Studies in Success


Bending the curve and planning for the future – all powered by data.


ACO design and management

NICU admission
reduction and early identification

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Value-based care design and modeling

Readmission rate reduction initiative

Patient prioritization algorithm

 
 
 

Payers, MCOs, and employer groups

We help organizations who have a population to manage effectively. Whether it's cost containment for your population or specific subsets, developing detailed cost and utilization reporting with early identifiers and benchmarks against your peers,  detailed network analysis and community provider value-based strategies, using data for targeted case and disease management, or operational improvements across departments, we have deep experience in  population health operations and strategy.

From assessment, to program design, to implementation and redesign of workflows – or all of the above – we can help you can bend the curve and help your members.

 

Neonatal Intensive Care Unit (NICU)  –  Admission Rate Reductions

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Organization Challenge

In response to a large increase in NICU admits, a Fortune 300 health plan launched a NICU Admit Reduction Initiative to prevent further increase in these costly admissions and to improve outcomes among their newborn population. Appropriate preventative measures were required for the care of expectant mothers to catalyze a NICU admission rate reduction. It was critical to identify pregnant members as early as possible – something the health plan historically had troubles with.

The organization required comprehensive pregnancy identification logic that could be informed from any indicators available and a real-time reporting solution to monitor the mothers through the pregnancy, identify key indicators and root causes leading to high-risk. After project kickoff, this would facilitate rapid intervention and steadily monitor progress compared to baselines.

 

Versatile MED's Approach and Solution

  • Collaborated with clinicians and reporting teams to review existing pregnancy identification logic and to develop strategy around identification of new pregnancy indicators
  • Developed enhanced pregnancy identification logic with improved accuracy
  • Identified additional methodology to further identify members with high-risk pregnancies (as most NICU admits are the result of high-risk pregnancies)  
  • Strategized and developed an interactive reporting suite to monitor and track outcomes of members identified as having high risk pregnancies
  • Provided ad hoc analysis of root cause, process inefficiencies, and inaccuracies in current assumptions to medical directors and C-suite on the high-risk population throughout the engagement; findings were used to drive key interventions
  • Supported targeted workgroup with stakeholders to develop action plans based on findings
  • Crafted a cost analysis on the financial impact of NICU admits to the health plan and compared to national averages to identify areas of improvement
  • Interventions included: high-risk member intensive OB Case Management, opportunities for contract renegotiation, identified claims for chart review to assess appropriateness based on comparable cases, identified and monitored improvement with ongoing feedback/monitoring

 

Value / Business Impact / Outcomes

  • 1 admit per 1,000 Reduction in NICU Admissions over 6 month rolling period
  • Average savings ~$40k per avoided admission
  • Comprehensive and validated pregnancy identification logic
  • Detailed tracking of at-risk members and other known NICU indicators
  • Standardized and automated outcomes reports
  • Improved understanding of high-risk population behavior
  • Streamlined communication between clinical and reporting sides of organization
  • Empowered decision makers with insights in making decisions surrounding this initiative

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ACO Model: Integrated System and Employer Group

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Organization Challenge

A multi-billion dollar employer group wanted to take a proactive approach to improving the health of their employees and reducing diminished productivity due to absenteeism from employee illness. This employer group entered into an ACO arrangement with a large integrated health system to manage the care of approximately 4,000 employees. It quickly became clear that data and analytics would need to power all decision making required to manage this population and their spend.

Championed by the system’s Executive Medical Director, our role was providing all the tiger team, exploratory analytics needed for a project of this size and rapid turnaround. A targeted and cost-effective approach would be taken by the ACO to manage these members, focusing on the specific opportunities identified where the employee population could improve. With this being the largest ACO Model the health system had managed and the only ACO Model that the employee group had participated in, there was a great deal of apprehension on how to create an ideal process agreed upon by both parties.

 

Versatile MED's Approach and Solution

  • Collaborated with clinicians, employer group and health system leadership in assessing the population’s most immediate areas of need and opportunities for improvement
  • Prepared the analytics behind a deep dive into cost of care, utilization, and “waste” opportunities
  • Worked extensively with the clinical team in providing data to support intensive case and population management
  • Used prioritization methodology to identify members with high likelihoods of hospitalization for early and proactive intervention, prepared Episodes of Care analysis and provider profiling
  • Calculated the baseline and regularly monitored performance for quarterly program evaluation
  • Provided ad hoc analysis and recommendations for areas of concern – rising behavioral health utilization, rising NICU utilization, out-of-state service utilization.
  • Strategized, developed, and implemented a standard suite of reports for tracking outcomes, members, workplans, and performance

 

Value / Business Impact / Outcomes

  • Effective management of the population powered exclusively by data and analytics resulted in $240,000 year-end bonus to health system, not possible without data and analytics to manage the PMPM
  • Reduced Emergency room visits, Inpatient utilization, and targeted Behavioral Health outreach
  • Detailed analysis of high-risk member trends specific to this population and their demographics
  • Standardized and automated outcomes reports requiring little ongoing manual work
  • Improved understanding of high-risk population behavior for employer and health system
  • Empowered decision makers with insights to make confident decisions on modifications/enhancements to the management strategy and real-time course correction
  • Significantly improved communication and comfort between health system and employer group

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Value-based Care and Readmission Reductions – Provider Evaluation

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Organization Challenge

Many organizations are shifting toward new provider payment models to address the growing demands on the healthcare industry to improve the quality of care provided to patients and tie outcomes to reimbursement. In a targeted effort to improve outcomes for patients undergoing knee and hip replacements, a large health plan in the Southwest implemented a Value-based reimbursement arrangement with a top orthopaedic surgeon group.

Using evidence-based medicine to redefine criteria determining medical necessity of knee and hip replacement, the organization needed a method of evaluating the effectiveness and provider adoption of this new criteria. This evaluation would allow the health plan to monitor improvements in care delivery or lack of progress, allowing provider performance to determine the level of incentive payments to be paid to the participating medical group. The plan also required a way to benchmark and rank provider performance in the ongoing arrangement, as well as provide actionable guidance and data to the participating group.

 

Versatile MED's Approach and Solution

  • Supported the business stakeholders and medical director, including exhaustive review of contract requirements, reimbursement scenario modeling, and baselines
  • Interviews with clinicians and internal/external stakeholders to identify requirements, goals, challenges, and feasibility
  • Extensive industry research to assess peer performance of similar measures and amassing peer-reviewed literature for stakeholder consideration
  • Designed, developed and implemented automated provider scorecards to track performance related to each program milestone and to industry benchmarks
  • Results of scorecard used to ensure physician reimbursement is commensurate with milestone performance and identify cases/patients with opportunities
  • Provided data consulting for mini-Kaizen held with the surgeon group

 

Value / Business Impact / Outcomes

  • Improved milestone performance across entire surgeon group due to effective implementation of refined criteria and tracking of outcomes monthly (with regular feedback loop)
  • Improved discharge practices led to better outcomes, such as increased patient satisfaction post-surgery and reduced complications
  • Increased financial shared savings for group with upward mobility for increases over 3 years
  • Reduced SNF-admit rate for targeted patients and noticeable reduction in post-acute care costs via increased emphasis on appropriate discharge to home
  • Through mini-Kaizen, the surgeon group self-identified additional areas of improvement within their own business processes that helped them reach and exceed their target goal metrics
  • With hands-on approach and consultancy, external surgeon group thoroughly understood, accepted, and used the metric calculations and payer-computed results for targeted patient outreach

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Hospitals and Health Systems

Hospitals and health systems often have dozens of disparate systems containing valuable data -– both structured and unstructured. We can pull it out, marry it together, and help you identify specific areas for improvement. From targeting variations in your process to larger value-based and population health initiatives that touch multiple functional units, we have the data expertise to get to the root and the implementation expertise to transform.

From identify opportunities hidden deep within the noise, to targeted improvements, to population health care model design and implementation, we have you covered from start to finish, placing data at your fingertips to measure, monitor, and maintain.

 
 

Readmission Reduction initiative for 400+ bed hospital

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Organization Challenge

An integrated delivery system, which included more than 5 hospitals, had an executive goal to reduce all-cause readmission rates. This system was already in the 90th percentile for readmission rate performance. This system had one large hospital of 400+ beds, several smaller hospitals in rural counties, and a provider/medical group of varying specialties. The initiative was championed by the Executive Medical Director of integrated care and a Master Black Belt. A multi-functional project was planned, executed, and monitored to reduce the readmission rate, as the system did not get reimbursed and/or could be subject to reimbursement rate reductions based on readmission rate performance.

Our role was supporting this initiative with all data and analytics required, including: root cause research, data insights, analytic advisory and co-development of analytic strategy to bend the curve. After a thorough root cause analysis, three “Critical X’s,” or primary factors that were impacting the readmission rate, were identified. Engaging multiple stakeholders (including clinicians doing the work within the hospital, care managers, IT/EMR integration team, and others), new workplans/flows were developed based on the findings and targeted interventions to address those factors and reduce the readmission rate across all hospitals within this network.

 

Versatile MED's Approach and Solution

  • Testing of all proposed factors that were identified as potential impacts to the readmission rate
  • Freeform data mining and exploration to identify additional drivers that had not been considered from back-end EMR data
  • Design and development of more robust logic, using EMR data available, to calculate LACE risk score (predictor of mortality and readmission). This score was used in the clinical workflow to prioritize and stratify patients for subsequent interventions
  • Developed analytic strategy and tracking mechanisms to implement, provide a feedback loop for monitoring at a nurse or CM level, and provide C-suite with updates/high-level analysis on an ongoing basis
  • Automated process for incorporation into EMR workflows

 

Value / Business Impact / Outcomes

  • Using data, reduced readmission rate by nearly 1 point, resulting in ~ $1,000,000 savings to system
  • Standardized workflows for all discharged patients, standard work and measurable actions for all staff members involved in discharge and post-discharge care
  • Increased communication between hospital and PCPs (both internal and external), post-discharge team (transitions of care team), and case management
  • Improved collaboration between care teams across the continuum
  • Automated, measurable, ongoing KPIs and reporting bench was developed to track, monitor, and maintain this initiative post-closeout

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Vendors and Consultants

We love collaboration and we believe that knowledge comes through learning, sharing, and working together.

We've worked with vendors to make their population health products more robust, provide data and analytics support when they need to understand payer or provider data and initiatives, and served as expert SME's for unique projects.

 
 

Patient Prioritization for Intensive Case Management

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Organization Challenge

A remote patient monitoring vendor, who works primarily in home health, wanted to improve the offering of their monitoring tool and make it more enticing to payers, providers, and hospitals who use it. This tool already had a dashboard of valuable information, but to make it more robust, they wished to add a patient prioritization value. This value would allow the nurses and other transition of care teams to implement higher-risk patients into their workflow in a prioritized fashion, targeting those in home health who are more apt to readmissions. 

Adding functionality to the tool would allow them to participate more actively in the population health and value-based care conversation, as well as provide valuable insights to their clients that they may not be incorporating currently.

Versatile MED's Approach and Solution

  • Collaborated and exhaustive review of literature to review existing findings and to develop strategy around identification of new inputs that were of importance to stakeholders (for instance, number of ED visits, recent admission, etc.)
  • Tested variables/events for significance of impact on outcome.
  • Tested buckets of groupings for key triggers (for instance, determine if having 1 ED visit was impactful or should only patients with 5+ visits be considered for prioritization).
  • Added additional factors that were identified by business owners as those they wanted to target (for instance, patient members who just had an admit were brought to the top of the list)
  • Finalized a weighted model with 5 factors to prioritize patients for Case Management outreach. Certain factors carried more weight than others based on the organization's priority and what they are focused on.
  • Participated in Case Management workgroup to explain methodology, how to interpret and use the prioritized list, including work-plans and scripting.
  • Provided production-ready information.

 

Value / Business Impact / Outcomes

  • Easy-to-use and -understand prioritized patient listing to identify patient members most important to the business unit for targeting
  • Productionalized model so no technical intervention was required by clinical staff or data analytics department.
  • Algorithm shuffled patients to the top of list based on factors that were important to business stakeholders and workplans that were developed around certain kinds of events.
  • Although the target goal was to reduce total spend, this model also worked to move patients towards the top of a list in order to target for other initiatives not related to spend (such as frequent ED use).
  • This prioritization algorithm was used to easily identify patients this organization wanted to target to support their internal initiatives (not a risk of readmission score).
  • The outcomes of this workflow change are still being evaluated.

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