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Risk-Readiness™: A Much Bigger Piece of the Pie

™

Unwarranted VariationRowdMap's Risk-Readiness™ Platform helps identify “unwarranted variation” in the practice of medicine. This term was defined decades ago by medical researchers at Dartmouth to describe the collective practice pattern fingerprints of physicians around the country. Some physicians prefer to start with less intensive treatment options, while others may send patients straight to surgery. In other cases, treatments vary by geography. Understanding this variation is a significant key to success in pay-for-value programs.

Indentify and Managing Variation is a New OpportunityRisk-Readiness™, at its core, describes payers and providers that can successfully identify and manage unwarranted variation. This unnecessary spend drives billing in a fee-for-serve economic model, but success in pay-for-value comes from managing and mitigating these pockets of variation. Both payers and providers use RowdMap's Risk-Readiness™ Platform to identify high-performing physicians that manage variation and have practice patterns that meet the needs of the populations within their geographies.

Beyond Risk-Readiness™After identifying Risk-Ready physicians, payers and providers then build strategies that focus their businesses around them. They develop high-performing networks, identify new candidates for pay-for-value partnerships, match populations to the right physicians, and design plans around these partnership.

“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

“Unwarranted variation cannot be explained on the basis of illness or the preferences of patients. Such variations result from influences that the supply side exercises on the patterns of practice.”

- John E. Wennberg,Founding editor of The Dartmouth Atlas of Health Care

Necessary Care$3.0bn

$1.5bnClinically Appropriate, but Unnecessary Care

$0.5bnFraud, Waste, and Abuse

Example Claims Spend for a $6bn Revenue Plan

For decades, payer and provider payment integrity efforts have focused on Fraud, Waste, and Abuse spend through clinical edits, audits, and recovery efforts. Although these services have traditionally shown returns, they only address a small fraction of total spend.

Unwarranted Variation, Financial Opportunity

RowdMap's Risk-Readiness™ Platform takes a look at a different category care. RowdMap helps to identify and manage provider practice patterns that lead to clinically appropriate, but unnecessary care. RowdMap’s methods come from the team behind The Dartmouth Atlas and decades of research identifying unwarranted variation and unnecessary, high-cost care.

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About RowdMap

RowdMap helps health plans, government payers, providers, and hospital systems develop Risk-Readiness strategies to excel as they transition from fee-for-service to pay-for value. As CMS sunsets fee-for-service payments, RowdMap's Risk-Readiness™ Platform helps payers and providers identify and manage unwarranted and unexpected variation. RowdMap identifies ideal provider arrangements based provider practice patterns and population characteristics within a geography. Payers and providers then use RowdMap to build strategies around these new risk relationships. RowdMap helps them enter new markets, segment populations, identify waste, design products, and understand referral patterns. RowdMap's platform comes preloaded with government benchmarks out of the box—no IT integration required. RowdMap's Risk-Readiness ™ Platform works across all market segments and has significantly larger returns than traditional medical economics approaches.

ChallengeLooking to enhance pay-for-value strategies in its Medicare segment, a regional health plan sought to identify Risk-Ready orthopedists in its geographic footprint. Based on regional variation, the orthopedic specialty was one of the highest spend areas for the health plan. The plan’s medical economics team wanted a deeper understanding of geographic and physician-to-physician variation against benchmarks.

SolutionThe plan employed RowdMap's Risk-Readiness™ Platform to analyze individual practice patterns of physicians within a key county for members presenting with lumbago (lower back pain). Lower back pain is a classic clinical condition that decades of research has shown results in clinically appropriate, but unnecessarily intense, high-cost care. Lower intensity treatments for back pain like pain management or physical therapy are as clinically effective as high intensity treatment options like spinal fusions or decompressions. Specifically, the plan used RowdMap’s platform to compare ratios of decompressions to fusions, the highest intensity, highest-cost treatment options for back pain.

Identifying Risk-Ready Orthopedists : A Case Study

Ratio of Decompressions to Fusions (Indexed)

County Average

0.46x

HighestPerforming Orthopedis

t

0.2x

LowestPerforming Orthopedis

t

10.3x

A single physician performs the highest intensity treatment option for back pain at an order of magnitude higher rate than the county benchmark. Fee-for-service economics would reward this orthopedist for volume, but this doctor is clearly not risk-ready. Based on $332 of average cost per decompression for this county, this orthopedist delivers over $540,000 of unnecessary care. Standard utilization or unit cost analysis would not identify this unwarranted variation since this practice pattern is clinically appropriate.

Understand practice patterns for every doctor, in every county, across all major DRGs, and every major drug class.