAP15189accreditation
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TRICOREREFERENCELABORATORIES
TriCoreVisionTobeanationallyrecognizedlaboratoryfocusedonindividualandpopulationhealth.
PopulationHealthMajorityofmedicaldecisionsarederivedfromlaboratoryresults1ClinicalDataprovidesthebestinsightintohowtoimproveoverallhealthandhealthcare2,3
AnalyticspoweredbyRhodesGrouptechnology
• Accesstorealtimedata• Uniquepatientidentifier• Longitudinaldatarepositoryacrosscarecontinuum
1. Forsman,R.W.WhyistheLaboratoryanAfterthoughtforManagedCareOrganizations?(1996)ClinChem.42:813-8162. Adler-Milstein,JandJha,A.K.Healthcare’s“BigData”Challenge.(2013)AmJManagCare.19(7):537-5383. Hartman,C.Healthcare’sGrowingDataOpportunity.LeveragingClinicalIntelligencetoElevatePopulationHealthManagementStrategies.(2014)HealthManagTechnol.35(5):24v
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BACKGROUND:NATIONALMEDICALSPEND(2017)=$3.5TRILLION1
HospitalCare
PhysicianandClinicalServices
RetailPrescriptionDrugs
OtherHealth,Residential,andPersonalCare
NursingCareandContinuingCare
Dental
HomeHealthCare
OtherProfessionalServices
Othernon-durableMedicalProducts
ProtectingAccesstoMedicareAct
1. CenterforMedicaidandMedicareServices.NationalHealthExpenditures2017Highlights.https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/downloads/highlights.pdf(Accessed:March1,2019)
Year CMS2,3 %ofSpend
2017 $9.7B 1.71%2,3
2018 $8.7B 1.54%
2019 $7.9B 1.38%
2020 $7.1B 1.34%
2021 $6.0B 1.06%
2022 $5.1B 0.90%
2023 $4.3B 0.76%
Year TriCore
2017 -
2018 2.9%
2019 1.9%
2020 ?!
2021 ?!!
2022 !!
2023 !!!!!
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STRATEGYSHIFT:LABORATORY2.0Lab1.0–Volume-based• SamplecentricinaFFSmarket• Measuredbycostperunit• Unfulfilledneedforprimarycareproviders• Limitedcarecoordination• Complicatedhealthcareenvironmentinsilos
Lab2.0–Value-based• Patientcentricinabundledmarket• Costperlife-population• Increasedaccesstocare/primarycare• Enhancedfocusedcoordinatedcare• Actionableinterpretativeresults
Pre-Analytical Result Post-Analytical
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INPATIENT’SSERUMCREATININE(mg/dL)
0.83
0.50mg/dL
1.40mg/dL
June30 July1 July2 July3 July4 July5
0.750.770.90
1.381.48
July6
1.01
July7
0.88
7/5/20184:05AMHospitalreactstokidneyinjury
7/4/20184:37PMLabanalysisobservedAcuteKidneyInjury
IncreaseinSCrby≥0.3mg/dLbaselineto48hours
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• 30-40%increaseinlengthofstay– $7,933increaseinhospitalizationcosts1
• 40%ofpatientscandevelopsepsis2– $32,421increaseincosts3
• 40%ofpatientsrequiredialysis4– ~$42,077increaseincosts1
• 50%increaseinmortalityrate4
ACUTEKIDNEYINJURYPOTENTIALEFFECTSANDCO-MORBIDITIES
1. SilverSA,LongJ,ZhengY,ChertowGM.CostofAcuteKidneyInjuryinHospitalizedPatients.(2017)JHospMed.12(2):7-762. MehtaRL,BouchardJ,SorokoSB,etal.SepsisasacauseandaconsequenceofAKI.(2011)IntensiveCareMed.37(2):241-2483. ArefianH,etal.Hospital-relatedcostofsepsis:Asystematicreview.(2017)JInfect.4(2):107-1174. LafranceJP,DjurdjevO,LevinA.Incidenceandoutcomesofacutekidneyinjuryinareferredchronickidneydiseasecontext.(2010)NephDialTranspl.25(7):2203-2209
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ProjectSantaFeFoundationacoalitionoflike-mindednationalleadersandinstitutionsinlaboratorydiagnostics,
comingtogethertocreateanewanddisruptivevalueparadigmtopushbackthefrontiersthatwilldefinetheandplacementofdiagnosticservicesinvalue-basedhealthcare
www.cl2lab.org
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TRICORE’SVALUEBASEDSTRATEGY
PopulationSurveillance
Pre-DefinedMeasures
• DiseaseSurveillance
• HCCs/RiskAdjustment
• HEDIS/PQRSFocused
PHASE11A
PAYFORREPORTING1B
BONUSINCENTIVE
• CMSStarBonuses
• PerformanceMeasures
• QualityRatings
PMPMPerReport/Condition
↓PMPM+/-Bonus
MEASURES
BundlePaymentforCondition
• DiabetesBundle
• PregnancyBundle
• HepatitisCBundle
Population+%SharedSavings
PartnershipModelw/ProviderGroup
• TotalCostofCare
• SpecificHealthConditions
• LabTriagestoProvider
PopulationBasedUpside/Downside
OUTCOMES
FFSBASEDUPSIDEWITHSHARESAVINGS
PHASE2CAPITATIONWITHRISKSHARING
PHASE3
TRIAGE/EFFICIENCY
OBJECTIVE
EXAMPLES
PRICING
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TRICORE’SLAB2.0BUSINESSPLAN
DIAGNOSTICOPTIMIZATION
ClinicalAnalytics Biometrics
SurveillanceData Reporting
Division
ProductsorServices
Features
AlertsandInformationPush
Integration(LabData,HRA)
ActionableWorkLists
PatientConsent PatientEngagementCenter
Datause TriageModel
SpecimenBanking ClinicalPharmacists
PatientEngagement
FacilitatedFollow-Up(FF)
AutomatedPatientNotifications
CareGapClosure
PM/PMPrice $/PatientTargeted AddsValuetoResearch ValueBasedCare MoreInsights
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HYPOTHESIS:CANLABORATORYINFORMATIONIMPROVEOUTCOMES?
• Clinicallabguidesmajorityofmedicaldecisionsandprovidessignificantvalueinpatientevaluation1,2
1. Forsman,R.W.WhyistheLaboratoryanAfterthoughtforManagedCareOrganizations?(1996)ClinChem.42:813-8162. LaposataMEetal.PhysicianSurveyofLaboratoryMedicineInterpretiveServiceandEvaluationofInterpretationsonLaboratoryTestOrdering.(2004)ArchPatholLabMed.128:1424-14273. HoAhnCetal.EvaluationofNon-LaboratoryandLaboratoryPredictionModelsforCurrentandFutureDiabetesMellitus:ACross-SectionalandRetrospectiveCohortStudy.(2016)PLoSOne.11(5):e01561554. BurtonLC.etal.UsingElectronicHealthRecordstoHelpCoordinateCare.(2004)MilbankQ.82(3):457-481
• Patientsmayhavemultipleprovidersenablingclinicallaboratoriestoprovidealongitudinalhistory
• Identifyingriskwithclinicallaboratoriescanoccurnearreal-time3
• Effectivecarecoordinationreliesonreal-timestandardizationofhealthdata4
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Salud!
StateCoverageInsurance
BehavioralHealthServices
CoLTS
SelfDirection
PersonalCareServices
PresbyterianHealthPlan
TPA/Molina
Molina
AmeriGroup
UnitedHealthcare
OptumHealth
BlueCross&BlueShield
Lovelace
HumanServicesDepartment.CentennialCare2.0:1115WaiverRenewalPublicEngagement.June2017.http://www.hsd.state.nm.us/uploads/files/Public%20Information/Centennial%20Care/CentennialCarePublic%20Meetings_06-20-2017%20FINAL%20V2.pdf.[Accessed:September19,2017]
BACKGROUND:NEWMEXICO’SMEDICAID<2014
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HumanServicesDepartment.CentennialCare2.0:1115WaiverRenewalPublicEngagement.June2017.http://www.hsd.state.nm.us/uploads/files/Public%20Information/Centennial%20Care/CentennialCarePublic%20Meetings_06-20-2017%20FINAL%20V2.pdf.[Accessed:September19,2017]
• Bendthecostcurveovertime
• Streamlineandmodernizetheprogram
• Promoteintegratedcare
• Carecoordinationforat-riskmembers
• Payprovidersforvalueandoutcomes
• Rightcare,righttime,rightsetting
• Purchasequalitycare
• InvolveMembersintheirownhealth
• Educatebeneficiariestobesavvyconsumers
DevelopComprehensiveDeliverySystem
EmphasizePaymentReform
SimplifyProgramAdministration
EncouragePersonal
Responsibility
BACKGROUND:NEWMEXICO’SMEDICAID>2014
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BACKGROUND:IMPLEMENTING&ASSESSINGCARECOORDINATION
• ~850,000residentsareinsuredbyMedicaid(NMHSD)1
• NMHSDrequirescarecoordinationforeachmember
• NMHSDevaluatescarecoordinationthroughPerformanceMeasures(e.g.HEDIS)– Example:TimelinessPrenatalandPostpartumCare
• %ofprenatalmembersreceivedOB/GYNvisitin1sttrimester• %ofprenatalmembersreceivedPCPvisitwithin56daysofbirth
1. NewMexicoLegislativeFinanceCommittee.2017AccountabilityReport:Medicaid.https://www.nmlegis.gov/Entity/LFC/Documents/Program_Evaluation_Reports/Accountability%20Report%20Medicaid%20-%202017.PDF(Accessed:June21,2018)
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BACKGROUND:NMHSDINCENTIVIZEDPERFORMANCEMEASURES
1. NMHSDAmendment#8totheMedicaidManagedCareAgreementAmongNMHSDandHCSChttp://www.hsd.state.nm.us/uploads/files/Looking%20For%20Information/General%20Information/Contracts/Medical%20Assistance%20Division/MCOs%20-%20Centennial%20Care/BCBSNM_CONTRACT_AMENDMENT_%238_SIGNED.pdf(Accessed:June7,2018)
2. MedicaidEnrollmentReportByManagedCareOrganizationFee-for-Servicehttp://www.hsd.state.nm.us/uploads/FileLinks/5bc82a76689a437682dbd68988331f79/March_By_Managed_Care_Organization_Fee_for_Service_2.pdf(Accessed:June7,2018)3. HealthNotes.ProgramEvaluationUnite.LegislativeFinanceCommittee.January13,2017https://www.nmlegis.gov/Entity/LFC/Documents/Health_Notes/Health%20Notes%20-%20Medicaid%20managed%20care%20rates.pdf
• PMsrequire2%increaseaboveHEDISRegionalAverage,failureresultsin2%ofcapitationwithhold1
• EightPMstotaling14points,eachpointisworth7%ofthetotal2%withhold• Example:AnMCOwith215,827members2has$1,154,366perpoint3
• PrenatalCareisworth3points• Example:PrenatalCarePMsareworth$2.4millionfortheMCO
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BACKGROUND:NEWMEXICOPRENATALCAREPROBLEM
• 72%ofNM’sbirthsareMedicaid2- 20%ofNewMexico’sbirthsreceivedprenatalcareinthesecondtrimester3- 8.5%receivednoprenatalcare3
• 30%ofwomenreceivedinadequateprenatalcare4
$13,668$14,175
$815 $827
$-
$4,000
$8,000
$12,000
$16,000
FY10 FY11
AverageCostofNewbornsforNewMexicoMCOs1
CostofNewbornswithComplications CostofNormalNewborns
1. NewMexicoLegislativeFinanceCommitteeReport.HumanServicesDepartment.September2012.http://www.nmlegis.gov/lcs/lfc/lfcdocs/perfaudit/Human%20Services%20Department%200Improving%20Outcomes%20for%20Pregnant%20Women%20and%20Infants%20Through%20Medicaid.pdf(AccessedOctober7,2015)
2. MedicaidFunds70%ofNMBirths.AlbuquerqueJournal.January27,2013.Availableat:http://www.abqjournal.com/163829/news/medicaid-funds-70-of-births-in-nm.html[AccessedJuly20,2015]3. PerinatalCareinMedicaidandCHIP.(February2015)http://www.medicaid.gov/midicaid-chip-program-information/by-topics/quality-of-care/downloads/secretarys-report-perinatal-excerpt.pdf.(AccessedOctober10,2015)4. InstituteofMedicine(US)CommitteeontheConsequencesofUninsurance.Washington(DC):NationalAcademiesPress(US):2002
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BACKGROUND:NEWMEXICOPRENATALCAREPROBLEM
0
10
20
30
40
50
60
70
80
90
100
%ofP
atientsC
ompliant
PrenatalCarein1stTrimesterbyYear1
NewMexico UnitedStates
• Receiveda“C”GradebyMarchofDimesdueto10%pretermbirthrate2
• Ranked43rdstatetohaveababy3
1. CompleteHealthIndicatorReportofPrenatalCareintheFirstTrimester.NewMexico’sIndicator-BasedInformationSystem(NM-IBIS).NewMexicoDepartmentofHealth.https://ibis.health.state.nm.us/indicator/complete_profile/PrenCare.html(Accessed:October18,2018)
2. Peristats.MarchofDimes.2018.https://www.marchofdimes.org/peristats/ViewTopic.aspx?reg=35&top=5&lev=0&slev=4(Accessed:October18,2018)3. McCannA.Best&WorstStatestoHaveaBaby.August13,2018https://wallethub.com/edu/best-and-worst-states-to-have-a-baby/6513/(Accessed:October22,2018)
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BACKGROUND:LABORATORIESROLEINPRENATALCARE
1stTrimester 2ndTrimester 3rdTrimester
Mother&FetusBloodTyping,Rubella,HIV
1stMaternalSerumScreen 2ndMaternalSerumScreen
GestationalDiabetes
GroupBStrep
• Identifyingandmonitoringpotentialmothers
MaternalBirthScreen
• Identificationofbirthstoestablishpostpartumcare
Age,Previousdx,Diabetes
• Identifyingandmonitoringprenatalrisks
UrinaryTractInfection(<3m&after) AbnormalPrenatalScreens
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Measureclosureofcaregaps
Clinical Financial
Createmultifacetedtoolwithactionableinsights
Assessoutcomes
TimelyidentificationofMCOmembersandneeds
Identifyadditionalbenefits
STUDY:LABORATORYDERIVEDINSIGHTSHELPANMCO?
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METHOD:INFRASTRUCTURE
CentralRepositories(Clinical,Financial,Operational)
• OrderManagement• SpecimenTracking• Turn-Around-TimeAnalysis• EfficiencyImprovement
Operation Analytics
• Pre-ClaimsScrubbing• EligibilityChecking• RejectionAnalysis• ClientManagement
Revenue Analytics
CentralNormalizedRepositories(Clinical,Financial,Operational)
InvoicesOrders
LIS ResultBillingSystem
• CareGapAnalysis• RiskStratification• InterventionNotifications• AccessAlerting(ER,etc.)
Clinical Analytics
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METHOD:MEMBERIDENTIFICATION&PRENATALINSIGHTCREATION
EligibilityFile MatchwithinTriCore’sPatientRepositoryFocus:Medicaid
TargetedInterventions
HealthConditionAlgorithms
• Memberfilesentbycustomer(payer,provider,etc.)viaSFTP• KeymemberidentifiersmatchedwithTriCorepatientrepository1• SuccessfulmatchesanalyzedwithTriCore’sPrenatalTargetedInterventionalgorithm• Resultsdeliveredeveryweekfor~7monthsforMCOcarecoordination
1. Just,B.H.,Fabian,D.P.,Webb,L.L.,andHjort,B.M.ManagingtheIntegrityofPatientIdentityinHealthInformationExchange.(2009)AHIMA.80(7):62-69
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METHOD:INFORMATIONSENTTOPAYER
• Excelspreadsheet• Patientneeds
• CareGaps• Risks
• Updatedcontactinformation
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METHOD:ENHANCEDPRODUCTFORPAYER
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METHOD:RISKSTRATIFICATION
Elevated Patient Risk Factors
Elevated Patient Risk Factors
AND Care Gaps
Optimal Care Gaps
Riskcreated
from
patient
riskfactors
Riskcreatedfromgapsinhealthcare
2016
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METHOD: POPULATION LEVEL ANALYTICS
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METHOD: POPULATION LEVEL ANALYTICS – MEDICAID
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METHOD: POPULATION LEVEL ANALYTICS – MEDICAID & PRENATAL
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METHOD: POPULATION LEVEL ANALYTICS – MEDICAID & PRENATAL W/ ER
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METHOD: PRENATAL ANALYTICS
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METHOD: PRENATAL ANALYTICS AND MEDICAID
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METHOD: PRENATAL ANALYTICS AND MEDICAID W/ ER
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METHOD: INDIVIDUAL PATIENTS
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METHOD:PATIENTTAILOREDINSIGHTS
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METHOD:PATIENTTAILOREDINSIGHTS
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METHOD:PATIENTTAILOREDINSIGHTS
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EXAMPLERESULT#1:MCOPRENATALMEMBERS23year-oldfemaleinruralNM
1/12/17:AccessesAlbuquerqueER;dxpregnant
1/26/2017:ReceivesprenatalworkupwithCNM
3/15/2017:AccessER;UTIdiagnosed
8/27/2017:Babygirlborn,admittedtoNICU
10/2/2017:BabydischargedfromNICU
27year-oldfemaleinurbanNM
7/12/17:AccessesER;dxpregnant
9/5/2017:CareManagercalls,coordinatesOBGYN
2017-2018:Receivesallprenatalscreens
3/18/2018:Boabyboyborn,40weeks
3/19/2018:Momandbabydischargedforpostpartum
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EXAMPLERESULT#2:MCOPRENATALMEMBERS
30year-oldfemale
01/17/2017:Accessesfamilypractice,dxpregnant
Receivesmonthlydrugmonitoring
08/02/2017:Babygirlborn;admittedtoNICU
08/30/2017:BabydischargedfromNICU
27year-oldfemale
09/01/2017:Initialprenatalscreen
09/20/2017:LabinfosenttoCareManager
10/17/2017:OBGYN&Hospitalprovidealltests
04/05/2018:Babyborn,39weeks
04/06/2018:Momandbabydischarged
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RESULTSALIGNEDWITHOBJECTIVESClinical Financial
TimelyidentificationofMCOmembersandneeds
Createmultifacetedtoolwithactionableinsights
CATEGORY FOCUS
Quality Timeliness&frequencyofprenatalandpost-partumcare
Outcome Pretermdelivery,NICUcare
• >65%ofTriCoreinsightswerenotreflectedinMCO’sclaimsdata
• 77%ofmembersinfirsttrimesterwithadditionalinsightsinnearreal-time(within24hours):
– Careneeds
– Births
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RESULTSALIGNEDWITHOBJECTIVESMeasureclosureofcaregaps
• 73%ofalllaboratorycaregapsclosed(645of889);63%withoutGroupBStrep(350of558)• 486birthsidentifiedinnearreal-time(within24hours)
Clinical Financial
FullTerm(≥37wks) Preterm(<37wks) Total
Study 72(89%) 9(11%) 81
Control 55(80%) 14(20%) 69
*Termdeliverycalculationisreliantuponpatientcompletingamaternalserumscreeningtest.p=0.092
Assessoutcomes
TermDelivery
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RESULTSALIGNEDWITHOBJECTIVES
No Yes Total
Study 141(89%) 18(11%) 159
Control 188(81%) 44(19%) 232
NeonatalIntensiveCare
N MeanLoS(days) MedianLoS(days)
Study 18 12.3(0.29–94.34)* 6.66*
Control 44 12.3(0.13–64.30) 6.05
NeonatalIntensiveCare:LengthofStay
*Resultsshowsafterremovalofasingleoutlierof94.34days
*p<0.025
Assessoutcomes
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TIMELINESSOFPRENATALCARE
1. HealthcareEffectienessDataandInformationSet(HEDIS)Reports.NewMexicoHumanServicesDepartment.http://www.hsd.state.nm.us/LookingForInformation/healthcare-effectiveness-data-and-information-set.aspx(Accessed:November1,2018)
MCO#3
MCO#2
MCO#1
MCO#4
63%
2015 2016 2017
74% 68%
77% 77% 73%
78% 80% 71%
73% 75% 78% $1.4million
-------
-------
($2.4million)
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POSTPARTUMCARE
1. HealthcareEffectienessDataandInformationSet(HEDIS)Reports.NewMexicoHumanServicesDepartment.http://www.hsd.state.nm.us/LookingForInformation/healthcare-effectiveness-data-and-information-set.aspx(Accessed:November1,2018)
MCO#3
MCO#2
MCO#1
MCO#4
48%
2015 2016 2017
59% 56%
54% 54% 52%
61% 59% 59%
54% 58% 61% $1.4million
($2.4million)
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($2.4million)
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TOTALPRENATALCAREPENALTIESFOREACHMCO/YEAR
MCO#3
MCO#2
MCO#1
MCO#4
2016 2017
$940,000 ($940,000)
($2.4million) ($2.4million)
---- ($2.4million)
$1.4million $1.4million $2.8million
($2.4million)
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($4.8million)
TOTAL
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CONCLUSION
HealthCondition Measure/Outcome 2016MCOPerformance1
TRLClinicalAnalyticsResult2 ROI
Prenatal
TimelinessofPrenatalCareNMHSDPM#5 75% 77% $1,154,3663,4
Post-PartumCareNMHSDPM#5 58% 60% $1,154,3663,4
FrequencyofPrenatalCareNMHSDPM#6 56% 73% $1,154,3663,4
NICUOccupancy 19% 11% $3,371,8203
PretermDeliveryOutcome 20% 11% $868,5482,5
Diabetes HemoglobinA1cTestingPM#4 82% 92% $1,154,3663,4
NephropathyScreeningPM#4 87% 91% $1,154,3663,4
HepatitisC NMHSDHepatitisCDSIM 350members 1,577members $2,424,1694
TOTAL $11,628,312
1. BCBSNMAuditReviewTable.http://www.hsd.state.nm.us/uploads/FileLinks/485263ae1ad040ea9d52673aef6109b4/2016_HEDIS_BCBS.pdf(Accessed:March21,2018)2. ResultsprojectedfrompilotperformedwithBCBSNMSpecialBeginningsSeptember2017throughApril20183. AssumesBCBSNM’srevenueforCentennialCareisapprox.$536,736,096.HealthNotes.ProgramEvaluationUnite.LegislativeFinanceCommittee.January13,2017https://www.nmlegis.gov/Entity/LFC/Documents/Health_Notes/Health%20Notes%20-
%20Medicaid%20managed%20care%20rates.pdf4. NewMexicoHumanServicesDepartment.RequestforProposals.RFP#13-630-8000-0001CentennialCarehttp://www.hsd.state.nm.us/uploads/FileLinks/c06b4701fbc84ea3938e646301d8c950/Centennial_Care_RFP_and_Contract__8_28_12__FINAL_.pdf(Accessed:
August11,2017)5. ThanhNXetal.HealthServiceUseandCostsAssociatedwithLowBirthWeight-APopulationLevelAnalysis.(2015)JPediatr.167(3):551-5566. CenterforDiseaseControlandPrevention.Health,UnitedStates,2016.https://www.cdc.gov/nchs/data/hus/hus16.pdf#093(Accessed:August29,2017)
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TRICORE’SVALUEBASEDSTRATEGYMAP
PopulationSurveillance
Pre-DefinedMeasures
• DiseaseSurveillance
• HCCs/RiskAdjustment
• HEDIS/PQRSFocused
PHASE11A
PAYFORREPORTING1B
BONUSINCENTIVE
• CMSStarBonuses
• PerformanceMeasures
• QualityRatings
PMPMPerReport/Condition
↓PMPM+/-Bonus
MEASURES
BundlePaymentforCondition
• DiabetesBundle
• PregnancyBundle
• HepatitisCBundle
Population+%SharedSavings
PartnershipModelw/ProviderGroup
• TotalCostofCare
• SpecificHealthConditions
• LabTriagestoProvider
PopulationBasedUpside/Downside
OUTCOMES
FFSBASEDUPSIDEWITHSHARESAVINGS
PHASE2CAPITATIONWITHRISKSHARING
PHASE3
TRIAGE/EFFICIENCY
OBJECTIVE
EXAMPLES
PRICING
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HEPATITISC:LABKNOWSALL
SCREEN DIAGNOSE TREATMENT/MONITORING
HepatitisCAntibody HepatitisCQuantitation
HepatitisCGenotype
HepatitisCQuantitation
Platelets
• Identifyinglevelofcirrhosis
AST/ALT Albumin
HIV
• Identifyingriskofcomplications
HBV Diabetes(HA1c,Glucose)
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BACKGROUND:NMHSDINCENTIVIZEDDSIM
1. NMHSDAmendment#1totheMedicaidManagedCareAgreementAmongNMHSDandHCSChttp://www.hsd.state.nm.us/uploads/files/Looking%20For%20Information/General%20Information/Contracts/Medical%20Assistance%20Division/MCO's%20Centennial%20Care%202.0/BCBS%20Contract%20PSC%2018-630-8000-0033%20A1.pdf(Accessed:March1,2019)
2. MedicaidEnrollmentReportByManagedCareOrganizationFee-for-Servicehttp://www.hsd.state.nm.us/uploads/FileLinks/5bc82a76689a437682dbd68988331f79/March_By_Managed_Care_Organization_Fee_for_Service_2.pdf(Accessed:June7,2018)3. HealthNotes.ProgramEvaluationUnite.LegislativeFinanceCommittee.January13,2017https://www.nmlegis.gov/Entity/LFC/Documents/Health_Notes/Health%20Notes%20-%20Medicaid%20managed%20care%20rates.pdf
• HepatitisC=DeliverySystemImprovementTarget#4
• MCOmustachieveDeliverySystemImprovementTargetorbeimposed1.5%oftotalcapitation1
• EachDSIMisworth20%ofthetotal1.5%withhold
• Example:AnMCOwith215,827members2has$2,424,169perDSIM3
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GAINSHARINGMODELSREQUIRETHELABORATORY
• HealthPlansareturningtoprovidersforvalue-basedarrangements1
• Providersreluctanceinvaluemodelsaregravitatingtowardsgainshare2
• Laboratoriesknowmoreduetolongitudinalperspective3
1. BeveridgeRA,HappeLE,andFunkM.ThePhysician-InsurerDynamicMustShifttoSuccessfullyImplementValue-BasedPayments.(2016)Healthcare.4(4):282-2842. LongG,MortimerR,andSanzenbacherG.EvolvingProviderPaymentModelsandPatientAccesstoInnovativeMedicalTechnology.(2014)JMedEcon.17(12):883-8933. StreetRL,LiuL,FarberNJ,ChenY,CalvittiA,ZuestD,etal.ProviderInteractionwiththeElectronicHealthRecord:TheEffectsonPatient-CenteredCommunicationinMedicalEncounters.(2014)PatientEducCouns96:315–9.
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TRICORE’SIMPACTINGAINSHARE
• HepatitisC– 442patientsaremissingquantitation– 284patientsareinneedforgenotype1
– $268,414.36infuturelabcosts2
• 294oftheseweretouchedbyTriCoreinthelast90days(40%)3– $3,502invenipunctures– Additionalcostsinanalytes,reagents,
tubes,etc.– Physicianfees,patientindirectcosts
1. Pangenotypictreatmentsmayrenderthisadditionaltestingobsolete2. Calculationsderivedfrom2016CMSCLFS3. Containsbothinpatientandoutpatientsetting
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TRICORE’SLAB2.0BUSINESSPLAN
DIAGNOSTICOPTIMIZATION
ClinicalAnalytics Biometrics
SurveillanceData Reporting
Division
ProductsorServices
Features
AlertsandInformationPush
Integration(LabData,HRA)
ActionableWorkLists
PatientConsent PatientEngagementCenter
Datause TriageModel
SpecimenBanking ClinicalPharmacists
PatientEngagement
FacilitatedFollow-Up(FF)
AutomatedPatientNotifications
CareGapClosure
PM/PMPrice $/PatientTargeted AddsValuetoResearchInst. ValueBasedCare MoreInsights
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IMPACTISINTHEDRAWSITE?
• Laboratoriesknowneedsinreal-time
• Empowerclinicallaboratoryassistantstoimprovethehealthcaresystem
• Closecaregapsatthepointofcare
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• Reflextesting– Importanttoolinprovidingtimely,cost-effectiveand
qualityofcare– Generallyeachlabmustnegotiatewitheach
providerwhattestscanbereflexed1
• Labsneedautomationfordiseasemanagementprotocols
• BeckmanCoulter’svisionalignsperfectlywithourvisionandstrategy
BESTIMPACTISWITHSAMPLEINHAND
1. HHSOfficeofInspectorGeneral.PublicationofOIGComplianceProgramforClinicalLaboratories.FederalRegisterNotice.Vol.63,No.163,August24,1998,45076-45087
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BECKMAN’SSTRATEGYALIGNSWITH2.0
BeckmanCoulter,thestylizedlogo,andtheBeckmanCoulterproductandservicemarksmentionedhereinaretrademarksorregisteredtrademarksofBeckmanCoulter,Inc.intheUnitedStatesandothercountries.
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POSITIONLABORATORYATFOREFRONTOFCARE
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• Laboratory2.0isaboutrepositioningthelaboratoryandTriCore’sstrategyis:– Diversify– Changethelabfromancillarytotertiaryinvaluebasedcare
• BeckmanCoulter’smiddlewarealignswithourneedtoincreasethevalueofeachsample
SUMMARY
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THANKYOU
RickVanNess,MSDirector,ProductManagementTriCoreReferenceLaboratories
Albuquerque,[email protected]
(505)938-8906