Principles and Priorities of Accountable Care Transformation (Webinar)

Principles and Practices of Accountable Care Transformation
May 2015

[Marie Dunn]

Thanks so much, Tyler. Welcome to the presentation today. We really appreciate all of you taking the time to join us. And I’ll tell you, Darian and I are both just thrilled to get the chance to spend the next hour talking about accountable care transformation. It’s a topic that we’re both passionate about, and I know we both feel it’s just such an exciting time in healthcare. So we’re excited to walk through some of our thinking with you.

Let me give you a quick overview of where we’re going to spend our time today.

Today’s Presentation [00:25]

So first, I’m going to start by reviewing the state of the industry. And really, I’m going to do that pretty quickly. For an in-depth review, I would encourage you to go back and watch our last week’s webinar by Bobbi Brown, called Value-Based Reimbursement: The New Reality. But I’ll tee that topic up.

Next, I’m going to spend most of my time walking through set of principles for entering the value-based payment space, and really thinking about how do you manage those contracts successfully. In this section, we’re going to focus specifically on the use of data and show you some of our analytic tools as examples of the types of analyses you’re going to want to consider as you drive your decision-making.

I’m going to close by talking about how these near-term efforts made the groundwork for population health management, of course, which is the journey that we’re going to be navigating over the course of the next decade.

So let’s go ahead and get started.

State of Value-Based Payment

Now, value-based payment is not a new concept. [Inaudible] these types of contracts for the last couple of years. That said, we’ve gained some real momentum in the past year.

Broad Support for Value-Based Payment

So in January, health and human services announced pretty aggressive targets for expanding its value-based payment programs. By 2016, it hopes to have 85 percent of payments in some form of value-based contract. Now, keep in mind, this includes everything from its readmissions, reduction effort to its accountable care payment models. So really a pretty wide range of programs. The number to watch is the percent of payments and alternative payment models and that’s the dark blue slice of that pie. That represents the more aggressive payment reform efforts, like bundled payments and accountable care programs.

Now, in 2016, HHS hopes to put 30 percent of payments in such models. By 2018, just three years from now, it hopes to expand alternative payment models to 50 percent of total payments.

Now, given that CMS is the single largest payer for healthcare in the US, it’s pretty aggressive stance on these new models. It really sets the tone and raises the bar for the rest of the market.

Now, CMS is not alone in voicing its commitment to value-based payment. So the members of the healthcare transformation task force, which is comprised of a number of major payers, providers, and practitioners, have similarly announced that they would put 75 percent of their respective businesses under value-based payment by 2020, and that announcement came up this past January as well.

So again, we’re seeing the commitment on both the commercial and government sides to really transform the way that we pay for healthcare for the next decade.

Still in a Pilot Phase [03:06]

So I would say at this point it’s pretty clear where we’re headed. But I think the question is, where are we today in the context of that broader journey. On this slide, I’m showing data from a 2015 HealthLeaders Survey on value-based payment, really getting a sense of where are organizations today in terms of rolling out these types of programs.

So on the left-hand side of this slide, you’ll see that 10 percent of organizations haven’t begun pursuing any sort of value-based payment initiative. On the right-hand side of the slide, you’ll see that there’s similarly a very small percent of organizations that report having fully rolled out these types of programs. So what I would say makes sense, we’re still all figuring it out. Most organizations are somewhere in between, with 28 percent in the investigation phase and 33 percent having some sort of pilot underway. And I’ll tell you, this data resonates really strongly with the conversations that I have every day on the topic. For the most part, healthcare organizations are in a competency building phase in anticipation of a pretty dramatic change to the way we pay for healthcare in the next couple of years.

Anticipating a Tipping Point

Kaufman Hall Survey Update April 2015 [04:14]

Now, the data on this slide shows you just how much momentum the industry is gaining. In 2014, just 22 percent of organizations reported having more than 10 percent of their revenue coming from value-based payment contracts. Just six months later, the number have doubled to 42 percent. Now, what’s even more interesting to me is how quickly most organizations anticipate that the transition to value-based payment is going to take place. So in 2014, just 7 percent of organizations anticipated that more than 50 percent of their revenue would come from value-based payment in 24 months. So looking into the future, how many are going to get to that point. Six months later, that number had tripled. So I want you to stop and think about that.

Today, most organizations have 10 percent or less of their revenue in value-based contracts and yet a not insignificant number, expect it’s going to grow five-fold in the next two years. Now, why is that? I would argue that the idea of such a dramatic acceleration in value-based contracting isn’t unrealistic, given how fundamentally different the incentives are in their fee-for-service and value-based payment systems. So under fee-for-service, you’re incentivized to drive up volume typically by providing very expensive acute inpatient services. Under fee for value, you do exactly the opposite, reduce utilization and reduce cost typically by driving towards more preventative services.

Well is it possible to pilot the value-based payment models in today’s fee-for-service world? It seems unrealistic that the two models will coexist for long. And so, instead, what I think you see here is organizations anticipating that once they exit the pilot space, this transition to a predominantly different way of contracting is going to happen pretty quickly.

What is your primary functional area of expertise? [06:02]

So before we go too much further, I want to pause and get a better sense for the folks on the line where you are today.

Poll Questions # 1

What percentage of your organization’s revenue comes from value-based contracts today?


And so, our sort of second poll question. What percentage of your organization’s revenue comes from value-based contracts today? And our options are less than 10%, 11% to 30%, 31% to 50%, or more than 50%.

[Tyler Morgan]

That poll question is up and live. We’ll leave this up for a few moments to give everyone a chance to respond. Now, we are getting several questions in. People are asking if the slides will be made available and I would like to remind everyone that after today’s session, we will send out an email with links to the recorded on-demand webinar, the presentation slides, the results of these poll questions, as well as the names of the summit giveaway winners that we’ll take care of later.

Alright. We’re going to go ahead. Let’s close that poll right now and let’s share the results.

Poll Results [06:57]

Alright. It looks like 61 percent answered at less than 10%, 29 percent answered at 11% to 30%, 5 percent answered at 31% to 50%, and 5 percent answered at more than 50%.

[Marie Dunn]

This is really interesting for me to see. So what this tells me is we saw that data on the last slide where most organizations are in a pilot phase, have less than 10 percent of their contracts at risk. Really interesting to see those folks on this line probably are ahead of the market and to see so many of organizations that already have 11% to 30% and their contract revenue coming from value-based contracts. That’s really interesting to know.

Poll Question #2

What types of value-based contracts are most prevalent at your organization?


Another quick question to follow that up. What types of value-based contracts are most prevalent at your organization? Again, just to get a sense of the scope. We have first, a fee-for-service plus bonus model; second, bundled payments; third, shared savings; fourth, none of the above; or fifth, all of the above.

So again, if there’s one that’s more prevalent, select that. But if you really do have a good mix, we would love to see it reflect on that final option.

[Tyler Morgan]

Alright. We’ve got that poll question up. We’ve got folks answering that. Again, we’ll leave this open for a few moments. We did have a question from someone asking if they have to do anything to be included in the raffle for the summit tickets. And yes, I’ll have some poll questions right before the Q&A of this webinar, where if you respond “yes” to those poll questions, you’ll be included in that drawing for the summit giveaway tickets. We’ll take care of that right before the Q&A time of the webinar.

Alright. We’ll close the poll now and let’s share the results. Okay, Marie, we’ve got fee-for-service plus bonus, 27 percent responded that way, bundled payments 12 percent, shared savings 20 percent, none of the above 26 percent, and all of the above 15 percent.

[Marie Dunn]

Thank you. Again, more interesting results. And so we’ve seen a really nice spread across different types of contracts. And I’m sure for none of the above, some folks are in different models that maybe aren’t even reflected on the slide. So great context for us going in. Not altogether surprising, I think. After all, we knew what types of value-based contracts we would sort of end up with in the long-term, I think we’d be there already. And so, what you’re really seeing here is a reflection of not only just pilots around the idea of going at risk but the various types of models that folks are experimenting with to see what works as they’re building these competencies.

The Common Denominator: Reduce Costs, Improve Quality [09:43]

So I would say despite the fact that we’re seeing widespread experimentation even in data from the folks on the webinar today, our long-term goal is pretty clear. So the models that survived fundamentally need to do two things – reduce cost and improve quality. And so, as we’ve thought about what healthcare organizations need to do to prepare to survive, even in a seemingly uncertain landscape, it seems safe to orient ourselves around the idea of both reducing cost and improving quality really as our north star, and our jobs are of course made easier by the fact that that’s fundamentally the right thing for us to be doing as well.

Balancing Short-Term Imperatives with Long-Term Transformation [10:24]

So I would say the challenge for most organizations that I’ve talked to is not figuring out the long-term vision. It’s knowing where to start. It’s knowing that first step to take in a journey that’s going to take place over the course of the next 5 to 10 years. And so, helping you to prioritize that work is where we’re going to spend our time today.

So on this slide, I’ve listed a set of competencies that will both help an organization drive down cost while simultaneously improving quality. Again, both are fundamental goals of value-based payment. The competencies are broken into two categories, near-term goals and long-term goals. So let me break that out a little bit.

In the near-term, our main goal is to learn to successfully manage at-risk contracts – so how do they work, what types of models work, how does my organization need to fundamentally re-orient to succeed. In the organizations that I’ve worked with, this is typically managed by a relatively small team of individuals. We set the firm strategy and tactics for accountable care. And I would know, I’m using the term “accountable care” here pretty loosely to refer to a wide variety of value-based payment contracts.

Now, in the long-term, our goal is to fundamentally change the way that we deliver care. And this is not, of course, achieved by any small group of individuals but rather by engaging your full care delivery team and care transformation and I’m going to refer to that concept throughout the rest of our webinar as population health management.

Now, the orange we’ve listed as near-term priorities and I want to quickly walk through them as that is where we’re going to go next.

So first, at-risk contract management. This is about having the know how and the resources to monitor and manage key metrics and negotiate with your payers. Second, network management, again monitoring and managing your physician network, being able to think strategically about who you want to bring into that network over time. Next, care management – so identifying and effectively managing those high-risk high-cost patients. Fourth, performance monitoring – so this could be the easier 33 measures or any other measures that you’re reporting on in a commercial contract. And then finally improvement prioritization, which is really teeing up what you’re doing today around managing these couple of at-risk contracts that you have with where am I going in the next decade to transform care delivery and thinking about what improvement initiatives do I start with now as I’m thinking about that long-term goal of fundamentally transforming care.

So I’m going to start by spending some time on those near-term priorities – where do you need to start, how can you leverage data to inform your efforts. But I promise to spend some time at the end wrapping up and taking the long-term view, how does all of these tie back to population health management, which is of course where we’re headed in the next decade.

Near-Term Priorities for Accountable Care [13:17]

So without further ado, let me dive in to the five competencies. I’m actually going to move through them relatively quickly with the goal of setting context, and then I’m going to turn over the reins to Darian to show you some demos. We’ve found that seeing the analytic tools themselves is a really great way to give you an understanding of the types of analyses that you’re going to want to start to perform as you think about supporting your accountable care efforts.

Contract Management

On a Journey without a Map [13:43]

So the first in our five competencies is contract management. And again, this refers to building the know how to successfully monitor and manage in the way of value-based contract. Now, luckily for most organizations the stakes are relatively where to start and early value-based contracts are really less about making money and more about building the skill set.

So what I’ve listed on the slide are some of the key questions you’re going to want to ask your team as you think about performance in a value-based contract space. Now, if you have the benefit of evaluating a brand new contract, you’re going to want to start by asking questions like what type of populations do I want to go at-risk for, what payers in my market are going to be good partners. And again, thinking of things like the patient volume that they have to drive to your system, the benefit design, and whether that is going to actually send that group of patients that they have to their network. Finally, do you know where within your care delivery system you have meaningful opportunities to drive down cost, and of course that will be critical as you’re setting those cost targets to know how much you can do and how quickly.

Now, let’s say most organizations that I work with aren’t so lucky, they’ve already signed on the dotted line by the time they start to ask some of these types of questions. And so, assuming you’re in this game position, where do you start? I’ve listed a set of different but equally important questions here. So the types of questions that you start asking here are around, you know, how am I trending against contractual targets like PMPM performance? Analyzing your claims data of course is critical here. What about how you’re performing on key utilization metrics? Like length of stay and readmissions? Another big one – how do I know what percent of total payments I’m sending out of network and why? I’m going to leave the full list for your later review but you’ll notice a common theme. It pays to know your data. That’s going to give the insight that you need to successfully manage your performance in these contracts.

Network Management

Moving Beyond our Four Walls [15:43]

So moving on to our second competency, and that’s the network management. So this is about having the ability to successfully monitor and manage your physician network as you work to reduce cost and improve quality. So I’m going to break this out into a couple of areas, a couple of big questions that I’ve encouraged you to be thinking about and asking your team.

So the first big one is how do you manage your physician network today? For example, do you have a handle on things like leakage and referral patterns? For healthcare organizations that I’m working with, leakage is a really big concern and this is really drilling in to get data to help understand which providers, specialties, procedures, etc. are going out of network. I would say, sometimes when you look at the data you realize that not all leakage is a bad thing. So you may find that some services are actually provided at a lower cost out of network. The key is just knowing which those are, so you know where to focus your efforts and where it’s fine to leave things as is.

Another big set of questions here is around attribution. So who is the most appropriate provider to make accountable for your attributed patients for quality and cost? And again, data is really helpful here for giving you a sense of, you know, who are my attributed patients seeing most regularly and therefore, who’s going to be the most appropriate to hold accountable for the cost and quality metrics that you’re thinking about as part of these contracts.

And then finally, I’d say, third big set of questions is really around what types of providers do you want to have in your network, not just today but as you’re moving down the road and thinking about a fundamentally different way of providing care? And so the types of questions you are starting to ask here are who are the lowest cost providers in my community? Who are the highest quality providers in my community? But also who is accessible, both in terms of availability to take more patients and geographically? And then finally of course we’re shifting our specialty mix. So starting to think about where are my gaps in terms of primary care or various specialists which of course will shift as we start thinking about new payment models and moving towards preventative care.

Care Management

Today: High-Risk, High-Cost Patients [17:56]

So I’m moving on to our third competency, care management. This one is no surprise, I think, given how expensive, high-risk, high-cost patients can be for your program. So it’s pretty well known here the data on this slide, just 1 percent of patients comprise 20 percent of healthcare spending, 5 percent comprise 50 percent. And so, healthcare organizations spend a significant amount of resources in an attempt to better manage the care of these patients, to improve their outcomes, and to reduce cost.

How do we do that?

Care Management

Tomorrow: Patient Engagement [18:31]

I would set the stage here. At Health Catalyst, we think about care management and patient engagement as fundamentally related. So today, what we’re calling care management, I think in a couple of years we will be thinking about more broadly as patient engagement as we grow the pool of patients that we’re thinking about. And so, as I walk through this slide, I just encourage you to have that framework in mind.

Now, as we think about the first goal of care management, it’s really about identifying who we reach out to. And at the identification phase, our goal is not just to identify the right patients but the right care and the right provider. So part of this comes a little bit back to that topic of attribution that we talked about, making sure that they’re getting to the right person, whether that’s a care manager or a physician or anyone else in your care delivery system.

Your second set of goals is around the intervention itself. So here you’re not only developing the right plan of action for each patient but ensuring that you execute on it. And should the care team realize that the plan isn’t working, having the ability to recognize that and intervene before it’s too late.

Now, the final question I’d encourage you to be asking about these programs is are they working? After all, care management isn’t cheap. So using data again to assess both the patient compliance and program return on investment. And we have illustrated this all as a continual cycle because you’re going to be iterating throughout. So as you improve your abilities to identify patients, as you realize which interventions work, feeding that information back in to make sure that you’re continuously improving this system and the effectiveness of these programs overall.

Performance Monitoring

Minimizing Burden, Maximizing Value [20:13]

So here I am at our fourth competency, performance monitoring. Of course, quality measures serve an incredibly critical role in value-based contracts, and one of our primary goals, of course, is to drive down costs and these are really there to make sure that as we really try do that and are effective at doing that, we’re not letting quality slip. I would say the challenge for most of the organizations that I worked with is that they’re just struggling under the shared administrative burden of hundreds of different measures for many different programs. And that measure reporting is quite honestly taking away from time meaningfully spent improving care. So a number from IOM, they reported recently that CMS has 1700 measures in use today and that’s just CMS. I’m sure your commercial payers are adding to that mix.

And so, a couple of thoughts here on reducing the administrative burden of measure reporting. I think the first is no surprise, automate as much as possible, so you don’t need an army of abstractors to support these efforts. The second piece is really leveraging data to get smart about where you place your efforts. So it’s not just about monitoring your performance. What I’m highlighting here is a sample dashboard from our ACO measures tool. And what you can see in the aspect that I just highlighted is you see the number of patients required to get to the next performance threshold. So as you can see, on ACO 34, you need 143 more patients to move to that next threshold here, currently in the 30th percentile or below the 30th percentile. To move them up that mark, you need to bring 143 more patients into the fold.

Well what if I look at ACO 9. On ACO 9, same thing, kind of get above the 30th percentile but I need just 4 patients to do that. As you can see, how having that information, which lead you to make pretty different decisions about where to invest your efforts.

Now, of course in the long term your goal is to use data to inform meaningful improvement work, to identify the places where you do have meaningful improvement opportunities, to identify the best measures, and to align your payers around a smaller group of meaningful measures in addition to reducing administrative burdens, but I think recognizing that we’re also working through that at the highest levels from the government to your individual organization today, this is really we’re seeing is the best effort to make sure that you can rationalize the process and focus your efforts.

A Note about Data

Clinical or Claims Data? Both are Key [22:45]

Now I’m going to save our fifth competency, improvement prioritization, until after our demos. And I’m going to turn the reins over to Darian in just a second, so he can walk through in a little bit more depth some of what we’ve just been talking about. Before we do that, I want to give a little bit of a caveat around the data that’s driving the analyses.

So I’ve mentioned claims data a number of times at this point. But I want to clarify that both clinical and claims data are critical. Now, claims data of course is [inaudible] but it’s incredibly valuable for these types of value-based agreements and that it’s giving you access to an out-of network view of care. So you’re seeing not only the patients in your network but those that are out of your network as well. And so, this makes it critical for doing analyses like per-member-per-month performance, leakage, and also for something like quality measures.

Now, clinical data tends to be more comprehensive and the beauty of it is that it’s always available. So remember, as you’re entering these agreements, your payers are typically going to be unwilling to give you claims data until you sign on the dotted line. So it’s not that helpful for doing any sort of pre-work before you enter an at-risk contract. And so, there’s a lot you can do with your clinical data before and after that’s really valuable and it’s great for getting a better understanding of your patient population. And the demos I’m going to show you today, it’s actually driving some of the risk scores that are giving you a more nuance view of the payment data.

So from here, I’m going to turn the presentation over to Darian and he’s going to demo some of our accountable care tools, again, to give you a sense of how this data can support the key competence areas that we’ve been talking through so far.

[Demo starts at 24:30]

ACO Explorer [24:33]

[Darian Allen]

Thank you, Marie. Before I get started, there’s a couple of things that I want to make clear. First of all, I’m going to be demonstrating complete apps today. Instead, I’m going to be focusing on the competencies that Marie has walked us through. Secondly, just overall where this is all demo data, no PHI to worry about when we’re looking at this.

So to start, I would like to look at the competency of at-risk contract management. And to demonstrate that, I’m going to use a tool that Health Catalyst built, called ACO Explorer. The ACO Explorer is an executive level dashboard that’s used for monitoring how you’re doing across the various at-risk contracts.

ACO Explorer [25:24]

So, one of the things that Marie pointed out was contractual target. One of those targets that you would probably have in your at-risk contracts has to do with your per-member-per-month and how you’re trending over time.

ACO Explorer [25:43]

So for example, if I was to focus on the contract of CMS, we can see that our current per-member-per-month is $868. We can also see that our leakage out of network PMPM cost is $68, or meaning, of the total PMPM of $868, $68 of that has occurred outside of your network.

It’s also important when you’re looking at your contracts to understand how things are trending. So in any analytics that you have, it would be nice to see how your PMPM changed over time, as well as how your out of network costs have changed over time.

ACO Explorer [26:22]

It’s also important to be able to look at your contracts and your PMPM by different categories, for example, the institutional claims. Now, you can still have that trend chart, so you can see how you’re doing over time. But it’s also nice to be able to see how things have changed based on things like specialty or provider, or maybe principle diagnosis.

ACO Explorer [26:47]

So for example, looking at provider, we can see that for the institutional claims, Healtheast St. Joseph’s Hospital is contributing $748 to the overall PMPM. Now, if we look around annual impact, we can click to see what has changed the most from the previous year to the current year in terms of its PMPM contribution. So for example, we can see that the University of Minnesota Medical Center, it’s PMPM has gone up $7 compared to its previous year.

ACO Explorer [27:22]

Another key thing when looking at at-risk contracts is to understand how you’re doing across the key utilization metrics. So let’s say if I want to look at all my at-risk contracts, and maybe I just want to look at my “in network KPIs”. So now we can see things like admits per 1000, ER visits per 1000, etc., how we’re doing now compared to the previous year and how things are trending.

ACO Explorer [27:50]

And lastly, it’s nice to see at a high-level executive view how you’re doing across your various performance metrics – current score, target, and variance to that target.

So when you’re looking at at-risk contract management, I think it’s key to be able to leverage the claims data that you have obtained and able to look at how you’re doing across your utilization, PMPM, and how you’re doing to any contractual targets that you have set.

PMPM Analyzer [28:26]

I would now like to move to the second competency that Marie discussed and that would be network management and that’s specifically going to focus on leakage.

PMPM Analyzer [28:39]

So I’m going to go to the payments tab of the product we have built, called PMPM Analyzer. And I am going to look at just out of network cost by hitting the flag here that says in network NO. So again, right now, we are looking at the claims data that we have. And now, we can quickly see how much total payments that we have outside of our network. So for example, our total payment is over $1.7 billion but out of network, $84 million has occurred outside of our network, which represents a little over 5 percent of our total payments. We can also still see that the total PMPM for all contracts for all time and how much of that PMPM has occurred outside of our network. It’s key when you’re doing an analysis to be able to see things, your PMPM or your leakage, to look at it by things like diagnosis, procedure, HCPCS. It’s also nice to see the quick glance, maybe your top patients in terms of payments. Another thing to look at is things like claim type, specialty, or provider.

PMPM Analyzer [29:54]

So for example, maybe we want to look into the internal medicine specialty.

ACO Explorer [30:00]

And maybe we want to actually go over and look at providers. So now what we’re looking at is a chart that shows us our various out of network providers and how they’re doing with their total payments compared to the average. So, on the X axis here we have encounters, on the Y axis we have the variants from the average. So if you are above the average, your costs are above your peers. And if you’re below the average, you’re doing better than compared to your internal medicine peers. So knowing that this provider here has a lot of encounters and is below the average, we can look into that provider.

PMPM Analyzer [30:40]

And see if this is a provider that we may want to reach out to and either include as part of our network or to partner with. We can see quickly things like their average price per encounter compared to the specialty average, their total payments compared to the specialty average. And look at things like diagnosis, procedure codes, their patients, etc. The idea here is that we’re having a way to look at and identify leakage and look at providers that you may want to partner with to bring in to the network.

Patient Risk Stratification [31:23]

The next competency I would like to look into is care management, and specifically I would like to focus on high-risk, high-cost patients.

Patient Risk Stratification [31:36]

So one important thing when you’re looking at high-risk and high-cost patients is to be able to switch their various risk models.

Patient Risk Stratification [31:55]

So in this example here, we have different risk models of that, like HCC, Charlson Deyo, etc. Obviously, it would be nice as well, and this tool can do that, you can put in any other risk models that you may have. This chart is showing us total payments on the X axis, risk on the Y axis. The bubbles represent patients and the size of the bubble indicates the number of encounters. We have little reference lines here to show us that over to the right of this Y axis line is the top 1 percent in terms of payments. We also have a similar line to show us the top 1 percent in terms of risk. So we can quickly identify and highlight our high-risk, high-cost patients.

Patient Risk Stratification [32:52]

We may want to limit it to only look at patients that are alive. And now we can see quickly the patients that are high-risk, high-cost, the total payment, and we can even see how their risk is trending.

Patient Risk Stratification [33:10]

So we can actually even go in and look at a particular patient, get some basic demographics of that patient and see the contributors to that patient’s risk score over time. We can see that end-stage renal disease, diabetes, etc., have been part of what’s contributed to this patient’s risk score. Additionally, down below, we can see the current contributors to the patient’s risk score. So we can see in a spider chart where we could say that end-stage renal disease is contributing part of if I hover over that – we can see how it adds up and shows us the risk score and how it adds up to 77.21.

Patient Risk Stratification [34:05]

It’s also important in any analytics you’re using for any of these competencies that I’m talking about, that you’re able to go and see the details behind the metrics. So all the things that I’ve demonstrated have that built-in.

ACO Measure Summary [34:24]

The last competency I would like to talk about is performance monitoring. And specifically I’m going to look at the ACO 33. So we’ve already seen this page and the ACO Explorer tool. Now I want to dive in deeper.

ACO Measure Analysis [34:52]

I want these analyses to understand how the metrics are looking today and what I can expect when the ACO 33 report comes out at the end of the year. So for example, I could sort on current percentile and focus in on a metric, like ACO 30, and see what its current score is and what’s the N required to get to the next percentile – meaning, how many compliant patients do I need to add in order to move this score up into the 30th percentile. And doing that analysis, it’s nice to know the number of opportunities by the location, like Millrock Clinic, or by provider.

ACO Worklist [35:40]

We can even go and try to go to worklist to see the different opportunities that we have by provider and see how they’re doing across that ACO 30 metric.

ACO Worklist [35:54]

We can even drill into a patient and look at not only how they’re dealing with the ACO 30 but we can also see other opportunities across other metrics as well.

So in summary, I hope you see that using tools like this and leveraging the power of the claims data, as well as the EMR data, you can do the analysis you need to look at your various at-risk contracts across the competencies that Marie has showed us so far. And with that, I’ll turn it back to Marie.

[Demo ends  36:26]

[Marie Dunn]

Thanks so much, Darian. I don’t know about you but I always find it particularly helpful just to see what this looks like in action rather than just talking at a high level to what we’re doing here. So Darian, I appreciate you walking through that.

Driving toward Population Health Management [36:43]

So that covers four of our five near-term competencies. And as promised, I want to connect this to where does this stand in terms of our long-term goal of population health management.

The Long-Term Vision: Transforming Care Delivery [36:58]

So at the beginning of the presentation, I differentiated between accountable care and population health management. But when I used the term accountable care, I referred to a competency building around shared risk contracts and the type of efforts taking place today that are owned by your accountable care team. And when I used population health to refer to that long-term journey that truly transformed the way that we provide care, a journey that we’re traveling not just right now as we figure out different types of contracts but over the next decade. And again, not the work of a single team but really a coordinated effort across your delivery system.

Of course these are both interrelated. So the long-term goal of at-risk contracts is to incentivize true population health management. That said, in today’s predominantly fee-for-service world, many of the organizations I work with are rightfully hesitant to completely transform their care delivery system because they worry about putting themselves at financial risk.

So after all, in the world where we’re compensated for volume, it’s detrimental to our bottom lines if we succeed at the type of things incurred by value-based payment, like reducing utilization. And so, how do we balance that? This is where we get to our fifth and final competency around improvement prioritization. So this competency is about using data to identify the greatest opportunities as a health system for transformation and then it really serves two purposes – the first is to focus your organization on the biggest and most meaningful opportunities for improvement and the second is to give you a means to start conversations with your payers about how to get paid for value.

Outlier Management [38:37]

Inlier Management (Focus on Better Care)

So let’s talk a little bit more about what this path to care transformation looks like. Thus far, we’ve been talking about initiatives like identifying high-risk, high-cost patients, identifying major sources of leakage, and really developing very targeted initiatives to address those aims. So in these instances, I would say we’re focused on the outliers, we’re focused on quick wins. So on this slide, I’m just illustrating that graphically, we’re taking the example of patient outcomes. And you can see there’s a distribution from poor outcomes to excellent outcomes with most cases falling somewhere in between. It’s pretty typical to set a minimum standard for quality improvement, or for that matter, leakage reduction, and work to ensure that everyone meets the target. Now, this is absolutely critical in the short term. After all, most of you have performance measures or financial targets that you need to hit very soon. And this is a pretty effective strategy for targeting the low-hanging fruit. But let’s be honest, this is not what’s going to completely transform your care delivery system. So where are we going on that journey?

So I’m showing the same normal distribution of cases here. In the outlier management model I described, we were focused on the red dots, so again our poor outcomes. An alternate model is to focus on improving your care process for everyone involved by minimizing variation across the board. So as you can see, the long-term goal of focusing on redefining the process instead of simply targeting those that are under performing is to improve everyone’s performance. And as you can see on the chart on the right, this means minimizing variation and raising performance for the entire group instead of just for a few outliers. So this is nice in theory but where do we start? We can’t just do this all overnight.

Improvement Prioritization [40:26]

Now, what I’ve illustrated on this slide is a pretty typical distribution of care process families. And a care process family is something like asthma or heart failure or process that you’re going to want to transform. Now each dot, it is a care process. And the blue dots, so the blue that’s are a care process and the red dots represent their cumulative resource consumption. What’s obvious from this chart is a very small percent of care processes comprise of very high percent of our overall resource consumption. So here, the top 10 care processes account for 34 percent of your resource consumption. And your top 40 care processes account for 80 percent. Now, the goal of this exercise, which of course you’re going to want to do using your own data, is to help you focus. As you start to think about care transformation, this helps you figure out where to start.

Choosing a Place to Start [41:17]

So here’s another graphic from our key process analysis tool that gets to the same concept. On this slide, you’re seeing all of our care processes represented by a bubble. So this is a level of granularity below what was on the last slide. Their graphed by total revenue and total variation and the size of the bundle represents the number of cases. Now, variation is a really important variable to consider here, and so I want to pause on that. Just because the care process has a lot of dollars attached doesn’t mean that there’s a lot of opportunity for improvement. What you’re looking for is a care process that’s in the upper right-hand quadrant of this graphic because that tells you that it’s both high dollar and highly variable which points to the fact that there’s an opportunity to improve it. As we know, variation is often an indicator of quality issues. And so, improving quality and reducing variation often go hand in hand. And of course, that’s what you’re fundamentally orienting around as you’re trying to improve quality in your system.

Now, we could spend much more time talking about exactly how you do this, how you go about reducing variation. The goal here, I think, is just to illustrate the fact that using data can help you prioritize those efforts because you can’t do everything at once. And so, what I would encourage you to do, if you are interested, is I will share some thoughts on folks in whitepapers later that really go in depth into this process of how you would think about actually driving down variation, improving quality, reducing cost and as you think about care transformation. Where I’m going to go instead is keeping that concept in mind, is to talk about how do we get paid for doing the right thing – because I think that is what is top of mind. When I talk to healthcare organizations, they say, well of course I want to do this, but I’m not getting paid for it today. And so, sort of teeing up for you some of the ways that you can start to think about doing that.

Doing Well by Doing Good [43:15]

So the previous analysis showed us completely independently of our current payment models, what are our opportunities for improvement based on high cost and variation. As you’re prioritizing this work, another filter that you’re going to want to consider is your current payment model. So what I’ve listed here is a slide that cross-walks the broad categories of potential improvements, for example, workflow improvement or patient safety improvements. And I’ve cross-walked them against various payment models.

Now, the intersection of an improvement and a payment model is coded green. That means that the financial system is going to reward that intervention. A red square means that under the specific payment model, you could actually hurt your bottom line. So immediately this graphic tells us that workflow interventions are rewarded under any payment model and that’s a great place to start.

So when you’re just starting, it of course helps your organization to prioritize the types of improvements that are rewarded under your current payment model first. And this is a pretty reasonable question, what happens if a meaningful improvement effort, a high dollar improvement effort with a lot of variation, is not aligned with your current payment infrastructure? And I’ll tell you, this is really easy to imagine as you get further along in your improvement efforts, particularly in markets where they’re moving a little bit slower for adopting value-based payment. And so, what I’m going to walk through next is how you think about making the case for getting paid for value.

Creating a Case for Quality [44:45]

So I’m going to think back to my bubble chart and I’m going to use the bubbles slightly differently here. Each bubble in the past chart represented a care process. I’m going to drill in a level below to show you how to make the business case and just using the example of vascular procedures. So the bubble that I’m about to drill into right now represents all of the particular physician, I’ll call him Dr. Jones, all of his vascular procedures. And Dr. Jones has 15 cases at an average cost per case of $60,000. Now, the mean cost of case at this facility is $20,000. And so, what would happen if I was to take Dr. Jones and somehow implement a quality improvement initiative and bring his cases in line with the new cost? Well there’s an opportunity to savings there of about $600,000. So now, all the dots here represent of course all of the physicians providing this particular care process. And we can look at another physician represented by that next bubble, 25 cases at an average cost per case of $35,000, almost $900,000 more in opportunity.

And so, this quickly adds up as you start to think about what happens if I standardize this process and I bring all of these physicians closer to the mean. Well, my total opportunity is $4 million for this particular care process. So again looking at vascular procedures. So it’s having this type of data that gives you the leverage that you need to make the case for quality.

So of course your payer can continue to pay based on volume. But one greater opportunity for both of you is to focus in on improving quality, on reducing variation, and it’s this type of data that’s going to help you take the lead in those conversations. For example, so I create a bundled payment around an opportunity that’s meaningful for your organization instead of you waiting for the payer to approach you on their terms.

For more information… [46:53]

Now, as I mentioned, I really just wanted to tee up that concept. Population health management is a journey that we’re taking to really transform our care delivery system. It’s something that we have covered in great depth to Health Catalyst.

And so, what I’m going to refer you to is to a number of whitepapers and books. Dr. David Burton wrote a wonderful ‘Accountable Care Transformation Framework’ and Dr. Haughom wrote a book ‘Healthcare: A Better Way’. Both great reading to go in depth on both of those topics. And again, we really just wanted to tee up the broader vision of what you’re doing today around at-risk contract management and building those competencies connects to that broader vision of population health management. So I’ll leave those for your later review.

Readying Your Organization for Value-base Payment [47:42]

So in closing, I want to summarize what we’ve covered today. We’ve covered a lot. First, I would say, don’t underestimate the value of data in driving your transition to value-based payment. You’re going to need to access a wide variety of data sources, clinical data, claims data, to do meaningful analyses. And so, think about how you’re going to get access to that data today.

Next, start to develop a plan for tackling each of those five short-term competencies, if you haven’t already. So again, at-risk contract management, network management, care management, performance monitoring, and then improvement prioritization. So you’re going to start asking questions in this realm, like how savvy am I at managing my performance contracts today, am I effectively managing my physician network, am I effective focusing my care management resources and iterating on those programs to improve them.

Now, this planning you develop is going to necessarily hinge on your organization’s timeframe. And some markets are moving a lot faster than others. So you may not have much of a choice in that, but some do. Assuming that you do have a choice, are you hoping to lead your market or follow? Is this journey going to take place in the next two years or the next decade? And really helping you understand, you know, how fast do we need to be moving along some of the competencies that we talked about today.

Finally, I’d really encourage you not to forget about the care transformation case. I think it’s easy to get very focused on what do you need to do around a particular at-risk contract and not to think about well what does this mean and when I follow down the path of not just having one contract or two contracts but all of my contracts at-risk. And so here it’s really sort of holding that concept in mind that this total retransformation doesn’t happen overnight. And so, starting to identify opportunities for improvement, thinking about how they align to your current payment models, and then really thinking about how you can build the case to proactively approach your payers around the meaningful improvement initiatives to get paid for value, again, with the idea that it’s better to start this on your own terms than to wait for them to approach you.

So with that, I’m going to wrap up. Thank you so much for taking the time to join us. It’s a topic that Darian and I are both just incredibly excited about and we’re thrilled to share some of what we’ve learned with you.

Upcoming Webinar [50:05]

In terms of where we’re heading next, Tyler has a few points to share and then Darian and I are going to stay on the line and would love to start answering some of your questions.

[Tyler Morgan]

Thank you Marie. Thank you Darian. But before we jump into the questions, I would like to let you know that next week we do have an upcoming webinar, Introducing our Health Catalyst University: An Accelerated Outcome Improvement and Innovative Approach to that.

Healthcare Analytics Summit 15 [50:59]

Now, we do have our Healthcare Analytics Summit coming up September 8th through 10th in Salt Lake City. So we’ve got a couple registrations to give away. The first is a single registration and the second of the registration for a team of three. Now, before doing this, because of high demand and limited space, these registrations must be redeemed by registering for the summit by June 30th when they will expire. So if you are interested, I’m going to go ahead and launch this first poll.

Are you interested in attending the Healthcare Analytics Summit in Salt Lake City? [51:32]

This poll is for the single registration. If you are interested and you feel confident you will be able to attend our summit on the 8th through the 10th of September, please go ahead and respond to this poll. I will leave this up for a few moments. And I would like to remind everyone that while we’re filling this out, if you have any questions, be sure to type your questions in to the questions pane of your control panel.

Alright. I’m going to go ahead and close this poll right now.

And now our next poll is for the team of three registration. And we’ll leave this up for a few moments to give you the opportunity to respond. And I will let you know that in the email that we’ll send out after the event, we will have the links to the recorded webinar, the presentation slides, the responses to the poll questions, and also we will include the names of the winners of these particular registration giveaways.

Alright. Thank you all so much for responding to that. And before we turn the time over, I do have one last poll question to ask.

How interested are you in someone from Health Catalyst contacting you

About a demonstration of our solutions? [52:59]

Our webinars are meant to be educational about various aspects affecting our industry, particularly from a data warehousing and analytics perspective. But we have had many requests for more information about what Health Catalyst does and what our products are. So if you are interested to have someone from Health Catalyst reach out to you to schedule a demonstration, please take the time to respond to this last poll questions.

Alright. Thank you very much. I’ll turn the time over to Marie and Darian with our Q&A.

Question and Answer [53:41]

When you say organizations, are you talking about health systems providers or payers? Great question and hopefully that became clear over the course of the presentation. As we were talking about healthcare organizations, we were really taking a provider-specific view. And again, most of the organizations that we work with are health systems or physician practices who are sort of moving down this path and then of course working with payers in tandem.
>So focusing again on payers, to what degree of those projected timelines that you shared towards the beginning align with the payer’s timelines? Certainly the organizations that we’re working with, it’s pretty variable by market. So you look at some markets like Massachusetts and they’re just really aggressively already into the space and I think the payers are often there too. And another market, we’re much further, I would say moving a lot more slowly, we are actually working with a lot of organizations where payers have been maybe reticent to move too fast. So this is where that piece about building the case, the business case or moving the value-based payment is really key. But if you are in a market where your payer is open to that conversation and at the table, that’s great. But sometimes you do need to come to the table and make a pretty compelling case for why you do want to get paid for value and why there is a reason for you to do some of these transformation efforts that you want to get paid for under fee-for-service today. And so, that’s where I’m hopeful that that piece comes in, that if you do need to help to move your payers along a little bit, that you can start to build that business case at your organization.
Can ACO Explorer be used for contracts other than ACOs? Yes but the key is that product is built for your various at-risk contracts, which may or may not be part of an ACO.   So any at-risk contracts that you may have in place, that’s what that tool is built for.
Question around patient risk app, does it also let you identify low cost, high risk patients? [Darian Allen]Yes. In purposes of demonstration, I’ve just kind of showed the high-risk, high-cost patients but you could easily cross over and identify your currently high-risk patient that have a low cost and those patients that you too may want to focus in on on your care management initiatives.

[Marie Dunn]

Or I would say even potentially different initiatives. So as we talked about care management and patient engagement being really in some ways a similar thing where care management is patient engagement for that high-risk, high-cost group. Of course, it’s helpful to think about a variety of interventions, maybe it’s care management, maybe it’s something else. And so, that’s where it is helpful to really look at your whole patient population. We are prioritizing based on risk and cost but you might want to look at a particular provider’s panel or a particular specialty area and start to drill in from there, and again use that to prioritize based on any number of interventions that you would be wanting to use.

What were the tools that were demonstrated? What are the names of those products? I started with ACO Explorer, PMPM Analyzer, Patient Risk Stratification, and ACO Measures.
What is the simplest definition of an at-risk contract? Simplest definition of an at-risk contract, I would say it’s a contract where you’re going financially at risk for cost and quality. So as opposed to being financially a risk for volume, really sort of changing the paradigm there around cost and quality.

[Tyler Morgan]

Alright. Thank you so much. I would like to thank everyone for joining us. And remind you that shortly after this webinar, you will receive an email with links to the recording of this webinar, the presentation slides, the poll question summary results, and the winners of the summit registration giveaways. Also, please look forward to the transcript notification we will send you once it is ready.

On behalf of Marie Dunn and Darian Allen, as well as the rest of us here at Health Catalyst, thank you for joining us today. This webinar is now concluded.