RowdMap Health Datapalooza Creating a Virtual Cycle: designing networks to mitigate no-value care from fee for service and create value-based wins for both payers and providers using cms benchmark data
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The document discusses strategies for reducing no-value healthcare spending through value-based care models, highlighting the shift from fee-for-service to risk-based arrangements. It emphasizes the importance of utilizing public health data to manage risk and improve patient outcomes while decreasing unnecessary costs. Experts in the field provide insights into creating networks that incentivize quality care delivery and foster sustainable financial models.
RowdMap Health Datapalooza Creating a Virtual Cycle: designing networks to mitigate no-value care from fee for service and create value-based wins for both payers and providers using cms benchmark data
- 2. OWNING RISK IS TOUGH, BUT IT’S WHERE THE ACTION’S AT Once upon a time plans had large group commercial populations with years of consistency and providers simply delivered services for a fee. But government programs like Medicare Advantage, Marketplace / Exchange and Medicaid, have populations changing every year, or even every month and providers managing a population's health over time. Changing populations and dynamic payment models may make it tough to predict and achieve member outcomes in a financially sustainable way precisely when providers are getting in the game to take on risk. Public health data are providing solid case studies of achieving member health and happiness with sustainable financial models for all players in this new game. If you are managing risk, considering taking on risk, or investing in or providing products or services to anyone bearing risk, camp out in these sessions to learn how to use public data and internal resources to: § Effectively leverage analytic approaches to manage risk § Accurately assess risks and project costs § Effectively align providers and incentivize care delivery
- 5. No-Value Care: CMS Is Paying on It 2016 World Economic Forum Annual Meeting in Switzerland On track to sunset 50% of FFS
- 6. No-Value Care: Success Defined by It “During its first year, the Pioneer ACO program was associated with modest reductions in low-value services, with greater reductions for organizations providing more low- value care. Accountable care organization–like risk contracts may be able to discourage use of low-value services even without specifying services to target.”
- 7. “Millions of people are receiving drugs that aren’t helping them, operations that aren’t going to make them better, and scans and tests that do nothing beneficial for them, and often cause harm.” Dr. Atul Gawande, Professor, Department of Health Policy and Management at the Harvard School of Public Health & the Department of Surgery at Harvard Medical School. No-Value Care: Media Is Reporting on It
- 11. No-Value Care: Decades of Research on It The estimated 30% of medical expense that goes to no-value care. Unnecessary spending drives billing in a fee-for-serve economic model, but success in pay-for-value comes from managing and mitigating these pockets of variation. Variation: Unwarranted or Unexplained? Every physician has a unique fingerprint Economic Drill Down: Example Utilization Review and Actuarial Unit Cost Analysis against Care Intensity Curve across Total Basket of Care Variation across geographies and within practices across physicians. “Physician-Level Practice Variation: Who You See Is What You Get” Brian Powers, Sachin Jain, David Cutler, & Ziad Obermeyer Health Affairs, 09.23.15 Definitions, research and geocoding by Hospital Referral Regional available via the Dartmouth Atlas for Unwarranted Variation: www.dartmouthatlas.org NB: Unwarranted variation refers to practice patterns, which hold up across populations but pricing variation may also be unwarranted and marked fluctuates across insurance product and lines and geography. “The Price Ain’t Right.” Cooper, Craig, Gaynor and Van Reenen, 2015.