rowdmap himss 2016 - no value care meets no it needed
TRANSCRIPT
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AllcontentsareproprietarytoRowdMap,Inc.andarebeingprovidedonaconfidentialbasis.Anyuse,reproductionordistributionofthisinformation,inwholeorinpart,orthedisclosureofanyofitscontents
withoutthepriorwrittenconsentoftheCompany,isprohibited.
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2Allcontentsareproprietary toRowdMap,Inc.andarebeingprovidedonaconfidential basis.
Anyuse,reproduction ordistribution ofthisinformation, inwholeorinpart,orthedisclosure ofanyofitscontentswithout theprior written consent oftheCompany,isprohibited.
NoValueCareMeetsNoITNeededSummary
PopulationHealthismorethanpublicandsocialgood,butcreatessignificantfinancialbenefitsthroughvaluebasedarrangements.
Newlyreleasedgovernmentbenchmarkdataallowsprovidersandpayerstodeterminewhethertheywillsucceedandhowtoflourishinpayforvalueandriskarrangements.
Datahaverevolutionizedtechnologyandotherverticals,nowopendatafromthegovernmentandtheCentersforMedicareandMedicaidServicescomestohealthcare.
VirtuallyeveryproviderintheUSandtheirpracticepatternsandreferralsareavailablewithnoITintegrationneeded.
Buildtherightnetwork,group,CINtocapturethevalueyoucreatethroughpopulationhealthprogramsthroughsharedrisk.
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3Allcontentsareproprietary toRowdMap,Inc.andarebeingprovidedonaconfidential basis.
Anyuse,reproduction ordistribution ofthisinformation, inwholeorinpart,orthedisclosure ofanyofitscontentswithout theprior written consent oftheCompany,isprohibited.
NoValueCareMeetsNoITNeededWhyYouShouldListen
LearnHowtoUsePublicGovernmentDatatoCaptureValuefromPopulationHealththroughPayforValueProgramsandRiskArrangements
Notadvocatingpolicy/programs servicesNotsellingyouanything
Bundle-O-MaticACOs-R’-USData/ClaimSystems
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4Allcontentsareproprietary toRowdMap,Inc.andarebeingprovidedonaconfidential basis.
Anyuse,reproduction ordistribution ofthisinformation, inwholeorinpart,orthedisclosure ofanyofitscontentswithout theprior written consent oftheCompany,isprohibited.
NoValueCareMeetsNoITNeededWhyYouShouldListen
We’vedoneitfor5yearsin42States,coveringover75MMpatientsacrossandwinningfinancialawardsandinkingpartnershipstohelpconsumers
WonErnstandYoungEntrepreneuroftheYearforfinancialimpactand
public andsocialgood
DoingthiswithpayerscoveringallP&Lsandproviders ofalltypesdirectlyandviapartners
PartneringwithUSNews(BestHospitalsandDoctorFinder) tohelppatientsmakegoodchoices
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5Allcontentsareproprietary toRowdMap,Inc.andarebeingprovidedonaconfidential basis.
Anyuse,reproduction ordistribution ofthisinformation, inwholeorinpart,orthedisclosure ofanyofitscontentswithout theprior written consent oftheCompany,isprohibited.
NoValueCareMeetsNoITNeededWhyYouShouldListen
SincethisisHIMSS,businessneedmaynotbeenough,sohere’stheChiefTechnologyOfficeroftheUnitedStates…
USCTOonRowdMap:“VisionaryGenius”
Leadingtheshiftfromfee-for-serviceto
pay-for-value.
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6Allcontentsareproprietary toRowdMap,Inc.andarebeingprovidedonaconfidential basis.
Anyuse,reproduction ordistribution ofthisinformation, inwholeorinpart,orthedisclosure ofanyofitscontentswithout theprior written consent oftheCompany,isprohibited.
NoValueCareMeetsNoITNeededSummary
PopulationHealthismorethanpublicandsocialgood,butcreatessignificantfinancialbenefitsthroughvaluebasedarrangements.
Newlyreleasedgovernmentbenchmarkdataallowsprovidersandpayerstodeterminewhethertheywillsucceedandhowtoflourishinpayforvalueandriskarrangements.
Datahaverevolutionizedtechnologyandotherverticals,nowopendatafromthegovernmentandtheCentersforMedicareandMedicaidServicescomestohealthcare.
VirtuallyeveryproviderintheUSandtheirpracticepatternsandreferralsareavailablewithnoITintegrationneeded.
Buildtherightnetwork,group,CINtocapturethevalueyoucreatethroughpopulationhealthprogramsthroughsharedrisk.
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7Allcontentsareproprietary toRowdMap,Inc.andarebeingprovidedonaconfidential basis.
Anyuse,reproduction ordistribution ofthisinformation, inwholeorinpart,orthedisclosure ofanyofitscontentswithout theprior written consent oftheCompany,isprohibited.
NoValueCareMeetsNoITNeededCapturingValuefromPopulationHealth
Ihavebetterengineering /architecture
Hmm, ‘fixing thepipes’wasnottheanswer
It’sNotaTechnologyProblem
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8Allcontentsareproprietary toRowdMap,Inc.andarebeingprovidedonaconfidential basis.
Anyuse,reproduction ordistribution ofthisinformation, inwholeorinpart,orthedisclosure ofanyofitscontentswithout theprior written consent oftheCompany,isprohibited.
NoValueCareMeetsNoITNeededCapturingValuefromPopulationHealth
It’sNotaDesignProblem
Ihavebetterdesign&experience
Hmm, theprettycolorsonmysocialappdidn’t stopme
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9Allcontentsareproprietary toRowdMap,Inc.andarebeingprovidedonaconfidential basis.
Anyuse,reproduction ordistribution ofthisinformation, inwholeorinpart,orthedisclosure ofanyofitscontentswithout theprior written consent oftheCompany,isprohibited.
NoValueCareMeetsNoITNeededCapturingValuefromPopulationHealth
It’sNotaDataProblem
Mydataisbigger thanyours Hmm,thisfixationindicates...
Sillyboys
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Anyuse,reproduction ordistribution ofthisinformation, inwholeorinpart,orthedisclosure ofanyofitscontentswithout theprior written consent oftheCompany,isprohibited.
NoValueCareMeetsNoITNeededCapturingValuefromPopulationHealth
It’sNotan‘Innovation’Problem
Speakingatamajorhealthcareconferencenearyou
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11Allcontentsareproprietary toRowdMap,Inc.andarebeingprovidedonaconfidential basis.
Anyuse,reproduction ordistribution ofthisinformation, inwholeorinpart,orthedisclosure ofanyofitscontentswithout theprior written consent oftheCompany,isprohibited.
NoValueCareMeetsNoITNeededCapturingValuefromPopulationHealth
It’sNotaNeedanotherAppProblem
*Direct-to-ConsumerNote:Peopledon’t liketopayoutofpocketforsomethingtheydon’t liketodoordon’twanttoknowabout
ProTip– AveragefamilyincomeinUSis~$42kandgreatestchallengesfortheleastaffluent
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12Allcontentsareproprietary toRowdMap,Inc.andarebeingprovidedonaconfidential basis.
Anyuse,reproduction ordistribution ofthisinformation, inwholeorinpart,orthedisclosure ofanyofitscontentswithout theprior written consent oftheCompany,isprohibited.
NoValueCareMeetsNoITNeededCapturingValuefromPopulationHealth
It’saPerverseIncentivizationProblem
*Source:DartmouthAtlasforUnwarrantedVariation
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13Allcontentsareproprietary toRowdMap,Inc.andarebeingprovidedonaconfidential basis.
Anyuse,reproduction ordistribution ofthisinformation, inwholeorinpart,orthedisclosure ofanyofitscontentswithout theprior written consent oftheCompany,isprohibited.
NoValueCareMeetsNoITNeededCapturingValuefromPopulationHealth
It’saPerverseIncentivizationProblem
Keeppatientsaway?!?
Iwastryingtobookyouforanextranight!
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Anyuse,reproduction ordistribution ofthisinformation, inwholeorinpart,orthedisclosure ofanyofitscontentswithout theprior written consent oftheCompany,isprohibited.
NoValueCareMeetsNoITNeededCapturingValuefromPopulationHealth
We’veBeenAskingtheWrongQuestions
Howcanwecapturevaluebykeepingapopulation healthy?
Thebestclinicalperformersmaybegeneratingthemostno-valuecarebecauseofFFSincentives
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Anyuse,reproduction ordistribution ofthisinformation, inwholeorinpart,orthedisclosure ofanyofitscontentswithout theprior written consent oftheCompany,isprohibited.
NoValueCareMeetsNoITNeededCapturingValuefromPopulationHealth
Payers and providers have financial incentives to undertake population health at a meaningful scale due to the ascendency of value-based programs and risk-bearing arrangements. These models represent a fundamental change from previous Fee for Service economic arrangements.
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Anyuse,reproduction ordistribution ofthisinformation, inwholeorinpart,orthedisclosure ofanyofitscontentswithout theprior written consent oftheCompany,isprohibited.
NoValueCareMeetsNoITNeededCapturingValuefromPopulationHealth
FFS PayforValue
TwoModelsforFinancingPopulationHealth
VS.
‘Bolt-on’Socialgood
SystemicSocialGood
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17Allcontentsareproprietary toRowdMap,Inc.andarebeingprovidedonaconfidential basis.
Anyuse,reproduction ordistribution ofthisinformation, inwholeorinpart,orthedisclosure ofanyofitscontentswithout theprior written consent oftheCompany,isprohibited.
NoValueCareMeetsNoITNeededCapturingValuefromPopulationHealth
FFS PayforValue
Crankout“WellnessVisits”
RiskSplitUpside(Problem isrollingpopulationvs.timehorizon tocaptureit)
Marketing /EnrollmentBump&Coding ‘bump’
RiskSplitUpside(Problem isrollingpopulationvs.timehorizon tocaptureit)
TwoModelsforFinancingPopulationHealth
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18Allcontentsareproprietary toRowdMap,Inc.andarebeingprovidedonaconfidential basis.
Anyuse,reproduction ordistribution ofthisinformation, inwholeorinpart,orthedisclosure ofanyofitscontentswithout theprior written consent oftheCompany,isprohibited.
NoValueCareMeetsNoITNeededCapturingValuefromPopulationHealth
MajorityofbookinFFSarrangement
MajorityofBookinPayforValue
Today
Paidmoretoperformmore&higherintensityservices
Sickerpopulationmaybemoreprofitable
Paidthesameregardlessofservicevolume&intensity
Healthierpopulationismoreprofitable
PopulationHealthasSocialInvestment
PopulationHealthProficiency
asProfitDriver
Upside Up/Downside FullCap
Low-ValueServicesDrivingBilling
Low-ValueServicesReduceProfit
MSSP ACO FlatPayment
GovernmentProgram
PrivateMarketArrangement%ofR
evenue
Time
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19Allcontentsareproprietary toRowdMap,Inc.andarebeingprovidedonaconfidential basis.
Anyuse,reproduction ordistribution ofthisinformation, inwholeorinpart,orthedisclosure ofanyofitscontentswithout theprior written consent oftheCompany,isprohibited.
NoValueCareMeetsNoITNeededCapturingValuefromPopulationHealth
Ratingareaswithgoodpopulationhealthand
networks
Ratingareaswithshort-termprofitabilitybased
onflawedreimbursementmodels
Ratingareaswithcurrentandlong-termprofitability
Profitableinthelongterm.
Profitabletoday,basedonflawedrisk-adjustment.
Goingforward,onestrategyistoidentifyandprioritizegrowthintheseratingareasbyreducingpremiumsintheselong-termprofitableratingareasrelativetothecompetition.
Year1 Year2 Year3
ProfitfromReimbursement
Flaws
ProfitfromMoreEfficientNetworks
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Anyuse,reproduction ordistribution ofthisinformation, inwholeorinpart,orthedisclosure ofanyofitscontentswithout theprior written consent oftheCompany,isprohibited.
NoValueCareMeetsNoITNeededCapturingValuefromPopulationHealth
Sohowdoyousucceedatvaluebasedarrangementsin
ordertocapturethevalueyoucreatewithpopulationhealth?
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21Allcontentsareproprietary toRowdMap,Inc.andarebeingprovidedonaconfidential basis.
Anyuse,reproduction ordistribution ofthisinformation, inwholeorinpart,orthedisclosure ofanyofitscontentswithout theprior written consent oftheCompany,isprohibited.
NoValueCareMeetsNoITNeededSummary
PopulationHealthismorethanpublicandsocialgood,butcreatessignificantfinancialbenefitsthroughvaluebasedarrangements.
Newlyreleasedgovernmentbenchmarkdataallowsprovidersandpayerstodeterminewhethertheywillsucceedandhowtoflourishinpayforvalueandriskarrangements.
Datahaverevolutionizedtechnologyandotherverticals,nowopendatafromthegovernmentandtheCentersforMedicareandMedicaidServicescomestohealthcare.
VirtuallyeveryproviderintheUSandtheirpracticepatternsandreferralsareavailablewithnoITintegrationneeded.
Buildtherightnetwork,group,CINtocapturethevalueyoucreatethroughpopulationhealthprogramsthroughsharedrisk.
![Page 22: RowdMap HIMSS 2016 - No Value Care Meets No IT Needed](https://reader031.vdocument.in/reader031/viewer/2022030120/58a17a2f1a28ab04278b671f/html5/thumbnails/22.jpg)
22Allcontentsareproprietary toRowdMap,Inc.andarebeingprovidedonaconfidential basis.
Anyuse,reproduction ordistribution ofthisinformation, inwholeorinpart,orthedisclosure ofanyofitscontentswithout theprior written consent oftheCompany,isprohibited.
NoValueCareMeetsNoITNeededNoValueCare
Over$9BinOrangeCounty, CA
$850BillionUnnecessarySpendin2014(InstituteofMedicine)
No-ValueCare(30%)
NecessaryUtilization(70%)
“It’sgenerallyagreedthatabout30percentofwhatwespendonhealthcareisunnecessary.Ifweeliminatetheunneededcare,therearemorethanenoughresourcesinoursystemtocovereverybody.”
-Dr.ElliottFisher,DartmouthInstitutefor
HealthPolicy
The economic driver for pay for value programs is the ability of a government program or marketplace arrangement to not only achieve Triple Aim goals but to also mitigate Low-Value services, which account for thirty cent of every dollar spent on the delivery of care.
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Anyuse,reproduction ordistribution ofthisinformation, inwholeorinpart,orthedisclosure ofanyofitscontentswithout theprior written consent oftheCompany,isprohibited.
NoValueCareMeetsNoITNeededNoValueCare
Often Low-Value Care is the result of perverse incentives from Fee for Service payment models but identifiable as unwarranted variation within practice patterns.
Theestimated30%ofmedicalexpensethatgoestono-valuecare.
Unnecessary spending drivesbilling inafee-for-serveeconomicmodel, butsuccessinpay-for-valuecomesfrommanagingandmitigatingthesepocketsofvariation.
Variation:UnwarrantedorUnexplained?Everyphysicianhasauniquefingerprint
EconomicDrillDown:ExampleUtilizationReviewandActuarialUnitCostAnalysisagainstCareIntensityCurveacrossTotalBasketofCare
Variationacrossgeographiesandwithinpracticesacrossphysicians.“Physician-Level PracticeVariation:WhoYouSeeIsWhatYouGet”
BrianPowers,Sachin Jain,DavidCutler,andZiad ObermeyerHealthAffairs,September23,2015
Definitions,researchandgeocodingbyHospitalReferralRegionalavailableviatheDartmouthAtlasforUnwarrantedVariation:www.dartmouthatlas.org
NB:Unwarrantedvariationreferstopracticepatterns,whichholdupacrosspopulationsbutpricingvariationmayalsobeunwarrantedandmarkedfluctuatesacrossinsuranceproductandlinesandgeography.“ThePriceAin’t Right.”Cooper,Craig,GaynorandVanReenen,2015.
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Anyuse,reproduction ordistribution ofthisinformation, inwholeorinpart,orthedisclosure ofanyofitscontentswithout theprior written consent oftheCompany,isprohibited.
NoValueCareMeetsNoITNeededNoValueCare
The economic driver behind both the policy push and market drive towards value based programs, as well as the criteria for success in value based programs is the ability of a government program to reduce Low-Value Services.
Research EvaluatingCMS&PrivatePlanPrograms:“DotheyreduceLowValuecare?”
CMSCritiqueofFeeforService:“FFShastoomuchLowValuecare.”
PopularPressReportingandProviderRankings:“Consumers are/shouldavoidLowvaluecare.”
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25Allcontentsareproprietary toRowdMap,Inc.andarebeingprovidedonaconfidential basis.
Anyuse,reproduction ordistribution ofthisinformation, inwholeorinpart,orthedisclosure ofanyofitscontentswithout theprior written consent oftheCompany,isprohibited.
NoValueCareMeetsNoITNeededSummary
PopulationHealthismorethanpublicandsocialgood,butcreatessignificantfinancialbenefitsthroughvaluebasedarrangements.
Newlyreleasedgovernmentbenchmarkdataallowsprovidersandpayerstodeterminewhethertheywillsucceedandhowtoflourishinpayforvalueandriskarrangements.
Datahaverevolutionizedtechnologyandotherverticals,nowopendatafromthegovernmentandtheCentersforMedicareandMedicaidServicescomestohealthcare.
VirtuallyeveryproviderintheUSandtheirpracticepatternsandreferralsareavailablewithnoITintegrationneeded.
Buildtherightnetwork,group,CINtocapturethevalueyoucreatethroughpopulationhealthprogramsthroughsharedrisk.
![Page 26: RowdMap HIMSS 2016 - No Value Care Meets No IT Needed](https://reader031.vdocument.in/reader031/viewer/2022030120/58a17a2f1a28ab04278b671f/html5/thumbnails/26.jpg)
26Allcontentsareproprietary toRowdMap,Inc.andarebeingprovidedonaconfidential basis.
Anyuse,reproduction ordistribution ofthisinformation, inwholeorinpart,orthedisclosure ofanyofitscontentswithout theprior written consent oftheCompany,isprohibited.
NoValueCareMeetsNoITNeededNewGovernmentData
CMS has made historic data releases both relevant both for a populations health and behaviors as well as the practice patterns of providers across the healthcare delivery system, allowing resource allocation and quantitative measurement of the impact of a given population health initiative.
OpenWeatherData OpenHealthDataOpenGeo-LocationData
GovDataPoweringaMarketplace
GovDataPoweringaMarketplace
GovDataPoweringaMarketplace
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Anyuse,reproduction ordistribution ofthisinformation, inwholeorinpart,orthedisclosure ofanyofitscontentswithout theprior written consent oftheCompany,isprohibited.
NoValueCareMeetsNoITNeededNewGovernmentData
Here’swhythesebenchmarksaresopowerful
Governmentbenchmarkdataservesasthecommonlanguagenecessarytobuildrelationshipswithproviderstoimprovethememberexperienceandprofitability
ThebenchmarksareavailabletodaywithnoITinvolvement
Thedataalreadyhavealevelofanalysis ontop,soyoucanseeifaproviderisover/underbenchmarks
It’sfromCMS;it’sastandard;it’salreadyusedtodaytodrivereimbursement
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Anyuse,reproduction ordistribution ofthisinformation, inwholeorinpart,orthedisclosure ofanyofitscontentswithout theprior written consent oftheCompany,isprohibited.
NoValueCareMeetsNoITNeededNewGovernmentData
ReferralFiles(PatientflowsbetweenPCPS,specialists,hospitalsandpostacutecenters)
DartmouthAtlasofHealthCare&Choosing Wisely(Decadesofresearchanddataonunwarrantedvariationbyconditionandgeographytokeepthingsapples-to-applesforcomparisons)
CMSFFSDataSets,CDCDataSets(MEDPAR,PartB,PartD,BRFSS)(Individualproviders,groups,hospitalsandpostacutecenters)
ProviderPatternIntensityProfilesandRiskReadiness®foreveryprovider,hospital,postacutecenterintheUS.Allpreloaded withno IT.
AffordableCareActdatatodetermineRisk-Readiness® ofProviders/Networks
TrickIsTyingIttogether
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29Allcontentsareproprietary toRowdMap,Inc.andarebeingprovidedonaconfidential basis.
Anyuse,reproduction ordistribution ofthisinformation, inwholeorinpart,orthedisclosure ofanyofitscontentswithout theprior written consent oftheCompany,isprohibited.
NoValueCareMeetsNoITNeededNewGovernmentData
GoaheadandTryYourHandatIt
DIY-ers GuidetoIdentifyingNo-ValueCare:
http://bit.ly/1QmNzWE
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30Allcontentsareproprietary toRowdMap,Inc.andarebeingprovidedonaconfidential basis.
Anyuse,reproduction ordistribution ofthisinformation, inwholeorinpart,orthedisclosure ofanyofitscontentswithout theprior written consent oftheCompany,isprohibited.
NoValueCareMeetsNoITNeededSummary
PopulationHealthismorethanpublicandsocialgood,butcreatessignificantfinancialbenefitsthroughvaluebasedarrangements.
Newlyreleasedgovernmentbenchmarkdataallowsprovidersandpayerstodeterminewhethertheywillsucceedandhowtoflourishinpayforvalueandriskarrangements.
Datahaverevolutionizedtechnologyandotherverticals,nowopendatafromthegovernmentandtheCentersforMedicareandMedicaidServicescomestohealthcare.
VirtuallyeveryproviderintheUSandtheirpracticepatternsandreferralsareavailablewithnoITintegrationneeded.
Buildtherightnetwork,group,CINtocapturethevalueyoucreatethroughpopulationhealthprogramsthroughsharedrisk.
![Page 31: RowdMap HIMSS 2016 - No Value Care Meets No IT Needed](https://reader031.vdocument.in/reader031/viewer/2022030120/58a17a2f1a28ab04278b671f/html5/thumbnails/31.jpg)
31Allcontentsareproprietary toRowdMap,Inc.andarebeingprovidedonaconfidential basis.
Anyuse,reproduction ordistribution ofthisinformation, inwholeorinpart,orthedisclosure ofanyofitscontentswithout theprior written consent oftheCompany,isprohibited.
NoValueCareMeetsNoITNeededIdentifyingSuccessinPayforValue
AnExample:Livein42Stateswith75MMPatientsRowdMap’sRisk-Readiness®benchmarkshelphealthplans,physiciangroups,andhospitalsystemsidentify,quantify,andreducedeliveryofno-valuecare—acentraltenetofsuccessfulpay-for-valueprograms.
RowdMaphasno-valuecareandpopulationhealthbenchmarks for…
everyphysician
everyhospital
everyzipcode
…intheUnitedStates.
“It’sgenerallyagreedthatabout30percentofwhatwespendonhealthcareisunnecessary.Ifweeliminatetheunneededcare,therearemorethanenoughresourcesinoursystemtocovereverybody.”
-Dr.ElliottFisher,DartmouthInstitutefor
HealthPolicy
No-ValueCare(30%)
NecessaryUtilization(70%)
Didyouknowthatmorethan$850billioninno-valuecareisdeliveredannuallyintheU.S?
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Anyuse,reproduction ordistribution ofthisinformation, inwholeorinpart,orthedisclosure ofanyofitscontentswithout theprior written consent oftheCompany,isprohibited.
NoValueCareMeetsNoITNeededIdentifyingSuccessinPayforValue
ProvidersinaMarketGroups
Individual Physicians
Whatisdrivingaprovider’sRisk-Readiness®?Isitprocedures,prescriptions,referralsorvisits?
Howbigisaprovider’spanel?
Howreadyisaprovidertosucceedinrisk
comparedtopeers?Byspecialty?
Withinaregion?
Fingerprintwithpracticepatternsthatmitigateno-valuecare=GreenDot
Fingerprintwithpracticepatternsthatcreateno-valuecare=RedDot
BenchmarksforRisk-Readiness®
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NoValueCareMeetsNoITNeededIdentifyingSuccessinPayforValue
Greatprofileforaggressiverisk
Treadcarefullyforsomerisk
MatchProviderPracticePatternswithValueBasedProgramsbasedon PopulationHealthBehaviors
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NoValueCareMeetsNoITNeededIdentifyingSuccessinPayforValue
RowdMapprovidesdataandanalysisonPopulationHealthfactorsthatdrivesuccessinvalue-basedprograms:
Behaviors – BroaderDefinitions ofHealthwithBehaviors
Utilization – UtilizationandCostsofProceduresandDrugs
Prevalence – MajorDiseasesandConditions
Supply – NumberofPrimaryCarePhysiciansandSpecialists
Socio-demographics – Income,Environment,etc.
Matchyourstrategiesto
yourpopulationtosucceedinvalue-basedprograms
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NoValueCareMeetsNoITNeededIdentifyingSuccessinPayforValue
AreyouReadyforRisk?ManageInternalVariation§ ProviderContractingStrategy§ ProviderCompensationStrategy§ ProcessVariation&Improvement§ ServiceLineBenchmarking§ ProviderReporting§ ProviderRecruitment&CINBuild§ ValueChain&LeakageReporting§ MedicalEconomicsReporting
AreYourPartnersRiskReady?PicktheBestPartnersforRiskArrangements§ PrimaryCareReferralSourceAnalysis§ AcuteCarePartnerReporting§ PostAcutePartnerReporting§ Consulting/SpecialtyPartnerAnalysis§ CompetingGroups/OrgsAnalysis
WhataremybestOpportunitiesforRisk?MatchProviderstoRisk• Risk-MatchingtoPayers:Government& PrivatePayers• PayerNegotiationReporting• MedicalEconomicsModeling
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NoValueCareMeetsNoITNeededIdentifyingSuccessinPayforValue
HarrisCounty, TX
RegionalBenchmarks
AmIcontractingtherightproviders?
Lookataprovider’spanelsize,overallrisk-readinessbenchmarkandit’sindividualdrivers(procedures, prescriptionsandreferrals)todetermineif
theyareagood fitforanoverallstrategyandaspecificcontract.
ProviderContractingStrategy
Groups
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NoValueCareMeetsNoITNeededIdentifyingSuccessinPayforValue
PCPs
RegionalBenchmarks
PimaCo,AZ
AmIincentivizingproviders inawaythatwillbesuccessfulinriskarrangements?
Incentivizeindividual physiciansbasedontheiroverallrisk-readinessbenchmarkandtheirindividual drivers(procedures,prescriptions and
referrals)tosucceedinvaluebasedandriskarrangements.
ProviderCompensationStrategy
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NoValueCareMeetsNoITNeededIdentifyingSuccessinPayforValue
ServiceLineBenchmarking
Whatlinesofbusinessarethemostriskreadyandwhichneedimprovements?
Lookatalineofserviceandtheoverallrisk-readinessbenchmarkandtheindividualdriverstoidentifyoutliers,bestpracticesandareastobe
improved tosucceedinvaluebasedandriskarrangements.
SportsValleyMedicine, LLC
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NoValueCareMeetsNoITNeededIdentifyingSuccessinPayforValue
Howdogroupsandindividualproviderswithinthegroupscomparetotheirpeersandcompetition?
Shareinformationaboutaprovider’s risk-readinessagainstpeersandcompetition tocomparehowwelltheyareabletosucceedinvaluebase
andriskarrangements.
ProviderReportingPhiladelphia, PA
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NoValueCareMeetsNoITNeededIdentifyingSuccessinPayforValue
ProviderRecruitment&CINBuild
HowdoyoudesignandimplementCINthatsucceedinvaluebasedarrangements?
Selectproviders thatarerisk-readyandcomplementeachother’spracticepatternstocreateaCINthatsucceedsinvaluebasedandrisk
arrangements.
SaintLouis,MO
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NoValueCareMeetsNoITNeededIdentifyingSuccessinPayforValue
ValueChain&LeakageReporting
PrimaryCareDocs
Specialist PostAcuteFacility
Thicknessoflinesindicatesthenumberofreferrals.Note:Somemarketsare
oversupplied.Thismarketiscontrolledbyoneprovider.
Lessefficient
Moreefficient
Howdoesyourpopulation flowthrough thecarecontinuum andwhenandwheredotheyfallout?
Identifynaturalpatientflowsanddetermineifyournetwork isbreaking themorreinforcinghighvaluepathwaysthenincentivize
providers tooptimize referrals.
TargetthisPCP/DXRadiologisttorefermorepatientstothehigher
performingspecialist
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NoValueCareMeetsNoITNeededIdentifyingSuccessinPayforValue
ValueChain&LeakageReporting
Howdoesyourpopulation flowthrough thecarecontinuum andwhenandwheredotheyfallout?
Identifynaturalpatientflowsanddetermineifyournetwork isbreaking themandcausingleakageaddressthrough
contracting,educationandincentives.
UniversityofMiami isunderperformingandreferralsareinternal.
Thisisaconcentrated,lowvaluepathway.
HolyCrosshashighperformingspecialists, butitsPCPsarereferringtoavarietyofspecialists.
Thisisafragmented,buthighvaluepathway.
Group ReceivingReferrals
GroupSendingReferrals
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Anyuse,reproduction ordistribution ofthisinformation, inwholeorinpart,orthedisclosure ofanyofitscontentswithout theprior written consent oftheCompany,isprohibited.
NoValueCareMeetsNoITNeededIdentifyingSuccessinPayforValue
MedicalEconomicsReporting
Howmuchnovaluecareareyoupayingforandhowmuchyoucansavebylineofbusinessanddowntoindividualproviders?
Determinethespecificeconomic impactthatyoucreateforwhoeverownstheriskyoumanage.
DecreasedCost
Average
IncreasedCost
LessEfficie
nt
1
2
3
4
5
MoreEfficient
$PMPYperSpecialty&EfficiencyScore
CARDIACSURGERY
GASTROENTEROLOGY
ORTHOPEDICSURGERY
DIAGNOSTICRADIOLOGY PATHOLOGY
$609 $228 $334 $65 $79
$770 $253 $365 $71 $88
$973 $271 $419 $72 $91
$1,191 $303 $467 $121 $106
$1,299 $387 $624 $245 $212
CardiacSurgery
Gastroenterology
OrthoSurgeon
DiagnosticRadiology Pathology
ImpactonSpend
Risk-Readiness®Benchmark
Florida
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Anyuse,reproduction ordistribution ofthisinformation, inwholeorinpart,orthedisclosure ofanyofitscontentswithout theprior written consent oftheCompany,isprohibited.
NoValueCareMeetsNoITNeededIdentifyingSuccessinPayforValue
MedicalEconomicsReporting
Howmuchnovaluecareareyoupayingforandhowmuchyoucansavebylineofbusinessanddowntoindividualproviders?
Identifyhowmuchno-valuecareyouaremitigatingandthespecificcostsavingsitgeneratesforwhoeverownstherisk.
$PMPYperSpecialtybyCountyIn&Out
Network
InNetwork
OutofNetwork
Scenario:Removingthelowestperformingphysicians
DrilldownintoPimaCounty(Phoenix) Thehighest$PMPYin
PhoenixiswithinnetworkGIdocsat$643
Inthisscenario,theywouldhavethegreatest dropin$PMPYat$119.
($634- $119=$524)
Arizona
$PMPYperSpecialty&EfficiencyScore
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Anyuse,reproduction ordistribution ofthisinformation, inwholeorinpart,orthedisclosure ofanyofitscontentswithout theprior written consent oftheCompany,isprohibited.
NoValueCareMeetsNoITNeededIdentifyingSuccessinPayforValue
PrimaryCareReferralSourceAnalysis
ReferralstoOrthopedists
GroupSendingReferrals
Group ReceivingReferrals
Group ReceivingReferrals
Group ReceivingReferrals
Group ReceivingReferralsGroup ReceivingReferrals
IndividualPhysicians
ReceivingReferralsNumber ofReferrals Performance of
PhysiciansReceivingReferrals
WhichPCPsaresendingpatientstoagivenspecialistandhowwelldothosePCPsperform?
MakesureyourPCPsaresending tohighperforming specialistswhoareRisk-Readytosucceedinvaluebasedandriskarrangements.
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NoValueCareMeetsNoITNeededIdentifyingSuccessinPayforValue
AcuteCarePartnerReporting
WhichHospitalsareRiskReadyandwhatarethedriversofsuccess?
Identifythehospitalsthatarerisk-readyandthedriversbehind theirpracticepatternstosucceedinpayforvalueandriskarrangements.
California
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NoValueCareMeetsNoITNeededIdentifyingSuccessinPayforValue
AcuteCarePartnerReportingCostbyDRG
Norton
Medical SurgicalMedical
Surgical
Baptist
WhichHospitalsareRiskReadyandwhatarethedriversofsuccess?
Determinewhichhospitalsarethemostefficientandhaveincentivetoworkwithyour specialtyinvaluebasedarrangements.
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NoValueCareMeetsNoITNeededIdentifyingSuccessinPayforValue
PostAcuteCarePartnerReportingWestchesterCounty,NY
WhichPostAcuteFacilitiesareRiskReadyandwhatarethedriversofsuccess?
Identifythepostacutecentersthatarerisk-readyandthedriversbehind theirpracticepatternstosucceedinpayforvalueandrisk
arrangements
HomeHealthTopProvidersOrange=Preferred
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NoValueCareMeetsNoITNeededIdentifyingSuccessinPayforValue
RegionalBenchmarks
Consulting/SpecialtyPartnerAnalysis
WhichPartnersareRiskReadyandwhatarethedriversofsuccess?
Identifytheconsultingandspecialtypartnersthatarerisk-readyandthedriversbehind theirpracticepatternstosucceedinpayforvalue
andriskarrangements
HarrisCounty,TX
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NoValueCareMeetsNoITNeededIdentifyingSuccessinPayforValueRisk-MatchingtoPayers:Government&PrivatePayers LargestCounties inTX
RegionalBenchmarks
RiskScores HealthRank
NetworkOpportunity
ProfitOpportunity
MA
ProfitOpportunityExchange
MedicareEligibles/MAEnrolled
ExchangeSubsidyEligibles/Exchange Enrolled
MedicaidBeneficiaryEligibles/
Beneficiaries
Whichvaluebasedprogramsorriskarrangementswillbesuccessfulinmypopulation?
Identifymypopulation’s socio-demographics, healthbehaviorsandprevalencethatleadtosuccessinspecificvaluebasedprogramsand
privatepayerriskarrangements
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NoValueCareMeetsNoITNeededIdentifyingSuccessinPayforValue
PopulationHealth&SupplyImpactonRisk-Readiness®
Risk-MatchingtoPayers:Government&PrivatePayers
Whichvaluebasedprogramsorriskarrangementswillbesuccessfulinmypopulation?
Youpracticeingeographieswithspecificpopulation healthprofilesandaspecificsupplyofcare,sothesearethepressuresyouwillface
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NoValueCareMeetsNoITNeededIdentifyingSuccessinPayforValue
PayerNegotiationReporting
HowdoIusegovernmentbenchmarkdatatonegotiatetomystrengthsandapayer’sweaknesses?
Identifyperformanceagainstnationalandregionalbenchmarks.Highlight whereyouperformwell,addressesandhaveanexplanation
and/orplanforareasthatneedwork.
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NoValueCareMeetsNoITNeededIdentifyingSuccessinPayforValue
Whatisthefinancialimpactofnovaluecarethatyoucreateforpayersthatyouarenotgettingcreditfor?
Identifyperformanceagainstnationalandregionalbenchmarks.Highlight whereyouperformwell,addressesandhaveanexplanation
and/orplanforareasthatneedwork.
Eachdotisaphysician.
Groupsarecreatedfromspecialty, networkstatus,Efficiencyscore,and
geography
JohnDorchakNPI:1528000379$PMPY:$874
Savingsforremoving5’s
forminNetwork
MedicalEconomicsModeling
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NoValueCareMeetsNoITNeededIdentifyingSuccessinPayforValue
NetworkDevelopmentCreateaRisk-ReadyNetwork• NetworkExplorer• NetworkBuilder• NetworkOptimizer• NetworkCalculator
ProductDesign&RiskDesignProfitableProducts• Competitive BenefitDesignAnalysis• NetworkBasedBenefitDesign• PopulationHealthBasedProductAnalysis
Sales&MarketingGrowintoProfitableMembership• NetworkBasedGrowthAnalysis• ProviderGrowthAnalysis• MeasuringGrowthAnalysis
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NoValueCareMeetsNoITNeededIdentifyingSuccessinPayforValue
HowdoIcreatemyRisk-Ready®networkandwhichphysiciansdoIneedtosucceedinPay-for-Valuearrangements?
Optimizeyourspecialistnetworkthrough PCPreferrals.Educateandcontracttocreatehighvaluespecialistnetworksordesignproductsto
mitigateriskanddownstreamcosts.
NetworkBuilder GeneralCardiology
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NoValueCareMeetsNoITNeededIdentifyingSuccessinPayforValue
NetworkCalculator
AverageNetworkefficiency:$414PMPYMarketBaseline:$488PMPY
AverageNetworkefficiency:$208PMPY-25%
Removed:90physiciansAdded:84physicians
Removed:Additional34physiciansAdded:Additional37physicians
-50%
AverageNetworkefficiency:$311PMPY
Actual Scenario1 Scenario2
Whatarethefinancialimpactsofmydecisionsandwhatdoesthismeanforour1-year,5-year,or10-yearforecasts?
BayArea,CA
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NoValueCareMeetsNoITNeededIdentifyingSuccessinPayforValue
NetworkBasedBenefitDesign
Premiumsrelativelylowtonetworkperformance.Likelyunderpricingthatwillleadtolowerprofitability.
Premiumsrelativelyhightonetworkperformance.Likelyoverpricingandlosingoutonmembership.
HowdoIdesignbenefits tomatchproviderperformancewhileoptimizing profitability?
Designproducts todrivemembershipwhereyouhavethemostefficientproviders.Savingsfromhighperforming providersoffset lowerpricesand
createavirtuouscycleofgrowth.
NetworkEfficiency
RatingArea
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NoValueCareMeetsNoITNeededIdentifyingSuccessinPayforValue
HowdoIdesignbenefits tomatchpopulation demandwhileoptimizing profitability?
Determinehowthepopulation’s healthbehaviors,prevalenceandeconomicsimpactyourprofit.Growintoareasthatareprofitable today
withgooddriversforlongtermsustainability.
PopulationHealthBasedProductAnalysis
PopulationBehaviors
PremiumVariance
Competition
HealthOpportunityIndex:Prevalence,healthbehaviors&socio-economicfactors Relativeviewofclient
premiumsandcapturestheassumedcostof
providinghealthbenefitstogivengeography
PremiumVarianceInternal
MLRVariance
Membership/SubsidyEligible
Strategy fromBenchmark&InternalData
RatingArea
YourDataGoesHere
BenchmarkCMSData
Difference inpreriskadjustedandpostrisk
adjustedMLR
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NoValueCareMeetsNoITNeededIdentifyingSuccessinPayforValue
MeasuringGrowthAnalysis
EquallyAllocateSalesandMarketingEffortsScenario1
Scenario2
Bytargetingmarketingeffortsaround thehighestperforming practiceshowmuchmoneywillIsave?
TargetedSalesandMarketingwithHighestPerformingPractices
CombinedAverageEfficiencyPMPY:
$238
CombinedAverageEfficiencyPMPY:
$189
-20.6%
Targetedmarketingexamples:
• Focusedbrokers• Co-marketing• AffiliationLetters• Preferential
benefitdesign
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NoValueCareMeetsNoITNeededIdentifyingSuccessinPayforValue
5 4 3 2 1EfficiencyScore
MembershipVolume/Episodes
ShiftingMembersandpercentagesofcareinteractions
intoourPhysicianswithEfficiencyScoresof1-3
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NoValueCareMeetsNoITNeededIdentifyingSuccessinPayforValue
Membership&ServiceDensityChangeTacticsRecommendedtacticstoshiftpatientinteractionflows
Network• Addingand/orremovingproviders.Addinghighperformers,cuttinglowperformers• Incentivizingefficientreferralchains• ClinicalManagementofshiftingmostintensepatientencounterstohighestperformers
ProductDesign• Designingproductstoshiftmemberbehavior• Designproductstodisproportionatelydrawmembersinadvantageouslybymarket• Designproductstodrivemembershipwhereyouhavethemostefficientproviders
Sales&Marketing• AllocateresourcesstrategicallyinSales&Marketingeffortstoshiftmembershiptohigh
performersinyournetwork.• Promoteyourhighestperformingproviders
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NoValueCareMeetsNoITNeededIdentifyingSuccessinPayforValue
Over/UnderCodingCounty&ZipCode
UnderCoding OverCoding
Under-codingJacksonville
Overs-codingMiami
HealthFactors
AverageRiskScores
Watcha2minute videoonthemethod&concept:www.bmj.com/content/348/bmj.g2392
RowdMapuses publicdataonpopulation behaviorswithin asocio-demographic cohortandriskbandtodeterminewhichgeographiesandproviderswilllikelysucceed inthemovementfromFeeforServicetoPayforValueandRiskArrangements.
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NoValueCareMeetsNoITNeededIdentifyingSuccessinPayforValue
Months1-3 Months4-6 Months10-12Months7-9
Months1-3 Months4-6 Months10-12Months7-9
OpportunityAssessment
NoDeliverables
InitialFindings/Documentation
ProjectSale/Start FieldTeam
On-site– Ongoing
NoValue-AddTeamRamp-UpPeriod
Value-Add,ActionableRecommendations,SolvingBusinessProblemsCustomizedDeliverables–Day1
Pre-KickOffAnalytics
ClientKick-Off
Project1–Completed,
DeliverableSubmitted
Project2–Completed,
DeliverableSubmitted
Project3–Completed,
DeliverableSubmitted
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64
NoValueCareMeetsNoITNeededIdentifyingSuccessinPayforValue
TheACAatyourfingertips
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NoValueCareMeetsNoITNeededSummary
PopulationHealthismorethanpublicandsocialgood,butcreatessignificantfinancialbenefitsthroughvaluebasedarrangements.
Newlyreleasedgovernmentbenchmarkdataallowsprovidersandpayerstodeterminewhethertheywillsucceedandhowtoflourishinpayforvalueandriskarrangements.
Datahaverevolutionizedtechnologyandotherverticals,nowopendatafromthegovernmentandtheCentersforMedicareandMedicaidServicescomestohealthcare.
VirtuallyeveryproviderintheUSandtheirpracticepatternsandreferralsareavailablewithnoITintegrationneeded.
Buildtherightnetwork,group,CINtocapturethevalueyoucreatethroughpopulationhealthprogramsthroughsharedrisk.
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Anyuse,reproduction ordistribution ofthisinformation, inwholeorinpart,orthedisclosure ofanyofitscontentswithout theprior written consent oftheCompany,isprohibited.
NoValueCareMeetsNoITNeededCapturetheValueYouCreateinPopHealth
BridgetheGapintheMedEconomicTransition
Byidentifying,quantifyingandreducinglowvaluecare
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Anyuse,reproduction ordistribution ofthisinformation, inwholeorinpart,orthedisclosure ofanyofitscontentswithout theprior written consent oftheCompany,isprohibited.
NoValueCareMeetsNoITNeededCapturetheValueYouCreateinPopHealth
Find therightvaluebasedprogrambasedonyourproviderpatternsaroundno-valuecare.
Identifythemostefficientproviders;thismaynotshowupinutilization
revieworunitcostanalysis.Thennegotiatelikeapro.
Now,takeonrisktocapturethevalueyoucreatethroughpophealth
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NoValueCareMeetsNoITNeededCapturetheValueYouCreateinPopHealth
CMS:50%ofFFSwillbegoneby2018
Whatifyouknewwhichproviderswould
driveyoursuccess?
Whatifyouknewwhichproviderswouldsinkyou? WHATWOULDYOUDOIFYOUKNEW
whowillwinandwhowillloseinvaluebasedarrangements