Presentation mat at CAPG 2015 Colloquium. Thirty cents of every dollar goes to no and low value care. While that drove billing in FFS service, success in value based arrangements comes from mitigating it by matching your practice patters with the right arrangements and payer partners. Often providers delivering the best care have hidden value that traditional utilization reviews and unit cost analysis don’t uncover. Fortunately, the newly-released HHS government benchmark data allow providers to pick the right risk arrangements and identify their exact contributions to payers. Attend this session to learn what public government data is available to help providers move to risk, how payers and providers are using it to successful negotiate and manage capitation.

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2. 2
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CAPG
Risk-Readiness SM
What Is Happening:
A – Public Data: CMS releasing benchmark data on geographies and docs
B – CMS Policy: Sun-setting Fee for Service to mitigate Unnecessary Spend
C – Market Trends: Payers rolling through with narrowing networks
What This Means for CAPG:
1 – Provider profiles for CAPG with CMS benchmarks for Unnecessary Spend
2 – Provider & market profiles showing the best arrangements for CAPG members
3 – Payer report cards using CMS benchmarks to negotiate more effectively

3. 3
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CAPG
Risk-Readiness SM
What Is Happening:
A – Public Data: CMS releasing benchmark data on geographies, payers and docs
New powerful data on every provider, market and health plan in the US
When combined with Dartmouth, allows national benchmarks on providers
Providers often perform better against these metrics than traditional payer-
driven evaluations such as unit cost and utilization
The data also shows every health plan’s expected profits, strengths and
weakness and which providers are contributing to them
Data is public, does not require IT or integration, up the next day

4. 4
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CMS: 50% of FFS will
be gone by 2018
CMS is releasing new, powerful data to support their
goals of transitioning providers in to Pay for Value
New Powerful Data on Every Provider,
Market and Health Plan in the US

5. 5
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Medicare DocGraph
Referral file
(Patient flows between
PCPS, specialists, hospitals
and post acute centers)
Dartmouth Atlas of Health Care &
Choosing Wisely
(Decades of research and data on
unwarranted variation by condition
and geography to keep things
apples-to-apples for comparisons)
CMS FFS Data Sets, CDC Data Sets
(MEDPAR, Part B, Part D, BRFSS)
(Individual providers, groups,
hospitals and post acute centers)
Provider Pattern Intensity Profiles and
Risk Readiness for every provider,
hospital, post acute center in the US.
All preloaded with no IT.
New Government Benchmark Data
Particularly powerful when pulled together
Affordable Care Act data to determine
Risk-Readiness SM of Providers / Networks
When Combined with Dartmouth, Allows
National and Regional Provider Benchmarks

6. 6
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At the core of Risk-Readiness SM is
Unwarranted Variation:
Every provider has a unique practice pattern
that informs Risk-Readiness SM
Providers often Perform Better against These
Metrics than Traditional Payer Evaluations
Apply the Dartmouth Atlas for Unwarranted
Variation methodologies to the newly
released CMS data. This research has been
repeatedly validated over the last 30 years
and we now have a national data set to
apply the methodologies at a large scale.
This doctor has lower
utilization and unit costs
But this doctor is making money for
whoever owns the risk
Often, physicians with practice patterns that make money for
whoever owns risk do not receive the right compensation
because traditional payer utilization review and actuarial analysis

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7
Data on Every Health Plan’s Expected Pro Forma,
Strengths, Weakness and Provider Contribution
Payer Profiles and Report Cards California
Determine which payers have acute needs and
where and how you help them.
For a payer with low reimbursement, poor population health
scores, poor overall clinical metrics and a small population,
negotiate less from your medical performance and
more from your coding and panel size.
Blue = Volume
Every Payer in
your market

8. 8
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Parent Org %Parent Org %
Layer on your state and self-reported data
sources and get the benefit of external and
internal perspectives side by side
Explore and track based on an integrated
view of your data and gov benchmarks
(including Cal-Index and/or IHA Data, etc.)
Start with Government Benchmarks,
then Layer on Internal Sources
Data Is Public, Does Not Require IT or
Integration, up the Next Day

9. 9
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CAPG
Risk-Readiness SM
What Is Happening:
B – CMS Policy: Sun-setting Fee for Service to mitigate Unnecessary Spend
Burwell’s announcement on sun-setting FFS is real and the CMS
ortho bundled payments is the tip of iceberg
Goal is to get rid of unnecessary spend – the 30 cents of every dollar that
goes to no value care drove billing in Fee for Service
Concern is providers will not be able to successfully transition
(cf. AMA/RAND study) and CMS is making multiple bets on payers &
providers across programs
Win is to create a virtuous cycle where providers who mitigate unnecessary
spend are paid more and have more membership from plans

10. 10
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Burwell on Sun-Setting FFS Is Real;
CMS Ortho Bundles Is the Tip of Iceberg
CMS: 50% of FFS will
be gone by 2018
No, Really,
CMS Means
Business!
These are just the first pieces
to move and transforming
payment across the system!

11. 11
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Risk-Readiness℠ looks at a
different category of spending
Goal Is to Get Rid of Unnecessary Spend,
the 30 Cents of Every Dollar of No-Value Care
Clinically Appropriate,
but Unnecessary Care
(30% of spend)
Claims Spend for a Health Plan /
Government Program
Necessary Utilization
(70%)
“Bigger than higher prices, administrative expenses, and fraud, however,
was the amount spent on unnecessary health-care services.
Now a far more detailed study confirmed that such waste was pervasive.”
In just a single year, up to 42% of patients receive “No Value” Care.
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.
“It’s generally agreed that
About 30 percent of what we spend on
health care is unnecessary.
If we eliminate the unneeded care, there
are more than enough resources in
our system to cover everybody.”
-Dr. Elliott Fisher,
Dartmouth Institute for Health Policy

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Magnitude of Problem Means Darwinian Approach
30% of the U.S. health care spend goes to no value care
and unnecessary spending driven by FFS Incentives
Over $9B in
Orange County, CA
Over $66B in Florida
$850 Billion Unnecessary Spend* in 2014
30% of U.S. health care spend that goes to
clinically appropriate, but unnecessary
care. Newly released data and historic
models can identify the cost-savings
opportunities in a geography based on the
collective intensity of care delivered by
doctors in that area.
* Unnecessary Spend =
(Dartmouth Avg cost) * (Population) *
(Network Opportunity Index)
Concern Is Providers Won’t Successfully Transition;
CMS Is Making Multiple Bets across Programs
RAND/AMA study confirms providers face challenges, especially
on data, and may not be able to achieve success. CMS A/B
testing payers and providers across a wide variety of programs
and ratcheting economics to find winners.

13. 13
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Hospital Marketshare
by Major Clinical Categories
Provider Group Marketshare
by Major Clinical Categories
Physician Marketshare
by Major Clinical Categories
Decrease market
share of this group
for ortho
Circulatory
Respiratory
Unnecessary Spend in Miami
By condition across hospitals,
groups and physicians
Win Is a Virtuous Cycle where Providers with Less
Unnecessary Spend Have More Membership
System goal is virtuous cycle where providers with lower rates
of unnecessary care have higher market share.
Fastest path may come from payers, employers and
new network design and optimization.
Increase market
share of this group
for ortho

14. 14
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CAPG
Risk-Readiness SM
What Is Happening:
C – Market Trends: Payers rolling through with narrowing networks
Narrow networks pay off for payers and employers.
[E.g. High/Med/Low scenario in unnecessary spending via network construction.]
Market is consolidating around narrow networks with payers buying providers
who mitigate unnecessary spend and private equity accelerating groups to this
Providers often not aware of the valuation impact tied to ability to mitigate
unnecessary spend and transition to pay for value
Providers who do not create and articulate value may be ‘designed around’

15. 15
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All physicians in
Winston-Salem, NC generate
$1.37 BB of Unnecessary
Spending / No-Value Care
Winston-Salem, NC
Diamond Network
(95% of PCPs)
Emerald Network
(65% of PCPS)
Amethyst Network
(50% of PCPs)
Cut Bottom 5% of
physicians, save
$303 MM each Year
Cut Bottom 35%
of physicians, save
$615 MM each Year
Cut Bottom 50%
of physicians, save
$790 MM each Year
Possible Network Savings in Winston-Salem, NC
Curated and Narrow Networks Pay off
for Payers and Employers
Network optimization creates large, disproportionate gains as
metrically with the very bottom of physicians accounting for
large gains. Networks can be optimized by excluding specific
doctors or shifting members/patients within a network.

16. 16
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Market Is Consolidating around
Narrow Networks often Using This Data
Payers buying providers who mitigate unnecessary spending and
private equity groups accelerating groups to this. The newly
released data can identify hidden value in providers.

17. 17
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Risk-Readiness SM Provider Ranking Tool
Providers Often Not Aware of the
Valuation Impact Tied to Unnecessary Spending
Mitigating unnecessary spending seen as indicating ability to
successfully transition to Pay for Value and often has large
impact on overall valuation of providers. Hidden value also
drives negotiations from payers.
Blue = Volume
Shape = Practice
Patterns on Key Ratios
Blue = Volume
Purple =
Unnecessary Spend
Red = $ Lost
Green = $ Gained

18. 18
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Payers Activity Use This Data
You have heard payers describe market goals
We actively help payers use this data to:
Risk Adjust all P&Ls (commercial & exchange) without Claims
Design Curated Networks around Risk-Readiness SM
Grow Membership into Risk-Ready SM Providers
Design Products based on Risk-Ready SM Providers
Identify and Purchase Risk-Ready SM Providers
Design Risk Arrangements for Providers
Negotiate with Providers Based on Risk-Readiness SM
Often providers are not aware of their own hidden value
We prefer payers interested in creating a virtuous cycle and
partnership with providers, but some will use this data aggressively
Where we’ve done it…
Providers Who Do Not take ‘Value-Poor’ Deals
May Be ‘Designed around’

19. 19
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CAPG
Risk-Readiness SM
What This Means for CAPG:
1 – Provider profiles for CAPG with CMS benchmarks for Unnecessary Spend
New public data shows how risk ready each group is, what is driving that
readiness and where their individual physicians fall along that continuum
This can be used identify opportunities to mitigate unnecessary spend and
gain profitability from risk arrangements

20. 20
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New Public Data Shows Risk-Readiness SM and
Drivers for Groups, Individual Physicians
Practice patterns for unnecessary spending and no-value care
benchmarked nationally and regionally inform government
programs and payer-based risk arrangements
Great profile for
aggressive risk
Tread carefully on
path to risk
Match appropriate risk arrangements based on
provider practice patterns and
Population characteristics within a geography

21. 21
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EXAMPLE
Risk-Readiness SM
Practice Risk-Readiness SM Report
IPA (Chinese American IPA)
Staff Model (Advocate Health Partners)
Clinically Integrated Network (Geisinger Health System)
Academic Center (Tufts Medical Center)
Choose National or
Regional Benchmarks
All four candidates well positioned with current practice
patterns for risk with Tufts the highest on overall benchmark.
Chinese IPA should focus on prescription patterns and visit
intensity to improve position for risk and payer perception but
has potential best practices in managing referral intensity.
Blue = Volume

22. 22
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EXAMPLE
Risk-Readiness SM
Risk-Readiness SM by Provider Type
* CMS Anomalies
Choose National or
Regional Benchmarks
Chinese IPA issues with PCP care and cardiology should be
explored, explained for negotiating with payers on risk.
Geisinger here is well positioned for risk with a strong
negotiating position with payers around PCP care and cardiology.
Blue = Volume

23. 23
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EXAMPLE
Risk-Readiness SM
Chinese American IPA
Top 5 Largest Providers by Specialty
Choose National or
Regional Benchmarks
Chinese IPA prescription patterns in cardiology driven by
three physicians and in PCP care driven by four physicians
Blue = Volume

24. 24
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EXAMPLE
Risk-Readiness SM
Geisinger Clinic
Top 5 Largest Providers by Specialty
Choose National or
Regional Benchmarks
Geisinger particular pattern of PCP care driven by visit intensity.
For Cardiology risk readiness is largely driven by one physician.
Blue = Volume

25. 25
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EXAMPLE
Risk-Readiness SM
Advocate Health and Hospital
Top 5 Largest Providers by Specialty
Choose National or
Regional Benchmarks
Advocate is particularly well-positioned for risk in PCP care with
largest physician generating profit for whoever owns the risk
Blue = Volume

26. 26
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EXAMPLE
Risk-Readiness SM
Tufts Medical Center
Top 5 Largest Providers by Specialty
Choose National or
Regional Benchmarks
Tufts is particularly well-positioned for risk in both PCP and
Cardiology arrangements. On PCP, there is one physician with an
outlying pattern different from other top Tufts PCPs that will
raise payer eyebrows and is worth exploration.
Blue = Volume

27. 27
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CAPG
Risk-Readiness SM
What This Means for CAPG:
2 – Provider & market profiles showing the best arrangements for CAPG members
New public data shows what government programs or payer-based risk
arrangements will yield the best results short term and long term profitability
This can be used pick the risk government programs and risk arrangements with
payers to maximize strategic value today and over time

28. 28
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New Public Data Shows Best Programs and
Payer-Based Risk Arrangements
New public data shows what programs or payer-based risk
arrangements will yield the best results short term and long
term profitability and allows negotiating around financial impact
of mitigating unnecessary spending and no value care using
government benchmarks
High performers with practice patterns out-
performing unit cost and utilization analysis due to
case mix and population factors. Looking to grow.
Negotiate from Government Benchmarks for
Unnecessary Spend and Economic Impact

29. 29
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CAPG
Risk-Readiness SM
What This Means for CAPG:
3 – Payer report cards using CMS benchmarks to negotiate more effectively
New public data shows payer attributes including strengths and weaknesses
based on CMS finances, populations, and network impact
This can be used to negotiate with payers based on real provider value,
specific payer need and impact and alternative government provider options

30. 30
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New Public Data Shows Payer Attributes,
Strengths and Weaknesses
Determine which payers have acute needs and
where and how you help them. Walk in not only with your
contribute to payer profit through risk but also with the profile
of the payer with whom you are negotiating highlighting their
needs and your value in solving them.
Washington
Payer Report Card
Blue = Volume
Red = Members Lost
Green = Members Gained
Every Payer in
your market

31. 31
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CAPG
Risk-Readiness SM
What Is Happening:
A – Public Data: CMS releasing benchmark data on geographies and docs
B – CMS Policy: Sun-setting Fee for Service to mitigate Unnecessary Spend
C – Market Trends: Payers steamrolling through narrowing networks
What This Means for CAPG:
1 – Provider profiles for CAPG with CMS benchmarks for Unnecessary Spend
2 – Provider & market profiles showing the best arrangements for CAPG members
3 – Payer report cards using CMS benchmarks to negotiate more effectively

32. 32
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without the prior written consent of the Company, is prohibited.
CAPG
Risk-Readiness SM
US CTO on using
this public data:
“Visionary Genius”
This Is Real, a National Trend
Payers are using public data for risk and design
Risk-bearing providers are getting in the game

33. 33
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CAPG
Risk-Readiness SM
Jump on in!
[Referrals: http://1.usa.gov/1FzoEOV]
[Variation: http://go.cms.gov/1D8j7LE]
[Shared Savings: http://go.cms.gov/1Hh8vx0]
[Medicare FFS Part B: http://go.cms.gov/OCmyoy]
[Medicare FFS Part D: http://bit.ly/1mGyBxk]
[Medicaid: http://go.cms.gov/1z7b5ic]
[Dartmouth: http://bit.ly/1GXvlJp]
[Behaviors: http://1.usa.gov/1PzcisT]
[Health Data All Stars: http://bit.ly/1GAsVC3]