using analytics for successful plan and provider collaboration · 2019-10-29 · using analytics...
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©Blue Health Intelligence, an Independent Licensee of the Blue Cross and Blue Shield Association. All rights reserved. Proprietary and Confidential. Blue Health Intelligence (BHI) is a trade name of Health Intelligence Company, LLC
Using Analytics for Successful Plan and Provider CollaborationOctober 16, 2019
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Our Speakers Today
Barb FernandezGuideWell Health
Melissa SingerGuideWell Health
Kimberly GaskaBHI
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Presentation Agenda
• What is Truli Health?– What is the Operating Model?– Foundational Strategic Goals– What is Truli Doing Differently?
• Data and Analytics Principles– How Does Data Governance Support Truli for Health’s Goals?– Utilizing a Common Data Platform– What Larger Analytic Strategy is at Play?
• Truli for Health and BHI’s Partnership – Leveraging National Data– Providing Targeted Audience Specific Analytics– Solution Timing
Who Is Truli for Health and What Market Issues Are They Addressing?
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MISSION and VISIONHelp people and communities achieve better health
Launching July 2020
Truli Overview
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A highly curated network
Use high performing provider partners
Leverage Centers of Excellence
Truli for Health’s Four Strategic Pillars
Bi-directional data sharing through moderndata platform and analytics
Personalized member support
Real-time notifications to help membersmaximize their benefits and stay on course
A more integrated Plan/Provider operating model
Engaged and financially aligned delivery model
Optimize network configuration secured via a curated set of high-performing providers
Significant financial alignment betweenthe plan and providers to replicate the economics of plan ownership
Personalized benefits to support chronic care management and consumerism
Reduce cost shares on benefits that improvecare pathway compliance
Incent healthy behavior by awarding Care Credits
Co-develop provider-friendly, physician-led CareManagement Programs
Truli Overview
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For product salability to local employer groups, GWHP will be an open access HMO. However, levers can be pulled to support PCPs in managing populations in a self-referral environment.
A Care Model That Supports Product Design
Member onboarding process will introduce the PCP as the member’s clinical guide to consult before seeking urgentor specialist care
Care and Disease Management supplement PCP’s course of treatment to provide additional support for members with chronic conditions (e.g., diabetes, hypertension)
Product design includes chronic condition management programs for members with certain disease states (e.g., diabetes, hypertension)
Lighter prospective medical necessity review requirementsfor high performing providers simplifies UM process
To provide services beyond Evaluation and Management, specialists must notify PCPs within preferred turnaround times before appointment in order for the specialist to receive payment forthe service1,2
GWHPProduct
Care Coordination
Levers
GWHP Care Model
Truli Overview
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The GWHP product promotes access to high value care — care that provides the best health results for patients at the right price, in the right setting, for the right reason enabled through just-in-time data analytics. VBID promotes patients’ use of high-value care options by reducing cost sharing for treatments providing increased clinical value.
Truli’s Approach to Value Based Insurance Design (VBID)VBID
Program Goals
Guide Consumers via Product DesignPromote High-Value Care Delivery
• Reward providers for delivering health care based on clinical evidence
• Informed by clinical research that assesses the comparative clinical benefit of different treatment options and the cost of delivery
• Product designs encourage members to build relationships with their provider
• Allow consumers to get care that fits their conditions
• Provide resources that clearly explain value-based benefits structure to members
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Truli Wants to Work Differently with its Provider Partners
• Easy access/use of information
• Low effort to extract actionable insight
• Reports that contain the latest and greatest information available
• More frequent, on-going reporting to evaluate changing performance results
• Reports with consistent results acrossdata sources
Providers’ Fears Providers’ Needs
We Don’t Trust Your Data We’re Not Engaged
Truli Overview
Lack of CommonValue-Based Care Insights
Leveraging Data and Analytics Differently?
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Engaged Data Owners and Stewards
Policies, Procedures and Repeatable
Processes
Data Governanceand Quality Tools
Critical Success Path
Data Governance Practiced Daily
Governance at a Glance: Enabling a Truli Data Driven Health Plan
Data Governance DefinedData Governance is the orchestration of business-led decision making based on trusted data assets through a system of decision rights and accountabilities for information-related processes, executed according to agreed-upon models which describe who can take what actions with what information, and when, under what circumstances, using what methods. Data Governance enables controlled access to data at the speed of business.
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Implementation of Data Governance and Qualitywithin the Analytic Strategy
Identify Data Owners/ Stewards
Truli for Health Data
Mart
BusinessGlossary
SystemHealth
Dashboards
Data Quality Scorecards
KDE’s
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AgilityFaster development and
deployment cycle to meet business needs
StabilityPhysical and logical layer
independence insulates end users from the underlying
physical data changes
VersatilityPull data from heterogenous data
platforms (RDBMS, no SQL, text files, applications, etc.) using API and other data transmission methods
BusinessFriendliness
Empower business to access data without relying on IT
BHI’s Common Data Platform (CDP): Best-in-Class Data Governance
Value Creations LeversSingle Source of Truth• All applications and methodologies share a single
common data model• Receive data one time for a customer and leverage
that data across all products
Operational Efficiency Goals• Streamline implementation processes for subsequent
product deployments• Supports and administers all internally and externally
developed methodologies• Enhances data with national data and other
supplemental data elements through virtualizationand API’s
Analytic Data Mart
• Ability to access data directly and apply BHI developed or customer developed methodologies and analytics
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Available Data SourcesMembership
Enrollment
Account Structure
Medical Claims
Pharmacy Claims
Dental Claims
Vision Claims
Hearing Claims
Capitation
Premium
Health Assessments
Care Management
Wellness (HRA, Lifestyle Coaching, etc.)
EHR/EMR Referral/Admission/DischargeBiometric Data
Lab Results
Engagement Status and Preferences
Call Center
Provider Reference, DesignatedProviders, ACO/System/Group
Relationships
Provider Network
Member Attribution
Socio-Economic, Behavioral, Lifestyle Factors
Program Participation
External Non-BCBS Experience
Demographicand
FinancialAdditional
Clinical
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GuideWell Health Plans Analytics Strategy Overview
Customer Demands GuideWell’s Response
Improving outcomes, lowering costs, and increasing overall access to care
Transitioning away from fee-for-service and use fee-for-value models
Collaborative Requirements
Provide access to a single source of accurate, actionable, and timely information to:• Assess financial performance• Understand quality performance• Identify opportunities for improvement
Trended Spend by Category of
Service
Population Health and
Clinical Performance
QualityPerformance
Employer and
Group Analytics
Value Based Program
Performance
Provider Performance, Efficiency and
Profiling
ProductStrategy
Leading Indicators
and Predictive
Scores
Sales andDistribution
Revenue Program
Management
Success Blue Print
Provided data will be uniform and consistent data across all delivery channels (direct and indirect)
Promote the democratization of data by enablingself service analytic capabilities
Adhere to the “three click presentation rule”
Truli Overview
The Truli-BHI Partnership
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What Analytics for Everyone Looks and Feels Like
• More time can be devoted to analysis insteadof manipulating data
• Business knowledge is more important foranalysis than technical skill (SAS, SQL, R, etc.)
• Less time is spent on arts and crafts results assembly since custom and standardized reports are generated automatically
• Stories are more easily told and explained in an easy a variety of formats – including Mobily accessible tool
• Everyone has uniform access to summary dashboards an drill down capabilities to examine root causes
Assuring Democratized Information and Self-Service Insights
Time
Past
Current
Data Manipulation
Data Analysis
Knowledge
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National Benchmarks
Provider Analytics
Delivering Self-Service Insights via the WhyzenAnalytics Platform
Employer/Group Analytics
Analytics Data Platform that delivers:• A single source of uniform and consistent data across all delivery channels
• Broad and comprehensive capabilities and content
• Powerful associative data model
| One Platform Three Modules
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BHIs Provider Analytics
Delivering consistent data, transparent methodologies, and easy-to use analytic tools needed to support successful provider engagement and collaboration
Evaluate Manage Enable
Identify High Performing Providers
Monitor Clinical and Financial Results
Enable Collaborationand Care Coordination
• Identify Cost, Quality and Efficiency outliers
• Build high performing networks
• Spot opportunities to steer care to High Value Providers
• Evaluate potential partners for risk-based arrangements
• Measure Cost/Use/Price and Quality
• Identify opportunities to reduce cost and improve outcomes
• Track contract specific performance metrics
• Calculate financial settlements from contract parameters
• Deliver timely, actionable information on attributed/ designated populations
• Identify and communicate careand coding gaps
• Alter providers to patients with potentially high impact events
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Leveraging the Power of Our National Data WarehouseBlue Data Depth and Breadth
10+ YEARSof historic data
Data refreshedMONTHLY
Data conformedUNIFORMLY
19+ BILLIONhealthcare claims
95%OF ALL U.S.PHYSICIANS1 of 2
American lives
96%OF ALL U.S.HOSPITALS
75%PROVIDER EXPERIENCE
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Facility PCP Specialists
Cost and Efficiency Indexes • Case/mix and severity adjusted. Efficiency index uses Standardized pricing methodology.
• At the ACO/Contract, facility, PCP, and specialist level
• At the episode level
Quality Measurement• Combined Quality Index blends results of Readmission and Complication Indexes
• Unplanned 30-day Readmission Index
• Complication Index for major complications and infections
Care/Cost Efficiency Opportunities• Predicted potentially avoidable hospitalizations, admissions, and readmissions
• Retrospective opportunities for care/cost efficiency (e.g., complications, avoidable admissions, readmissions, ER…)
• Sites of services, leakage, members with outlier utilization, etc.
BenchmarkingLocal, national, custom benchmarks to measure relative performance of acute care hospitals, ambulatory surgery centers, ACOs,individual and various groupings of providers
Provider Performance Evaluation
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BHI’s Foundational Provider Capabilities
Population Cost and Utilization
Efficiency Opportunity
Quality Performance
CareCoordination
ContractPerformance
Member Roster Cost and Utilization ꟷ Drill to 3 Levels
InappropriateER Use
Contract Specific Quality Measures
Care and CodingGaps
Key Contract Metrics Dashboard
PopulationOverview
Medical and Pharmacy
Potentially Avoidable Events
Quality Benchmark Comparison
High Cost Claimants Financial Performance Estimates
Attribution Trend
Leakage Advanced Imaging Quality Trend CM ProgramEngagement
FinancialSettlement Report
Site of Service CM Alerts
Low Value Care MedicationNon-adherence orContraindication
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Guidewell and BHI’s Provider Analytics Timeline
Release 1 – Jan 2020 Release 2 – April 2020 Release 3 – July 2020
EvaluateManage Enable
Thank you