Upload
others
View
1
Download
0
Embed Size (px)
Citation preview
Poweredby
ENGAGINGPAYERSTOCREATENEWVALUEFORLABSANDESTABLISHCOLLABORATIVECARERickVanNess,MSDirector,ProductManagementTriCoreReferenceLaboratories
InformationcontainedinthismaterialisconfidentialandproprietarytoTRICOREanditsaffiliatesandmaynotbemodified,copied,published,disclosed,distributed,displayedorexhibited,ineitherelectronicorprintedformatswithoutwrittenauthorizationofanofficerofTRICORE.
April30,2019
Poweredby
• Grant/ResearchSupport:None• Salary/ConsultantFees:
– TriCoreReferenceLaboratories• Board/Committee/AdvisoryBoardMembership:
– UNMMainInstitutionalReviewBoard,CommunityScientificReviewer– NewMexicoBiotechnologyandBiomedicalAssociation,President
• Stocks/Bonds– Mozak,LLC(CEOandCo-Founder)
• HonorariumExpenses:None• IntellectualProperty/RoyaltyIncome:None
FINANCIALDISCLOSUREINFORMATION
Poweredby
• Background– TriCoreReferenceLab
– ClinicalLaboratory2.0
• CustomerExample– PainPointsandLabSolutions
– ProductFeedbackandEnhancements
• ValueofLaboratoryInformation
• RoadMapforyou!
AGENDA
Poweredby
DEMING
GALLUP
ROSWELL
ARTESIA
TRICOREREFERENCELABORATORIESServices12clinicalspecialties
2,900highlyspecializedtests11,100,00+diagnostictestsperyear
Generate~60%ofNewMexico’sclinicallaboratorydata98.6%ofalltestsareperformedinTriCorefacilities
Footprint1300+employees30courierroutesacrossNewMexico
60+drawsitesthroughoutNewMexico50+pathologistsandscientists99%patientsatisfaction
15hospitallaboratories3cancercenters
LaboratoryNationallyrecognizedHematopathologyconsultservice
Thefirstmulti-siteCAP15189accreditation
Poweredby
TRICOREREFERENCELABORATORIES
TriCoreVisionTobeanationallyrecognizedlaboratoryfocusedonindividualandpopulationhealth.
PopulationHealthMajorityofmedicaldecisionsarederivedfromlaboratoryresults1ClinicalDataprovidesthebestinsightintohowtoimproveoverallhealthandhealthcare2,3
AnalyticspoweredbyRhodesGrouptechnology
• Accesstorealtimedata• Uniquepatientidentifier• Longitudinaldatarepositoryacrosscarecontinuum
1. Forsman,R.W.WhyistheLaboratoryanAfterthoughtforManagedCareOrganizations?(1996)ClinChem.42:813-8162. Adler-Milstein,JandJha,A.K.Healthcare’s“BigData”Challenge.(2013)AmJManagCare.19(7):537-5383. Hartman,C.Healthcare’sGrowingDataOpportunity.LeveragingClinicalIntelligencetoElevatePopulationHealthManagementStrategies.(2014)HealthManagTechnol.35(5):24v
Poweredby
BRIEFHISTORYOFMEDICALLABORATORYMEDICINE
LeeHJ,OhSH,ChangCL.OriginsandHistoryofLaboratoryMedicine.(2017)LaboratoryMedicineOnline.7(2):53-58DelwicheFA.MappingtheLiteratureofClinicalLaboratoryScience.(2003)JMedLabrAssoc.91(3):303-310
Poweredby
BACKGROUND:NATIONALMEDICALSPEND(2017)=$3.5TRILLION1
HospitalCare
PhysicianandClinicalServices
RetailPrescriptionDrugs
OtherHealth,Residential,andPersonalCare
NursingCareandContinuingCare
Dental
HomeHealthCare
OtherProfessionalServices
Othernon-durableMedicalProducts
ProtectingAccesstoMedicareAct
1. CenterforMedicaidandMedicareServices.NationalHealthExpenditures2017Highlights.https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/downloads/highlights.pdf(Accessed:March1,2019)
Year CMS2,3 %ofSpend
2017 $9.7B 1.71%2,3
2018 $8.7B 1.54%
2019 $7.9B 1.38%
2020 $7.1B 1.34%
2021 $6.0B 1.06%
2022 $5.1B 0.90%
2023 $4.3B 0.76%
Year TriCore
2017 -
2018 2.9%
2019 1.9%
2020 ?!
2021 ?!!
2022 !!
2023 WTF!
Poweredby
STRATEGYSHIFT:LABORATORY2.0Lab1.0–Volume-based• SamplecentricinaFFSmarket• Measuredbycostperunit• Unfulfilledneedforprimarycareproviders• Limitedcarecoordination• Complicatedhealthcareenvironmentinsilos
Lab2.0–Value-based• Patientcentricinabundledmarket• Costperlife-population• Increasedaccesstocare/primarycare• Enhancedfocusedcoordinatedcare• Actionableinterpretativeresults
Pre-Analytical Result Post-Analytical
Poweredby
SAMECUSTOMER,NEWPRODUCT
MarketDevelopment
ProductDevelopment
Diversification
MarketPenetration
ExistingMarkets
New
Markets
ExistingProducts NewProducts
TheAnsoffMatrix
Poweredby
CUSTOMER:NEWMEXICOMCO
• Integrateddeliverysystemcomposedofmedicalgroup,hospital,andinsurance
• 950+providersacrossNewMexico
• 8hospitals• 100clinics
• 12,000employees
• Insures595,298(~25%ofstate)
Poweredby
CUSTOMERBACKGROUND• RecentAccomplishments:
• AwardedManagedCareContractforNewMexicoMedicaid
• Deliverysystem-wideinstallationofEpic
• PainPoints• NewMexicoisarural,diverse
population• Prenatalcaremanagementissues• HepatitisCcomplexities
0
10
20
30
40
50
60
70
80
90
100
%ofP
atientsC
ompliant
PrenatalCarein1stTrimesterbyYear1
NewMexico UnitedStates
1. CompleteHealthIndicatorReportofPrenatalCareintheFirstTrimester.NewMexico’sIndicator-BasedInformationSystem(NM-IBIS).NewMexicoDepartmentofHealth.https://ibis.health.state.nm.us/indicator/complete_profile/PrenCare.html(Accessed:October18,2018)
Poweredby
MCOEligibilityFile MatchwithinTriCore’sPatientRepository
MembershipBackground
HealthConditionAlgorithms
• ApproachedMCOunder“HEDIS”datafeed(nearreal-time,resultoriented,outsideofEpicetc.)• MCOagreedtosendviaSFTPdaily• KeymemberidentifiersmatchedwithTriCorepatientrepository1
1. Just,B.H.,Fabian,D.P.,Webb,L.L.,andHjort,B.M.ManagingtheIntegrityofPatientIdentityinHealthInformationExchange.(2009)AHIMA.80(7):62-69
PRODUCTDEVELOPMENTPHASE:MEMBERSHIPINFORMATION
Poweredby
PRODUCTDEVELOPMENTPHASE:PRENATALCARE&LAB
1stTrimester 2ndTrimester 3rdTrimester
Mother&FetusBloodTyping,Rubella,HIV
1stMaternalSerumScreen 2ndMaternalSerumScreen
GestationalDiabetes
GroupBStrep
• Identifyingandmonitoringpotentialmothers
MaternalBirthScreen
• Identificationofbirthstoestablishpostpartumcare
Age,Previousdx,Diabetes
• Identifyingandmonitoringprenatalrisks
UrinaryTractInfection(<3m&after) AbnormalPrenatalScreens
Poweredby
OPPORTUNITYREVIEW:MCOMEMBERSHIPEPIC/NON-EPIC
TestresultsonlyavailableinEpic:41%TestresultsonlyavailableoutsideofEpic:36%TestresultsinEpicandoutsideofEpic:23%
0
50
100
150
200
250
0 50 100 150 200 250 300
WithinEpic(#ofuniquetestcodes)
Externalto
Epic
(#ofu
niqu
etestcod
es)
RandomSampleof2,000MCOMemberswithTriCoreOrders
Poweredby
OPPORTUNITYREVIEW:MCOMEDICAIDOBLIGATIONS
• NMMedicaidinstalledPerformanceMeasures(PMs)toincentivizecarecoordinationefforts
• PMsrequire2%increaseaboveHEDISRegionalAverage,failureresultsin2%oftotalcapitationwithhold1
1. NMHSDAmendment#8totheMedicaidManagedCareAgreementAmongNMHSDandHCSChttp://www.hsd.state.nm.us/uploads/files/Looking%20For%20Information/General%20Information/Contracts/Medical%20Assistance%20Division/MCOs%20-%20Centennial%20Care/BCBSNM_CONTRACT_AMENDMENT_%238_SIGNED.pdf(Accessed:June7,2018)
Poweredby
MINIMALVIABLEPRODUCT
• Excelspreadsheetsentviasecureencryptedemail
• Clearlystatedmemberneeds• CareGaps• Risks
• Updatedcontactinformationandfollowedpatientsthroughprenatalcare
Poweredby
CUSTOMERFEEDBACKCustomerAdvice ProductResponse
NMHSDrequiresustoquicklyidentifyandaddressrisk? Efficienteffectiveriskstratificationmethod
Claimdatadoesn’tsufficefortimeliness Attempttomaptrimesterstatus
Claimdatadoesn’tdelineatebetweenERandbirth Innovativeabirthalgorithm
Difficulttoascertainwhoisnotintegratedintocare AlignwithACOGtobringlightoncare
OutsideofEpicisactuallyproblem Utilizeorderingclienttoidentifynon-Epicclients
Latencyofclaimisanissue Algorithmanalyzesevery24hours
Workallocationvaries,canwedownloaddata? Extractionfeaturemethodneeded
PrenatalpatientsdiagnosedoraccessingER DrawlocationshouldbehighlightedforERaccess
Poweredby
PRODUCTENHANCEMENT:RISKSTRATIFICATIONMETHOD
Elevated Patient Risk Factors
Elevated Patient Risk Factors
AND Care Gaps
Optimal Care Gaps
Riskcreated
from
patient
riskfactors
Riskcreatedfromgapsinhealthcare
2016
Poweredby
ACTUALPRODUCT:PRENATALCARE
Poweredby
ACTUALPRODUCT:PRENATALCARENOTINEPIC
Poweredby
ACTUALPRODUCT:PRENATALCARE(PATIENTLOCATION)
Poweredby
ACTUALPRODUCT:PRENATALCARENOTINEPIC
Poweredby
HEPATITISC:LABKNOWSALL
SCREEN DIAGNOSE TREATMENT/MONITORING
HepatitisCAntibody HepatitisCQuantitation
HepatitisCGenotype
HepatitisCQuantitation(SVR)
Platelets
• Identifyinglevelofcirrhosis
AST/ALT BIL,ALB
HIV
• Identifyingriskofcomplications
HBV Diabetes(HA1c,Glucose)
Poweredby
MEDICAIDOBLIGATIONSFORHEPATITISC–OPPORTUNITYREVIEW
• NMMedicaidinstalledDeliverySystemImprovementTargetsandprovidedadditionalassistance
• DSIMforHepatitisCrequired90%ofallpatientseligibleforHepCtreatmentbetreated1
1. NMHSDAmendment#8totheMedicaidManagedCareAgreementAmongNMHSDandHCSChttp://www.hsd.state.nm.us/uploads/files/Looking%20For%20Information/General%20Information/Contracts/Medical%20Assistance%20Division/MCOs%20-%20Centennial%20Care/BCBSNM_CONTRACT_AMENDMENT_%238_SIGNED.pdf(Accessed:June7,2018)
2. MedicaidEnrollmentReportByManagedCareOrganizationFee-for-Servicehttp://www.hsd.state.nm.us/uploads/FileLinks/5bc82a76689a437682dbd68988331f79/March_By_Managed_Care_Organization_Fee_for_Service_2.pdf(Accessed:June7,2018)
3. HealthNotes.ProgramEvaluationUnite.LegislativeFinanceCommittee.January13,2017https://www.nmlegis.gov/Entity/LFC/Documents/Health_Notes/Health%20Notes%20-%20Medicaid%20managed%20care%20rates.pdf
Poweredby
ACTUALPRODUCT:HEPATITISC
Poweredby
HEPATITISCMEMBERSNOTINEPIC
Poweredby
HEPATITISCMEMBERSNOTINEPIC
Poweredby
CUSTOMERFEEDBACK
CustomerAdvice ProductResponse
Wehavecarecoordinatorswhoaddressriskchangesonly Track,trend,andalertriskchanges
Yourdataistootimely,canweidentifyabettertimetocall? Delayednotificationuntiladditionaltests
NMHSDprovidesatransitionofcarefile,butlacksdetail
NewstratificationgridResourcesarelimited,canyoutelluswhomissedcare?
EDIEdoesn’ttelluswhyERaccessoccurredorwhatisneeded
OnenursefocusesonNICUcare NICUreport
Poweredby
PRODUCTENHANCEMENT:FUTURESTRATIFICATION
Risk Status Change ER Visit within 7 Days
Onboarded Prenatal Stopped Receiving Care
Birth within 56 Days
2016
Poweredby
PRODUCTENHANCEMENT:TRENDSANDCAREALLOCATION
Poweredby
PRODUCTENHANCEMENT:AUTOMATEDREPORTING
Poweredby
DETERMININGVALUE-PRENATAL
• NMMedicaidinstalledPerformanceMeasures(PMs)toincentivizecarecoordinationefforts
• PMsrequire2%increaseaboveHEDISRegionalAverage,failureresultsin2%oftotalcapitationwithhold1
1. NMHSDAmendment#8totheMedicaidManagedCareAgreementAmongNMHSDandHCSChttp://www.hsd.state.nm.us/uploads/files/Looking%20For%20Information/General%20Information/Contracts/Medical%20Assistance%20Division/MCOs%20-%20Centennial%20Care/BCBSNM_CONTRACT_AMENDMENT_%238_SIGNED.pdf(Accessed:June7,2018)
2. MedicaidEnrollmentReportByManagedCareOrganizationFee-for-Servicehttp://www.hsd.state.nm.us/uploads/FileLinks/5bc82a76689a437682dbd68988331f79/March_By_Managed_Care_Organization_Fee_for_Service_2.pdf(Accessed:June7,2018)
3. HealthNotes.ProgramEvaluationUnite.LegislativeFinanceCommittee.January13,2017https://www.nmlegis.gov/Entity/LFC/Documents/Health_Notes/Health%20Notes%20-%20Medicaid%20managed%20care%20rates.pdf
Poweredby
DETERMININGVALUE–“HARD”NUMBERS(CONTRACTS)1. DeterminehowmucheachMCOisgettingpaidwithinMedicaid
2. DeterminehowmemberstheMCOcurrentlycovers
3. Identifycompensation:$312*373,369=$1,399,911,552
4. IdentifythetotalpotentialPM:2%*$1,399,911,552=$27,998,231
A. DetermineeachPerformanceMeasurePenalty:1/14*$27m=~$2m
5. DeterminetotalpotentialDSIMPenalty:1.5%*$1,399,911,552=$20,998,673
A. DetermineeachDSIM(HepC):20%*$20,998,673=~$4.2m
1. MedicaidEnrollmentReportByManagedCareOrganizationFee-for-Servicehttp://www.hsd.state.nm.us/uploads/FileLinks/5bc82a76689a437682dbd68988331f79/MER_By_Managed_Care_Organization_Fee_for_Service_13.pdf(Accessed:June7,2018)2. HealthNotes.ProgramEvaluationUnite.LegislativeFinanceCommittee.January13,2017https://www.nmlegis.gov/Entity/LFC/Documents/Health_Notes/Health%20Notes%20-%20Medicaid%20managed%20care%20rates.pdf3. NMHSDAmendment#8totheMedicaidManagedCareAgreementAmongNMHSDandHCSChttp://www.hsd.state.nm.us/uploads/files/Looking%20For%20Information/General%20Information/Contracts/Medical%20Assistance%20Division/MCOs%20-
%20Centennial%20Care/BCBSNM_CONTRACT_AMENDMENT_%238_SIGNED.pdf(Accessed:June7,2018)
Poweredby
DETERMININGVALUE–PRETERMOUTCOMES
Study Control
PretermRate 11.1% 20.3%
2018ProjectedNo.ofPretermBirths(N=3,076) 342 431
FirstYearofPretermCosts $33,096/year1 $33,096/year1
TotalFirstYearPretermCosts $11,311,964 $14,253,075
TOTALPOTENTIALSAVINGS $2,941,111
ADJUSTMENT 50%
TOTALSAVINGS $1,470,550
1. ThanhNXetal.HealthServiceUseandCostsAssociatedwithLowBirthWeight-APopulationLevelAnalysis.(2015)JPediatr.167(3):551-556
Poweredby
DETERMININGVALUE–NICUOUTCOMES
N=3,076 Study Control
NICURate 11.3% 19.0%Projected2018DeliveriesNeedingNICUCare 916 1,535AverageLOS 12.3days 12.3daysProjected2018NICUDays 11,272 18,884Avg.CostperDayinNICU $1,500 $1,500TotalNICUCosts $16,908,037 $28,325,820
TOTALPOTENTIALSAVINGS $11,417,783ADJUSTMENT 50%
TOTALSAVINGS $5,708,892
• NICUclaimdatarangeofcostswas$711/dayto$7,083/day:– Conservativeaveragecost/day=$1,500/day
Poweredby
PROPOSALTOMCO
HealthCondition Measure/Outcome 2017MCOPerformance1
TRLClinicalAnalyticsResult2 ROI
Prenatal
TimelinessofPrenatalCareNMHSDPM#5 75% 77% $1,999,8743,4
Post-PartumCareNMHSDPM#5 58% (35%) -
FrequencyofPrenatalCareNMHSDPM#6 56% 73% $1,999,8743,4
NICUOccupancy 19% 11% $1,470,5553
PretermDeliveryOutcome 20% 11% $5,708,8922,5
Diabetes HemoglobinA1cTestingPM#4 82% 92% $1,999,8743,4
NephropathyScreeningPM#4 87% 91% $1,999,8743,4
HepatitisC NMHSDHepatitisCDSIM 350members 1,577members $4,199,7354
TOTAL $19,378,676
1. BCBSNMAuditReviewTable.http://www.hsd.state.nm.us/uploads/FileLinks/485263ae1ad040ea9d52673aef6109b4/2016_HEDIS_BCBS.pdf(Accessed:March21,2018)2. ResultsprojectedfrompilotperformedwithBCBSNMSpecialBeginningsSeptember2017throughApril20183. AssumesBCBSNM’srevenueforCentennialCareisapprox.$536,736,096.HealthNotes.ProgramEvaluationUnite.LegislativeFinanceCommittee.January13,2017https://www.nmlegis.gov/Entity/LFC/Documents/Health_Notes/Health%20Notes%20-
%20Medicaid%20managed%20care%20rates.pdf4. NewMexicoHumanServicesDepartment.RequestforProposals.RFP#13-630-8000-0001CentennialCarehttp://www.hsd.state.nm.us/uploads/FileLinks/c06b4701fbc84ea3938e646301d8c950/Centennial_Care_RFP_and_Contract__8_28_12__FINAL_.pdf(Accessed:
August11,2017)5. ThanhNXetal.HealthServiceUseandCostsAssociatedwithLowBirthWeight-APopulationLevelAnalysis.(2015)JPediatr.167(3):551-5566. CenterforDiseaseControlandPrevention.Health,UnitedStates,2016.https://www.cdc.gov/nchs/data/hus/hus16.pdf#093(Accessed:August29,2017)
Poweredby
TRICORE’SCLINICALANALYTICSPIPELINECustomer(NM) LineofBusiness Pricing Objective Status
DeliverySystem#1 Commercial PM/PM PatientOutreach Executed
MCO#1 Medicaid PM/PM CareCoordination&Compliance Executed
IVD#1 InfectiousDisease TI Investigatesepsisbiomarker Executed
MCO#2 Medicaid PM/PM CareCoordination&Compliance Executed
MCO#2 Commercial PM/PM CareCoordination&Compliance Negotiation
Provider#1 AllPatients PM/PM CapitatedArrangement Negotiation
MCO#3 Medicaid PM/PM CareCoordination&Compliance Proposal
Provider#2 AllPatients PM/PM CapitatedArrangement Alignment
Provider#3 AllPatients PM/PM CapitatedArrangement Alignment
Poweredby
1. Identifyyourmarket’scontracts,incentives,andpatientneeds
2. Startaconversationwithyourinsurancecompaniesbyaskingthem:– Whatareyourpainpoints?
– WhatifyoucouldhaveHEDISdatanearreal-time?
– Pitchforeligibilityfile(orperforma270/272eligibilitybounce)
3. Withthefile,createaHEDISreportwhilereviewingtheirpopulation– No.ofdiabetics,location,care-gaps,risk
– Returnwithalivedemonstrationoftheirdataandpitcha“freestudy”
4. Presentresultsofstudy,ROI,andprice
ANYLABCANDOTHIS