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1© 2014 Valence Health. All rights reserved.
Clinical Integration
Using Electronic Health Information and Strategic
Analytics to Enhance Value Based Health Solutions,
Improve Care Delivery and Advance Care Coordination
HFMA Texas Gulf Coast & HIMMS South Central
Texas Chapter Joint Meeting
September 26, 2014
2© 2014 Valence Health. All rights reserved.
Clinical Integration
Objectives
1
Understand  What’s  Fueling  “Big  Data” Discussions in
Healthcare
2
Learn  How  Texas’  Children’s  Health  Plan  is  Using  
Electronic Health Information and Strategic Analytics
3 Address Your Questions
3© 2014 Valence Health. All rights reserved.
Clinical IntegrationACA is Providing Incentives for Providers and Hospitals to
Overcome Distrust and Align for Common Gain
Lack of
Shared
Incentives
Lack of
Physician
Governance
Fragmented
Structure
• Long term contracts
offered with no
productivity terms or
quality incentives
• Physicians were
promised a greater say
that was never delivered
• Hospitals failed to
organize multiple
physician groups into a
cohesive units
• Lack of communication
tools
Pre-ACA Implementation1 Post-ACA Implementation3
Aligned
Incentives
Demand for
Coordinated
Care
Technology
Incentives2
• Bundled payments
• Shared savings / risk
arrangements
• Must manage care
together
• Safe harbor for physicians
and hospitals to operate
• Penalties for poor quality
scores for hospitals
• Staying on top of quality
scores means improving
physician relationships
• Meaningful Use
initiatives provide
incentives for investment
in technology that
improves coordination
• Overcome data issues
$
1) Deloitte  Center  for  Health  Solutions.  “Physician-hospital  employment:  This  time  it’s  different.”  2013. http://www.deloitte.com/assets/Dcom-
UnitedStates/Local%20Assets/Documents/Center%20for%20health%20solutions/us_lshc_PhysicianHospitalEmployment_090313.pd
2) Centers for Medicare & Medicaid Services. 2014 Definition of Stage 1 of Meaningful Use. http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Meaningful_Use.html
3) PwC  Health  Research  Institute.  “From  courtship  to  marriage:  A  two  part  series  on  physician-hospital  alignment.”  2011.  http://thehill.com/images/stories/blogs/pwc%20trust.pdf
4© 2014 Valence Health. All rights reserved.
Clinical Integration
What We Are Seeing in the Market
Model ↑↓ Trends
Clinically
Integrated
Networks
• Major momentum in many/most markets
• Drivers different by  market  “type”
• Some cross-system collaborations
• Some IPA/Physician lead models, but
mostly hospital / system supported
ACOs and
Full Risk
Contracts
• Commercial and Medicare ~50/50
• Latest batch of MSSP about to be
released to applicants
• Data reporting/sharing often still
problematic
• Seeing selected expansion of full-risk
contracts – some provider inspired
• Medicaid risk contracts in some states
Provider-
Sponsored
Plans
• Some marquis growth (Sutter, NSLIJ) and
smaller players (CHOMP, Florida
Hospital, solutions
• ABCO says 1 in 5 systems to be payors
by 2018
Bundled
Payments
• Still limited in total application
• Still focused around cardio, ortho and
birth episodes/procedures
• Illinois Bone and Joint - Leader
PCMH
• ~5000 accredited sites
• New growth has slowed
• Funding from commercial payors may be
focused elsewhere
41
138
356
606
0
100
200
300
400
500
600
700
Q4 2010 Q4 2011 Q4 2012 Q4 2013
Rapid Growth of ACOs Year Over Year1
Number of ACOs by Referral Region1
1) Leavitt Partners Center for Accountable Care Intelligence, 2014
5© 2014 Valence Health. All rights reserved.
Clinical Integration
Inputs and Outputs that Support Quality and Risk
Management
Clinical Measures
and Quality
Improvement
Population Analytics
for Risk
Stratification
Programmatic Risk
Management Portal
Inputs: Multiple Sites
and Data Sources
Outputs: Population Management with
Decision Support Functionality
• National measures (e.g. HEDIS)
• CI measures
• Risk measures – and how they are
different
• Population health reporting
• Identification of gaps in care and high-risk
patients
• Proficient and proactive performance
management
• Physician report cards
• Registries and action lists for each patient
(e.g. overdue care)
Physician Offices
Practice Management Systems, EHRs
Hospital Data
ADT, Billing Data, Demographics
Lab Data
Quest, LabCorp, Other
PBM Data
Post-Acute Data
Claims Based
Payor Data
Eligibility, Paid Medical Claims
360o Clinical
Information for
Affiliates
• Virtual medical records support POC risk
management
• ED and Hospitalization alerts
• Encourages in-network referral
6© 2014 Valence Health. All rights reserved.
Clinical IntegrationAttribution of Members to Providers is Critically important
for Population Health Management
Attribution assignment can  be…
• Assigned by the payor or EMR
• Based on number and type of E&M codes
• Assigned using ranked specialists
• Triggered by Dx or Px
• More customized, if client wishes
Attribution is key to creating joint accountability
for risk and quality. Configuration can be based on:
• Provider type: specialty type, PCP, PCP
subtypes
• Single or multiple attribution: including
groups as defined by geography or specialty
• By encounter detail: counts, types, and
diagnoses specific
• Configurable at the measure level
• Any permutation of the above
Member matching capabilities reliably and
accurately link unique individuals across EMRs,
PMS, labs, Rx data, professional services,
hospitals, and other institutions. Algorithms are:
• Tuned to enhance specificity and avoid false
negatives
• High matching rates with capabilities for manual
clinician directed merging
• Incorporate advanced statistical methodologies
including probabilistic matching, Bayesian
algorithms, and deterministic logic
Attribution Member Matching
7© 2014 Valence Health. All rights reserved.
Clinical Integration
Objectives
1
Understand  What’s  Fueling  “Big  Data”  Discussions  in  
Healthcare
2
Understand  How  Texas’  Children’s  Health  Plan  is  Using  
Electronic Health Information and Strategic Analytics
3 Answer Your Questions
8© 2014 Valence Health. All rights reserved.
Clinical Integration
The Center for Children and Women
Texas
Children’s  
Texas
Children’s  
Hospital
Texas
Children’s  
Pediatrics
Texas
Children’s  
Physician
Services
Organization
Texas
Children’s  
Women’s  
Specialist
Texas
Children’s  
Health Plan
Texas
Children’s  
Health Plan—
The Center
For Children
and Women
TCH
Insurance
Company,
LTD
Texas
Children’s  
Hospital
Foundation
9© 2014 Valence Health. All rights reserved.
Clinical Integration
Background
• Located in the
community of
Greenspoint and
soon Southwest.
• Both areas with large
Medicaid populations
10© 2014 Valence Health. All rights reserved.
Clinical Integration
Access
11© 2014 Valence Health. All rights reserved.
Clinical Integration
Integration
• Pediatrics
• Obstetrics
• Behavior Health
• Pharmacy
• Optometry
• Dentistry
• Laboratory
• Diagnostic Imaging
• Speech Therapy
12© 2014 Valence Health. All rights reserved.
Clinical Integration
Coordination
13© 2014 Valence Health. All rights reserved.
Clinical Integration
Alignment
14© 2014 Valence Health. All rights reserved.
Clinical Integration
HEDIS Metrics
15© 2014 Valence Health. All rights reserved.
Clinical Integration
Valence Reporting Population Management
16© 2014 Valence Health. All rights reserved.
Clinical Integration
TCHP Utilization
Performance Relative to
Peers
17© 2014 Valence Health. All rights reserved.
Clinical Integration
• Eligibility
• Member Eligibility
o Member months from 2011-2013
o Ages 1-18
o Exclude newborn, pregnant women, TANF adults, and SSI members
• Claims Eligibility
o Claims incurred from 2011-2013
• Utilization: defined as rate per 1,000 members per year
• Numerator: sum of events
• Denominator: sum of member months
• Rate: 12,000 * (Numerator / Denominator)
Peer Comparison Methodology for Texas Medicaid
Children
18© 2014 Valence Health. All rights reserved.
Clinical Integration
TCHP is the Highest Performing System, Achieving a 61%
Reduction in ED Visits Relative to its Peers
Medicaid Pediatric ED visits, by Provider system
Rate per 1,000; Payor data; 2011-2013 average
348
435
721
577
894A
C
B
Average 595
D
-61.1%
TCHP
2011-2013 average
19© 2014 Valence Health. All rights reserved.
Clinical Integration
TCHP pediatric admission rate is 36% lower that its cohort
Medicaid Pediatric Admissions, by Provider System
Rate per 1,000; Payor data; 2011-2013 average
19.2
29.9
27.7
18.5
22.4
D
A
B
TCHP
Average 24
C
-35.8%
20© 2014 Valence Health. All rights reserved.
Clinical Integration
Objectives
1
Understand  What’s  Fueling  “Big  Data”  Discussions  in  
Healthcare
2
Learn  How  Texas’  Children’s  Health  Plan  is  Using  
Electronic Health Information and Strategic Analytics
3 Answer Your Questions
21© 2014 Valence Health. All rights reserved.
Clinical Integration
Contact Us
• Nathan Gunn MD, President of Population Health, Valence Health
• NGunn@valencehealth.com
• Ph: 312-526-7395
• Heidi  Schwarzwald  MD  MPH,  Pediatric  Director  Texas  Children’s  Health  Plan  
Center for Children and Women; Vice-Chair for Community Pediatrics, Baylor
College  of  Medicine  Department  of  Pediatrics  at  Texas  Children’s
• hlschwar@texaschildrens.org
• Ph: 832-828-1538

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Using Electronic Health Information and Strategic Analytics to Enhance Value Based Health Solutions, Improve Care Delivery and Advance Care Coordination

  • 1. 1© 2014 Valence Health. All rights reserved. Clinical Integration Using Electronic Health Information and Strategic Analytics to Enhance Value Based Health Solutions, Improve Care Delivery and Advance Care Coordination HFMA Texas Gulf Coast & HIMMS South Central Texas Chapter Joint Meeting September 26, 2014
  • 2. 2© 2014 Valence Health. All rights reserved. Clinical Integration Objectives 1 Understand  What’s  Fueling  “Big  Data” Discussions in Healthcare 2 Learn  How  Texas’  Children’s  Health  Plan  is  Using   Electronic Health Information and Strategic Analytics 3 Address Your Questions
  • 3. 3© 2014 Valence Health. All rights reserved. Clinical IntegrationACA is Providing Incentives for Providers and Hospitals to Overcome Distrust and Align for Common Gain Lack of Shared Incentives Lack of Physician Governance Fragmented Structure • Long term contracts offered with no productivity terms or quality incentives • Physicians were promised a greater say that was never delivered • Hospitals failed to organize multiple physician groups into a cohesive units • Lack of communication tools Pre-ACA Implementation1 Post-ACA Implementation3 Aligned Incentives Demand for Coordinated Care Technology Incentives2 • Bundled payments • Shared savings / risk arrangements • Must manage care together • Safe harbor for physicians and hospitals to operate • Penalties for poor quality scores for hospitals • Staying on top of quality scores means improving physician relationships • Meaningful Use initiatives provide incentives for investment in technology that improves coordination • Overcome data issues $ 1) Deloitte  Center  for  Health  Solutions.  “Physician-hospital  employment:  This  time  it’s  different.”  2013. http://www.deloitte.com/assets/Dcom- UnitedStates/Local%20Assets/Documents/Center%20for%20health%20solutions/us_lshc_PhysicianHospitalEmployment_090313.pd 2) Centers for Medicare & Medicaid Services. 2014 Definition of Stage 1 of Meaningful Use. http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Meaningful_Use.html 3) PwC  Health  Research  Institute.  “From  courtship  to  marriage:  A  two  part  series  on  physician-hospital  alignment.”  2011.  http://thehill.com/images/stories/blogs/pwc%20trust.pdf
  • 4. 4© 2014 Valence Health. All rights reserved. Clinical Integration What We Are Seeing in the Market Model ↑↓ Trends Clinically Integrated Networks • Major momentum in many/most markets • Drivers different by  market  “type” • Some cross-system collaborations • Some IPA/Physician lead models, but mostly hospital / system supported ACOs and Full Risk Contracts • Commercial and Medicare ~50/50 • Latest batch of MSSP about to be released to applicants • Data reporting/sharing often still problematic • Seeing selected expansion of full-risk contracts – some provider inspired • Medicaid risk contracts in some states Provider- Sponsored Plans • Some marquis growth (Sutter, NSLIJ) and smaller players (CHOMP, Florida Hospital, solutions • ABCO says 1 in 5 systems to be payors by 2018 Bundled Payments • Still limited in total application • Still focused around cardio, ortho and birth episodes/procedures • Illinois Bone and Joint - Leader PCMH • ~5000 accredited sites • New growth has slowed • Funding from commercial payors may be focused elsewhere 41 138 356 606 0 100 200 300 400 500 600 700 Q4 2010 Q4 2011 Q4 2012 Q4 2013 Rapid Growth of ACOs Year Over Year1 Number of ACOs by Referral Region1 1) Leavitt Partners Center for Accountable Care Intelligence, 2014
  • 5. 5© 2014 Valence Health. All rights reserved. Clinical Integration Inputs and Outputs that Support Quality and Risk Management Clinical Measures and Quality Improvement Population Analytics for Risk Stratification Programmatic Risk Management Portal Inputs: Multiple Sites and Data Sources Outputs: Population Management with Decision Support Functionality • National measures (e.g. HEDIS) • CI measures • Risk measures – and how they are different • Population health reporting • Identification of gaps in care and high-risk patients • Proficient and proactive performance management • Physician report cards • Registries and action lists for each patient (e.g. overdue care) Physician Offices Practice Management Systems, EHRs Hospital Data ADT, Billing Data, Demographics Lab Data Quest, LabCorp, Other PBM Data Post-Acute Data Claims Based Payor Data Eligibility, Paid Medical Claims 360o Clinical Information for Affiliates • Virtual medical records support POC risk management • ED and Hospitalization alerts • Encourages in-network referral
  • 6. 6© 2014 Valence Health. All rights reserved. Clinical IntegrationAttribution of Members to Providers is Critically important for Population Health Management Attribution assignment can  be… • Assigned by the payor or EMR • Based on number and type of E&M codes • Assigned using ranked specialists • Triggered by Dx or Px • More customized, if client wishes Attribution is key to creating joint accountability for risk and quality. Configuration can be based on: • Provider type: specialty type, PCP, PCP subtypes • Single or multiple attribution: including groups as defined by geography or specialty • By encounter detail: counts, types, and diagnoses specific • Configurable at the measure level • Any permutation of the above Member matching capabilities reliably and accurately link unique individuals across EMRs, PMS, labs, Rx data, professional services, hospitals, and other institutions. Algorithms are: • Tuned to enhance specificity and avoid false negatives • High matching rates with capabilities for manual clinician directed merging • Incorporate advanced statistical methodologies including probabilistic matching, Bayesian algorithms, and deterministic logic Attribution Member Matching
  • 7. 7© 2014 Valence Health. All rights reserved. Clinical Integration Objectives 1 Understand  What’s  Fueling  “Big  Data”  Discussions  in   Healthcare 2 Understand  How  Texas’  Children’s  Health  Plan  is  Using   Electronic Health Information and Strategic Analytics 3 Answer Your Questions
  • 8. 8© 2014 Valence Health. All rights reserved. Clinical Integration The Center for Children and Women Texas Children’s   Texas Children’s   Hospital Texas Children’s   Pediatrics Texas Children’s   Physician Services Organization Texas Children’s   Women’s   Specialist Texas Children’s   Health Plan Texas Children’s   Health Plan— The Center For Children and Women TCH Insurance Company, LTD Texas Children’s   Hospital Foundation
  • 9. 9© 2014 Valence Health. All rights reserved. Clinical Integration Background • Located in the community of Greenspoint and soon Southwest. • Both areas with large Medicaid populations
  • 10. 10© 2014 Valence Health. All rights reserved. Clinical Integration Access
  • 11. 11© 2014 Valence Health. All rights reserved. Clinical Integration Integration • Pediatrics • Obstetrics • Behavior Health • Pharmacy • Optometry • Dentistry • Laboratory • Diagnostic Imaging • Speech Therapy
  • 12. 12© 2014 Valence Health. All rights reserved. Clinical Integration Coordination
  • 13. 13© 2014 Valence Health. All rights reserved. Clinical Integration Alignment
  • 14. 14© 2014 Valence Health. All rights reserved. Clinical Integration HEDIS Metrics
  • 15. 15© 2014 Valence Health. All rights reserved. Clinical Integration Valence Reporting Population Management
  • 16. 16© 2014 Valence Health. All rights reserved. Clinical Integration TCHP Utilization Performance Relative to Peers
  • 17. 17© 2014 Valence Health. All rights reserved. Clinical Integration • Eligibility • Member Eligibility o Member months from 2011-2013 o Ages 1-18 o Exclude newborn, pregnant women, TANF adults, and SSI members • Claims Eligibility o Claims incurred from 2011-2013 • Utilization: defined as rate per 1,000 members per year • Numerator: sum of events • Denominator: sum of member months • Rate: 12,000 * (Numerator / Denominator) Peer Comparison Methodology for Texas Medicaid Children
  • 18. 18© 2014 Valence Health. All rights reserved. Clinical Integration TCHP is the Highest Performing System, Achieving a 61% Reduction in ED Visits Relative to its Peers Medicaid Pediatric ED visits, by Provider system Rate per 1,000; Payor data; 2011-2013 average 348 435 721 577 894A C B Average 595 D -61.1% TCHP 2011-2013 average
  • 19. 19© 2014 Valence Health. All rights reserved. Clinical Integration TCHP pediatric admission rate is 36% lower that its cohort Medicaid Pediatric Admissions, by Provider System Rate per 1,000; Payor data; 2011-2013 average 19.2 29.9 27.7 18.5 22.4 D A B TCHP Average 24 C -35.8%
  • 20. 20© 2014 Valence Health. All rights reserved. Clinical Integration Objectives 1 Understand  What’s  Fueling  “Big  Data”  Discussions  in   Healthcare 2 Learn  How  Texas’  Children’s  Health  Plan  is  Using   Electronic Health Information and Strategic Analytics 3 Answer Your Questions
  • 21. 21© 2014 Valence Health. All rights reserved. Clinical Integration Contact Us • Nathan Gunn MD, President of Population Health, Valence Health • NGunn@valencehealth.com • Ph: 312-526-7395 • Heidi  Schwarzwald  MD  MPH,  Pediatric  Director  Texas  Children’s  Health  Plan   Center for Children and Women; Vice-Chair for Community Pediatrics, Baylor College  of  Medicine  Department  of  Pediatrics  at  Texas  Children’s • hlschwar@texaschildrens.org • Ph: 832-828-1538