1) The document discusses the shift in healthcare from fee-for-service to fee-for-value and value-based care. It outlines challenges around information exchange, process automation, and community collaboration that are key to scaling partnerships under value-based models. 2) Edifecs is introduced as a partnership platform that can address these challenges through integrated data, automated workflows, and shared intelligence across organizations. 3) The platform is depicted as enabling various components of value-based care including population health monitoring, intervention programs, and payment calculations.

1. Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Healthcare
Michiel Walsteijn, Executive Vice President - International
Enabling Value Based Health Care
April 9, 2015

2. Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Healthcare
Software
Innovator in
Healthcare IT
Edifecs is the first Partnership
Platform for the healthcare
industry
Serving more than
215 Million lives through
our 100+ Health Plan
customers
Worldwide
700+ Employees
Leaders
In Configurable
Healthcare Data
Interchange & Compliance
70+
Provider
Customers
Multiple
Federal Agencies
incl. CMS
8/9
National
Health
Plans
25/37
Blue Plans
24/52
State Medicaid
Programs
Pre-integrated Business
Applications, e.g. Value
Based Healthcare
Enterprise Testing &
Compliance
Configurable
Healthcare Data
Interchange
Partnership Platform
1996 2015
Since 1996, Edifecs technology has been
helping healthcare insurers, providers,
pharmacy benefit management companies,
and other healthcare entities address key
challenges to scaling partnerships.

3. Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Healthcare
Some
Definitions
Quality (in medicine):
The degree to which health services for individuals
and populations increase the likelihood of desired
health outcomes and are consistent with current
professional knowledge (Institute of Medicine, 1990)
Value:
Outcomes Achieved divided by Resources Expended
Health
Cost

4. Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Healthcare
Understanding
the Shift from
Fee-for-
Volume
to
Fee-for-Value
Fee-for-Volume
(Old World)
Fee-for-Value
(New World)
Providers make money by
negotiating higher rates and
performing as many services as
possible
Providers make money by not only
providing services, but other results
valued by the industry, such as
quality, efficiency, wellness, care
coordination, and prevention
Providers see every touch as
revenue
Providers see every touch as an
expense to be managed
Payers primarily pay providers
based on claims
Payers pay providers based on
claims plus many other inputs (few
of which are automated)
Most providers have little regard for
evidence-based medicine.
Providers care a great deal about
evidence based medicine
Payers see providers as vendors Payers begin to see providers as
partners

5. Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Healthcare
Value Based Reimbursement
A Continuum of Provider Risk
Fee for
Service
Fee for Service
Plus P4P or
Shared Savings
Episode of
Care / Payment
Bundling
Partial
Capitation
Global
Capitation
Provider Sophistication
ProviderRisk

6. Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Healthcare
Scaling
Healthcare
Partnerships?
Addressing 3 challenges is emerging as the key to scaling.
Information
Exchange and
Integration
Process
Automation
Community
Collaboration
Is information flow between
partners flow seamlessly ?
Does it comply with industry &
partner standards?
Is it timely, trusted and visible ?
Are there any changes to core
process or workflow ?
Does the partnership model
need new analytics?
Can core systems adapt to
support the changes?
Is there a need for shared
intelligence between partners?
Do the workflows of the partners
need to be linked ?
How can best practices be
harvested and propagated

7. Pathways to Partnerships | Bridging Connections For Value edifecs confidential
Value Based Care
Maturity model
Consume Transactional Data
Value-Based Reimbursement Agreements
Align Financial Incentives with Clinical
Outcomes
Combine Clinical and Claim Data into
Member-centric and Population Views.
Monitor the Population, Create Clinical
Intelligence, and Drive Effective Interventions
Share Intelligence and Processes Across
Multiple Payers and Providers
Consume &
Interpret
Integrate &
Share
Intervene:
Change Care
Delivery
Expand to Other
Partners
Support
Payment
Reform

8. Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Healthcare
Value-Based Care Solution

9. Pathways to Partnerships | Bridging Connections For Value edifecs confidential
Provider
EMR
Billing
Practice Management
Core Systems
EDI
Gateway
Claim
adjudication
Membership
administration
Other
applications
Core Systems
Payer
EDI
Gateway
Partnership
Enablement
Future
Enterprise Apps
Business Applications
for
Providers
Liquid Transaction
Data
Liquid Transaction
Data
Community
Shared Intelligence and Workflow
Transaction Workflow Transaction Workflow
Edge-based innovation for supporting the industry initiatives.
Natural advantage of timeliness and completeness of
information. Filter out transactions that add downstream costs.
Edge
Transaction
Hub
Admin/ Clinical
Transactions
Admin/ Clinical
Transactions
Healthcare Information Pipe
EdgeSmart
Trading
(All
Initiatives)
EDI
Gateway
Business Applications
for
Health Insurers

10. Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Healthcare
Enabling Value Based Healthcare
Integrated Member Record
Workflow
PrioritizationReporting
Trigger Inventions
Set Monitoring/Intervention
Rules
Monitor Populations
Health Information Exchange Intervention Platform
Authorized
Care Team
Clinical
Analysts
Population
Analysis
Program
Targeting
Member
Attribution
Savings
Modeling
Model Population and Plan
Value-Based Agreement
Business/
Executive
Manager
Partnership Platform
Population Payment Administrator
Business/
Executive
Manager
Payment
Calculations
Reporting
Program
Automation
Program
Optimization
Tasks
Target
Populations
Design
Contracts
Assemble Integrated
Patient Records
Coordinate
Care
Measure
Outcomes
Pay for ValueTarget
Interventions

11. Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Healthcare
Population Payment

12. Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Healthcare
Financial Management
Edifecs’ Approach
Easily define, edit and re-use patient and provider sets
Examine costs & stratify risks, drill down by any number of variables
Asses impact of alternative reimbursement models
Perform targeted budget calculations
Leverage pre-defined templates and risk adjustment models
Compare historical and projected budgets
Design dashboards and reports for internal/provider use
Enable reporting transparency to all stakeholders
Automate program savings calculations
Reduce actuarial and regulatory risk
Employ advanced data analyses
Gauge utilization and assess saving opportunities
Provide multi-layer views of program measures
TARGET
Improve targeting
DESIGN
Scale
ADMINISTER
Minimize risk, improve experience
OPTIMIZE
Optimize
Shared savings and other VBR initiatives

13. Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Healthcare

14. Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Healthcare
How are
PMPM Costs
changing?
What is your
budget to
date
performance?
What savings
might you
anticipate?
How is your
attribution
changing?
What is your
leakage?
How is your
quality
performance
so far?
What is your
performance
against KPIs?
What is
driving your
costs?

15. Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Healthcare
Population Health Monitoring

16. Pathways to Partnerships | Bridging Connections For Value edifecs confidential
Intervention Gateway
Learning Engine Studio
Observation Agent Learning Engine
Design-timeRuntime
1
2 3
 Enables clinical analysts to define monitoring and
intervention rules
 Visual toolkit to model and test interventions
 Collaborate and share concepts and rules across
communities.
 Inspect incoming data streams and
extract real-time data to trigger
interventions
 Execute Intervention Rules against streaming
data and historical data
 Surface the intervention in payer and provider
systems
Intervention
Rules
List of Data
Elements to
Extract
Message Streams
Intervention Data
Alerts, Inferences
Intervention platform for early detection of changes to risk thresholds, quality
thresholds, morbidity patterns, behavioral patterns and protocol compliance

17. Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Healthcare
Story of George’s Father
 January, 1991 – PCP
 “Need to lose some weight – BMI 38,
waist circumference 41 inches, and you
need to stop smoking”
 February, 1991 – Routine lab work
 Triglyceride 160 mg/dL
 HDL 30 mg/dL
 Glucose 100 mg/dL
 Total cholesterol 250 mg/dL
 March, 1992 – To ER, “not feel well”
 “Every is ok except a bit stressed and
blood pressure borderline (145/95)”
 November, 1993
 Massive heart attack
 EHR CCD
 SNOMED 162864005
 LOINC 9844-2 = 41
 ICD-9 278.02
 ICD-9 305.1
 Lab Claims
 LOINC 2571-8 = 160
 LOINC 2085-9 = 30
 LOINC 1558-6 = 100
 LOINC 2093-3 = 250
 ER ADT + EHR CCD
 ADT-A04
 ICD-9 308.9
 LOINC 8480-6 = 145
 LOINC 8462-4 = 95
 Real life  Digital life  Edifecs logic
Metabolic syndrome
Framingham Risk 28%
clipboard
insurance
Physician-
supervised
weight loss
program
Health and
wellness
program1
point of intervention
1 Baicker et al. Workplace wellness programs can generate savings. Health Affairs. 2010 Feb
2 HCUP/AHRQ 2009 data. Accessed http://hcup-us.ahrq.gov/reports/factsandfigures/2009/exhibit4_1.jsp 2014 Sep
3 Ford et al. Prevalence and correlates of metabolic syndrome based on a harmonious definition among adults in the US. J Diabetes 2010;2(2):180-93
“Start Statin”

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19. Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Healthcare
Appendix

20. Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Healthcare
1990s All-at-once shift to full provider capitation
1998
Physician Profiling (used for public reporting
and contract rates)
2000
Leading California effort for third party to collect
and calculate quality-based payment
2001 Provider owned insurance companies
2003 Bonus payment for submitting quality data
2004 Bonus payment based on quality
2009 Payment based on episode of care
2011 Shared Savings based on total cost of care
2015 New forms of partial capitation
Progression of
Payment
Reform in US