1.
Population Health Management:
Enabling Accountable Care in Collaborative
Provider and Payer Initiatives

2.
1
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makes no guarantees, representations or warranties, either expressed or implied, about
the information contained within the document or about the document itself. SO
Health®, Salus One, Inc.™ are trademarks of SOE, Inc.
Copyright © 2017 SO, Inc. All rights reserved.
Created in the United States of America.

3.
Audience:
1
- Physicians and allied health professionals
- Information technologists
- Insurance (payer) management and staff
- Project and program management specialists
- Other administrative resources and management staff
Assumptions:
Audience has a cursory knowledge or "hands-on" understanding of
transformative care models such as:
- Patient Centered Medical Homes (PCMH)
- Care Management (i.e. case management, high-cost condition management)
- Accountable Care Organizations (ACOs)
- Provider Management in commercial and government payer organizations
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4.
Transformation of Care Delivery
2
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5.
Provider Strategy Summary
f
P)
3
Near-Term
1 Maintain a disciplined
approach to unit cost
management
• Ensure that rates are fair and reasonable
across the board, addressing outliers as
appropriate
2 Tier / narrow network to
drive to lower costs over
the near term
• Focus on existing, primarily unit cost, levers
to support low cost products in the near-
term:
– Tiered network for commercial via re-
solicitation of the network
– Narrow for Medicare Advantage
Longer-Term
3 Develop a physician-
centric value-based
approach to delivery
system transformation
• Select a strategic operating partner to
provide expertise on delivery
transformation
• Work with select local physician partners to
support the formation of a new provider entity,
focused on delivery system transformation
• Support aggregation of Primary Care Providers
(PC practices and seek PCP exclusivity when
possible
4 Selectively pursue health
system-centric value-
based partnerships
• In select geographies pursue health system-
driven opportunities
• Partner with select facilities to underwrite a local
insurance product with the facility and its
associated physicians as the central providers
5 Broadly support the move
towards value-based care in
any respective geographical
market(s)
• Maintain and expand current Vaule-
Based Health (VBH) reimbursement
programs
• Continue efforts toward development
of cost / quality transparency tools
for providers & members
• Develop provider enablement
capabilities through new and existing
relationships
• Develop methodology to accurately
measure the success of VBH
programs against medical cost
targets
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6.
Here is an Example of the Prototypical Accountable Care
Payment Model:
Annual Commercial/
Medicare incentives
generally range in the
low- to mid-millions
($$)
PCPs, Hospitals, and
Specialists are
integrated in a shared
performance model
Limited number of
payors rewards its
providers for integrated
care management and
total cost of care
Embedded Incentives Continuum of Care
Total Cost Population
Management Model
Works in tandem with
various program
incentives and drives
patient-centered care
Almost all eligible
health systems/ ACOs
initially originated are
still live in 2017
Replaces historical
“guaranteed” rate
increases and rewards
higher performing
systems
Integration with other
Models
Network Adoption Network Strategy
4
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7.
Analysis of healthcare interactions shows that most
are amenable to payer technology improvements
Provider-Provider
• Care
Coordination*
• Referral
information*
• Findings /
Discharge Info*
• Test results*
Member-Plan
• Care reminders*
• Health reports*
• Provider selection*
• Appointments*
• Billing*
• Payment*
Primary Care
Providers
Hospitals
Members
Employers Specialists
Member Care Interactions
A
Entities
Plan Provider Network Interactions
Specialists
Integrated Provider
Integrated Provider
Entities
Primary Care
Providers
Hospitals
Member-Provider
• Appointments /
requests*
• Forms*
• Payment*
• Triage
• Patient history*
• Examination
• Prescriptions*
• Instructions*
• Care Planning*
• Follow-up*
• Remote
monitoring*
• Web consults*
Member-Employer
• Plan selection
• Wellness
programs*
Plan-Employer
• Plan design
• Monitoring/
reporting
• Wellness
programs*
• Care messages*
Plan - Provider
• Care reminders*
• Confirm eligibility
• Forms*
• Payment*
• Patient history*
• Care Planning*
• Care Coordination*
• File Claims
• Claims payment
• Performance
management*
B
D
E
F
*Asterisks indicate interactions that can use technology to streamline interactions and improve coordination between stakeholders
(e.g., improve collection and sharing of information; enable tools to aid analysis, decision-making, and automation manual processes.
Interaction analysis
details are displayed
later in this deck
C
PAYOR
PAYORTypes of Interactions
• Member and Plan
• Member and Provider
• Provider to Provider
• Member and Employer
• Plan and Employer
• Plan and Providers
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8.
Prioritization of potential technology improvements
identifies four high priority solutions to focus on:
coordination and ordering
• Send care reminders
• Enablemember in-office
payments
1• Provide pertinent patient
history at the point of care
• Enable post-visitfollow
ups
4• Enablemember self-service 3 • Improveprovider selection
requests (e.g.,
appointments)
• Utilizee-prescriptions
• Provideoptionto send
instructions electronically
with cost and quality data
• Improvecare planning
with cost and quality data
• Support provider
performancemanagement
with cost and quality data
• Widen medical care access
through web consults
• Send health reports to
members
• Pre-populate member
check-in forms
• Enableremote monitoring
of patients
• Deliver care messagesvia
employer intranet or email
• Includecaremessages in
billing and benefit letters
• Streamline workplace
wellness data collection
Smaller
Benefits
Larger
Benefits
Easier
Implementation
Harder
Implementation
Medium
Benefits
Medium
Implementation
Share cost and quality
information to enable informed
provider selection, care
planning, and performance
improvement
Enable member self-service
requests (e.g., appointments,
prescription renewal, lab
results, non-urgent questions)
3
4
Initiative prioritization details and
Lower
Priority
2• Electronically share
solution descriptions in the appendix
findings/ discharge
instructions
• Electronically send referral
Information
• Electronically send test
results
• Electronically execute care
Provider Technology Initiative Prioritization
HIGH PRIORITY
SOLUTIONS:
1 Deliver pertinent patient
information to the provider at
the point of care
Strengthen electronic clinical
information exchange to
support evaluation, treatment,
monitoring, and coordination of
care across unrelated providers
2
Higher
Priority

9.
Integration of Live Member Information and Accountable
Care Infrastructure:
• Live Member Information By utilizing an integrated web-basedapplicationin
partnership with contracted physicians'office workflow, enables users to streamline
transactions with payer organizations.
– Additionally, when users work within these types of online applications, they
connect to the back-end-systems at payer organizations for real-time
administrative transactions, such as Eligibility and Benefits, the status of
submitted claims as well as inquiring on electronically submitted authorizations
and referrals
• Accountable Care Infrastructure/ Platform is an accountable care enablement
solution created specifically for population health management. Such a solution
provides the technology, operations, and service solutions necessary for health
systems, health plans, and provider organizations to transform into high-performing
accountable delivery systems.
– The technology platform integrates data from disparate systems across the
continuum of care – including medical claims, EMR/EHR, pharmacy, hospital
census, labs – to provide complete visibility and insights into patient care and the
clinical and financial performance of an enterprise.
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10.
Example:
Payor-sponsored Accountable Care Organization
• Concept is for payer(s) to sponsor the deployment of a ACO tightly
integrated with live, web-based member information verification:
• Rationale is two fold:
– Go beyond claims analysis by collecting patient clinical information for actuarial
analysis, benefit program design and monitoring of incentives and gain sharing
programs
• Big data investments, new contracting and reimbursement models and government business all require
integrated administrative/clinical workflows
– Provide critical longitudinal patient view for provider offices to manage patient care,
reduce redundant labs and imaging and meet current and future Meaningful Use
requirements
• Additionally, this solution makes the ACO accessible to healthcare
stakeholders and brings payer-provider interactions into the ACO:
– Leverages large existing high volume nationwide network
– Provider benefits from tight integration of the ACO into existing multi-payer office
workflows
– Existing NN user base (practice administrative staff, care coordinators/nurses) will be
the practice’s primary interface with ACOs
– Reaches non-EMR/EHR physician practices as well as other disparate providers
– On the following page, see an example of such an ACO solution:
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11.
9
State Health Information Exchange
Certified Health Information Exchanges,
Private ACOs and other similar entities
Certified HISPs and Other
SimilarEntities
State Partnership Governance and
Community Shared Services

12.
Transforming Health Care Delivery
Multiple
Data
Exchange
Sources:
Partnership
pharmacies
Labs
Clinics/
hospitals
Long-term
Care facilities
Patients Providers Continuation
of care team
Payors/
health plans
Other
individuals
and teams
Other
states and
territoriesFederal
Government
State Health
Partnership
Authority’s
governance
and community
shared services
Master
Patient
Index
Opt-out
Registry
Record
Locator
Service
Internet
connectivity
and access
ACOs and like
entities
HISPs and
like entities
Provider
Directory
State
Health
Information
Exchange

13.
Long-Term Infrastructure Needs Multiple Components:
PCP
Specialist
Hospital
Health Plan
Network Platform,
Applications,&Tools
• Office StaffWorkflows
• Care Dashboard
• Multi-Payer
Informatics
AccountableDelivery
System Platform
• Reimbursement Metrics
• Clinical Insight from
Longitudinal Patient
Record
ACO
• Direct and
Connect Models
• Patient and
Consent Mgmt
Expanded
Information
Sharing
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14.
STARS and Risk Adjustment Optimization Program Overview
• Prospective programoffers members an In-Home Assessments at no cost .
• Certified nurse practitionerhelps assess and close members healthcare
gaps.
• Engages payer Case Management with members havingsocial orchronic
conditions.
Prospective
(Personal Health Visits)
• Certified nurse practitionerreviews members medical records to bridge
documentationgaps.
• Allows a CapitatedRisk Adjustment solution optimizesdisease and co
morbidity identificationgaps in documentation.
• Improves captureofthe members overall health status.
Retrospective
(Chart Reviews)
• Targeted Member EducationOutreaches.
• Facilitate Encounter with the Provider at the right time.
• Close qualitymeasures duringa Personal Health Visit.
• Payer organization's contractedProvidercloses QualityMeasures and
Codinggaps
• Post DischargeMember Outreach – Impact Plan All Cause Readmissions
• Targeted Prescriber outreaches to impact a condition management
measure (i.e. PQRS – Diabetes Treatment Measure).
STARS
(Plan Rating)
13
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15.
Personal Home Visit
Clinical ,
Member &
Provider
Data
Payer
Process
and Host
Capitated
Risk
Mgmt
Nurse
Practioner
Completes
the Visit
Care/
Case
Mgmt
Member
SOAPNote
Subjective Objective
Assessment & Plan
Payer uses the
assessment data as
pseudo-claims
(HEDIS/STARS Risk
Score Accuracy &
Case Management)
14
Steps:
1. Capitated Risk Management software
schedules Payer Medicare members for a
Personal Health Visit.
2. Nurse Practitioner completes the visits and
documents in record.
3. Member’s Primary Care Provider is
notified with a summary of the visit.
4. Star Quality measures and coding gaps are
closed.
5. Nurse sends Care/ Case Management
Referrals to internal payer staff.
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16.
High Level Process Flow of the Program
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Retrospective Chart Review Program
The goal of such an initiative is to accurately document and reflect the health status of all
beneficiaries by submitting to CMS all ICD-10 diagnoses and archiving medical records within the
payer organization.
Medicare data –
Payer sends
Medicare data
(Plan, Claims,
bids)to Health
Provider
Analytics/Suspe
ct Generation:
Vendor creates
suspect list
based on payer
data
Chart Retrieval:
Contacts
Targeted
Provider Offices
and Retrieves
Medical Charts
Coding: Certified
Coders Code
Charts per
CMS/HCC model
Submission to
Payer: Submits
Additional ICD-10
codes based on
CMS HCC Model
Payer
Validation:
Payer validates
Financial
Projections and
ROI Statements
Financial
Projections and
Reporting:
Vendorcreates
Financial
Projections and
ROI statements
CMS Return
Data– Payer
shares the CMS
(Accepted/Reject
ed0 data with the
vendor
Payerto CMS:
Payer submits
additionalICD-10
codes to CMS
within CMS
submission
timeframes
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17.
STARS / Quality Health Care
• Payer utilizes a program to bridge the gaps in health care. The goal is to reach the highest quality rating,
provide the best possible care, close gaps, and have the provider and member connect.
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Interventions and strategies
Targeted Member Education Outreaches.
Facilitate Encounter with the Provider at the right time.
Close quality measures during a Personal Health Visit.
Payer informs Provider to close Quality Measures and Coding gaps
Post Discharge Member Outreach – Impact Plan All Cause Readmissions
> Targeted Prescriber outreaches to impact to impact D15 – the primary PQRS Diabetes Treatment
Measure.
Sample STAR Ratings
HMO1 PPO HMO2
4 Star 4.5 Star 4 Star
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18.
STAR Quality and Risk Adjustment Impact – through Payor-Contracted
Providers
Clinical ,
Member &
Provider
Data
Payer
Capitated
Risk Mgmt
Care
Mgmt
Member SOAP
Note
Subjective Objective
Assessment & Plan
Payer uses the
assessment data as
pseudo claims
(HEDIS/Star, Risk
Score Accuracy &
Case Management)
17
Tools & Strategies
1. Predictive Modeling, Data Driven and Targeted Approach
2. Payer Provider Network Services’ support
3. Data Capture Tool
4. Incentivize Providers
Process
and Host
Provider
Completes
Visit
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19.
Provider Payer Collaboration
Payer Provider
Provider
Engagement
Advantages to the Plan
Data Integrity&
Risk Score Accuracy
CMS STARS
Chart RequestNeeds
Challenge: Accurate Coding Practices
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Advantages to the Provider
Provider Performance
Incentives
Provider ImpactTo
Quality gaps
Less intrusion for
Chart Requests
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20.
High Risk Members
Chronic Disease Management Modules
Risk Analytics,along with Informatics are collaborating in order to lower healthcare costs, improve
quality care and expand access to members with Chronic Diseases by implementing the following
managementmodules.
Revenue Accuracy
Case
Management
Analytics
High Cost
Prescription Drug
Management
Chronic Disease
Management
Predictive
Modeling/
Interventions
STARS Analytics
e.g. CKD,
CHF
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Chronic Disease Management
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21.
Quality Performance Measures
Operational Process
Planning
• Identify eligible members
• Identify eligible providers
• Create measure populations
• Generate customized feedback forms
Implementation
• Mail forms to providers
• Providers enter feedback and send back
• Scan and validate returned feedback
Delivery
• Successful delivery is based upon a high response rate from Providers
• Accurate assignment of member health care centers (HCCs)
.
Advanced Training Protocol
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22.
Healthcare Delivery Model
360 Degree View of a Member’s Healthcare Plan
INTEGRATED VIRTUAL CARE MANAGEMENT MODEL
Pharmacy/Lab
Record
Transparency
Ability to Address
Complex Co-
Morbid Conditions
When implementing an Integrated Virtual Care Management Model:
1) Dedicatea team at the payer organization to analyze data, and monitor
congestive health failure (CHF) members to improve quality of life and increase overall revenue.
2) Develop real time strategies based on analytical data to understand the core issues and createthe
most efficient solutions.
Utilize NewReportingSystems to Address Gaps in Care
Awareness of Real
Clinical Conditions
Avoidance of
Hospital
Readmissions
Appropriate
Channel of Care
Choice
Assessment and
Triage of Disease
Stages
Provider and Payer
Informatics EMR
Transparency
Ability to capture
real records to
Informatics
BuildPredictive,OptimizationandSimulation
Models basedonAnalytic Datareceivedfrom
virtual offices.
Remedy Gaps in Communication
between members and their providers.
Followup with Nurses, Case
Management and Providers to address
gaps in healthcare.
360 Degree
View
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23.
SAMPLE INTEGRATED SOLUTION
EMR Connectivity
Payer
Partnering
University
Model
Direct
Connection
to major IPA
Group
Virtual
Outcomes
Real time
updates out
of EMR
Snapshot of PCP
group & PCP
performance
Correlation:
lab and
pharmacy
Conceptual Chronic disease management (i.e. CHF) solution is shown below.
V
I
R
T
U
A
L
O
F
F
I
C
E
Integrate all
systems into
one model
Real time
outcome
tracking
Quality of Care
related
automated
decision
support system
The above solution shows asample partnership with a university, private payer, and
ambulatory providers as well as conducting an analysis with larger PCP groups.
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