Transcript Slide 1

Designing Successful
Strategies and Alliances
Agenda
Overview
Partnerships
Population
Health
Implications
Clinical Quality – Integrity – Service Excellence – Teamwork – Accountability – Continuous Improvement
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Macro Context
Per capita spending on healthcare
$8,000
$7,000
$6,000
$5,000
$4,000
$3,000
$2,000
$1,000
US
SWIZ
CAN
GER
SWE
UK
JPN
NOR
NETH
DEN
FR
AUS
NZ
• 30% of retiree
discretionary
spending by
2025
• $1,400 per car
for General
Motors
$0
Clinical Quality – Integrity – Service Excellence – Teamwork – Accountability – Continuous Improvement
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Underlying Drivers
• Minimal incentives
• Consolidation
• Price opacity
• Technology
• Lifestyle
Clinical Quality – Integrity – Service Excellence – Teamwork – Accountability – Continuous Improvement
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Market Reaction
Deflationary
Inflationary
• Provider & health plan
consolidation
• Risk bearing
groups
• Vertical integration
• ACOs
• Technology
• Cost sharing
• IP  OP shift
• High
• Transparency
deductible
tools
plans
ASCs general benefit high-quality, low-cost provider
by health plans and risk bearing medical groups
Clinical Quality – Integrity – Service Excellence – Teamwork – Accountability – Continuous Improvement
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ASC Market Forces
• Hospital & MD group consolidation
• Referral patterns changing
• Reimbursement pressure
• Impact of exchanges
• Narrow networks & risk models
• Growing threats & growing opportunities
Clinical Quality – Integrity – Service Excellence – Teamwork – Accountability – Continuous Improvement
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Agenda
Overview
Partnerships
Population
Health
Implications
Clinical Quality – Integrity – Service Excellence – Teamwork – Accountability – Continuous Improvement
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Context
• Trend is towards three types of control:
health system, payer, and/or MD group
• Tend to be driven by:
• Alignment of PCPs
• HMO / MA penetration
• Strategy of major payers
• Vision / strategy of health systems
Clinical Quality – Integrity – Service Excellence – Teamwork – Accountability – Continuous Improvement
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Implication
• Strategic partnerships becoming more
important
• Starts with assessment of market
• Where is market heading?
• Who will winner(s) be?
• What is optimal strategic partnership?
• Then, long process to cultivate partnership
Clinical Quality – Integrity – Service Excellence – Teamwork – Accountability – Continuous Improvement
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Example: Health System
Partner’s Focus Areas
• One of two largest
health systems in DFW
• Clinical quality
• Employing / aligning
with PCPs
• Market share
• Developing risk models
• Specialist alignment
• Lower cost network
Clinical Quality – Integrity – Service Excellence – Teamwork – Accountability – Continuous Improvement
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Example: Payer
Partner’s Focus Areas
• Mountain state BCBS
plan
• Strategic focus on
reducing cost of care
• Active interest from
employer ASO clients
• Clinical quality
• Total medical cost
• Foster independent
community
• Customer pressure
Clinical Quality – Integrity – Service Excellence – Teamwork – Accountability – Continuous Improvement
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Example of Payer Focus
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Example: Medical Group
Partner’s Focus Areas
• 1,500 physician medical
group in Orange County
• Taken risk on MA and
commercial for 20+ yrs
• Acquired by Optum
three years ago
• Clinical quality
• Total medical cost
• Member experience
• Physician alignment
Clinical Quality – Integrity – Service Excellence – Teamwork – Accountability – Continuous Improvement
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Agenda
Overview
Partnerships
Population
Health
Implications
Clinical Quality – Integrity – Service Excellence – Teamwork – Accountability – Continuous Improvement
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Population Health
PMPM ($)
Surgery
$92
Medical/
Other
$202
Outpatient
& Office
$501
Higher Cost
Setting –
Existing
Outpatient
$35
OP-Eligible IP
$131
OP-Eligible IP
$10
Inpatient
$281
Optimal
Setting
$18
$45 PMPM of
addressable
spend
Clinical Quality – Integrity – Service Excellence – Teamwork – Accountability – Continuous Improvement
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Medicare Advantage Analytics
Hospital
Site of service optimization could
bend outpatient surgical spend by
$19 PMPM (~200 bps or more
reduction in MLR)
100%
ASC
Endoscopy Center
9%
37%
80%
45%
55%
60%
40%
93%
91%
63%
20%
55%
45%
0%
ORT
(154)
PAIN
(449)
OTH
(103)
GST
(3,991)
7%
OPT
(2,361)
Thousands
Opportunity by specialist
$70
Opportunity $ (Primary)
200
Opportunity Cases (Secondary)
$60
150
$50
$40
100
$30
$20
50
$10
$-
0
Surgeon A
(GST)
Surgeon B Surgeon C Surgeon D Surgeon E
(GST)
(GST)
(GST)
(GST)
Surgeon F Surgeon G Surgeon H
(GST)
(OPT)
(GST)
Surgeon I
(OPT)
Clinical Quality – Integrity – Service Excellence – Teamwork – Accountability – Continuous Improvement
Surgeon J
(GST)
16
Medicare Advantage Analytics
Site of Service Utilization by Specialist
Unneccessary HOPD Cases
Clinically Necessary HOPD Cases
ASC Cases
200
180
160
140
120
100
80
60
40
20
0
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Surgery Center Analytics
Highest Total Spend Items Highest Total Spend Items
Frequency of Utilization byFrequency
Physician of Utilization
Annualized
Annualized
Item Description
Item Description
Spend Current Price MD Spend
#15 MD#25
CurrentMD#34
Price MD
MD#49
#15 MD#25
MD#64 MD#34
phaco pack (P)
phaco pack (P)
$17,806
$29
$17,806
101%
100%$29 100% 101%
100% 100%
100% 100%
helon 5 (P)
helon 5 (P)
$15,165
$45
$15,165
0%
104%$45 103%
0%
0% 104%
82% 103%
VIGAMOX 0.5% 3ML DROPTAINER
VIGAMOX
(C)0.5% 3ML DROPTAINER (C)
$12,144
$26
$12,144
99%
84%$26 83%
99%
0%
84%
82%
83%
helon 0.55 (P)
helon 0.55 (P)
$10,248
$24
$10,248
113%
9%$24 16% 113%
120%
151%
9%
16%
BREVITAL 500MG 1VL
C4
BREVITAL
(C)
500MG 1VL
C4 (C)
$10,144
$38
$10,144
1%
73%$38 77%
51%
1%
73%
7%
77%
eye packs (P)
eye packs (P)
$9,247
$15
101%
$9,247 100%$15 99% 101%
100% 100%
98%
99%
TOBRADEX 0.3-0.1% 3.5GM TOBRADEX
OPTH (C) 0.3-0.1% 3.5GM OPTH (C)
$5,724
$36
$5,724
71%
0%$36
3%
71%
0%
47%
0%
3%
ZYMAR 0.3% 5ML OPTH
ZYMAR
(C) 0.3% 5ML OPTH
(C)
$4,662
$14
$4,662
0%
112%$14 107%
0%
0% 112%
27% 107%
Solution, Intraoccular Irrigation,
Solution,
BSS(R)
Intraoccular
(BalancedIrrigation,
Salt Solution),
BSS(R)
Sterile,
(Balanced
(S)
$4,199
Salt Solution),
$5 Sterile, (S)
$4,199
99%
103%$5 99%
100%
99%
103%
100%
99%
CYCLOMYDRIL 1-0.2% 5ML OPTH
CYCLOMYDRIL
(C)
1-0.2% 5ML OPTH (C)
$3,483
$6
$3,483
67%
93%$6 88%
67%
3%
404%
93%
88%
COLLAGEN CORNEAL SHIELDCOLLAGEN
(P)
CORNEAL SHIELD (P)
$3,121
$10
$3,121
0%
100%$10 100%
0%
0% 100%
36% 100%
Drape, Eye-Pak OphthalmicDrape,
Drape,Eye-Pak
Micro-Embossed
Ophthalmic
Plastic,
Drape,
Aperture,
Micro-Embossed
Mid-Size,
$2,709Plastic,
(S)
Aperture,
$6
Mid-Size,
$2,709
0% (S)100%$6 99%
103%
0%
100%
100%
99%
Solution, Ophthalmic Viscoelastic
Solution,
VISCOAT
Ophthalmic
.75 mLViscoelastic
(S)
VISCOAT .75$1,645
mL (S)
$47
$1,645
1%
9%$47
9%
1%
0%
18%
9%
9%
NEOMYC/POLY/DEX 0.1% 3.5GMOPTH
NEOMYC/POLY/DEX
(C)
0.1% 3.5GMOPTH (C)
$1,115
$3
$1,115
0%
100%$3 98%
100%
0%
100%
24%
98%
Catheter, IV, Introcan Safety,
Catheter,
Winged,IV,
Polyurethane,
Introcan Safety,
22gWinged,
x 1in (S) Polyurethane,
$1,112 22g x 1in
$2(S)
$1,112
98%
99%$2 96%
98%
99%
99%
93%
96%
Stab Knife 15 degree-StylusStab Knife 15 degree-Stylus
$1,076
$31
$1,076
19%
0%$31
0%
19%
0%
0%
0%
0%
Retractor, Iris, Grieshaber, Flexible,
Retractor,1Iris,
Box Grieshaber,
Contains 6 each
Flexible,
of 611.74
1 Boxfor
Contains
6 (S)
$1,073
6 each of$83
611.74 for 6 (S)
$1,073
7%
0%$83
0%
7%
0%
0%
0%
0%
Drape, Eye-Pak OphthalmicDrape,
Drape,Eye-Pak
Micro-Embossed
Ophthalmic
Plastic,
Drape,
Incise,
Micro-Embossed
Mid-Size,
$1,006
5 (S)
Plastic, Incise,
$5
Mid-Size,
100%
$1,006
5 (S) 0%$5
0% 100%
0%
0%
0%
0%
Clinical Quality – Integrity – Service Excellence – Teamwork – Accountability – Continuous Improvement
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Agenda
Overview
Partnerships
Population
Health
Implications
Clinical Quality – Integrity – Service Excellence – Teamwork – Accountability – Continuous Improvement
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Implications
• Markets trending towards three types of
control: health system, payer, MD group
• Strategic partnerships are, therefore,
becoming more important
• These partnerships are complex, and, if
structured well, highly valuable
Clinical Quality – Integrity – Service Excellence – Teamwork – Accountability – Continuous Improvement
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