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™
Risk-Readiness™: A Much Bigger Piece of the Pie
Example Claims Spend
for a $6bn Revenue Plan
$1.5bn
Clinically Appropriate,
but Unnecessary Care
$0.5bn
Fraud, Waste, and Abuse
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.
Necessary Care
$3.0bn
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.
Unwarranted Variation, Financial Opportunity
Unwarranted Variation
“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
RowdMap'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 Opportunity
“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
Risk-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 RiskReadiness™ 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.
All contents are proprietary to RowdMap, Inc. and are being provided on a confidential basis.
Any use, reproduction or distribution of this information, in whole or in part, or the disclosure of any of its contents
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Identifying Risk-Ready Orthopedists : A Case Study
Challenge
Looking 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.
Solution
The 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.
Ratio of Decompressions to Fusions (Indexed)
10.3x
0.46x
County
Average
0.2x
Highest
Performing
Orthopedist
Lowest
Performing
Orthopedist
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.
About RowdMap
RowdMap helps health plans, government payers, providers, and hospital systems develop RiskReadiness 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.
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