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1 Welcome to the Webinar All attendees are on mute, so if you would like to ask a question, please type it into the Q&A box in the control panel on your screen A copy of the slides from this presentation can be downloaded at: OR If you would like to minimize the control panel so that you can see more of the screen, click on the white arrow in the small orange box and the control panel will be minimized. You can click on the arrow to open the panel if you would like to type in a question.

2 Variation Reduction: A Tool To Improve Quality, Increase Access and Lower Cost Scott Hines, MD Jonathan Nasser, MD Crystal Run Healthcare

3 Outline Introduction to Crystal Run Healthcare Variation Reduction Pilot & Spread Using Variation Reduction to Engage Providers Results Questions

4 Outline Introduction to Crystal Run Healthcare Variation Reduction Pilot & Spread Using Variation Reduction to Engage Providers Results Questions

5 Crystal Run Healthcare Physician owned MSG in NY State, founded 1996 >370 providers, >35 locations ASC, Urgent Care, Diagnostic Imaging, Sleep Center, High Complexity Lab, Pathology Early adopter EHR (NextGen ) 1999 Accredited by JC since 2006 (1 st in NY State) Level 3 NCQA PCMH since 2009

6 Crystal Run Healthcare ACO Single Entity ACO MSSP April 2012 NCQA ACO Accreditation 2012 (1 st in NY) Multiple Commercial Risk Based Contracts 35,000 patients attributed patients to CRHACO Crystal Run Health Plan 2015 MSO 2015

7 Where is Crystal Run Healthcare?

8 Outline Introduction to Crystal Run Healthcare Variation Reduction Pilot & Spread Using Variation Reduction to Engage Providers Results Questions

9 Variation Reduction Definition A cost control measure which seeks to standardize care according to clinical guidelines and eliminate waste amongst those not adhering to national or local practice standards.

10 Variation Reduction Process Step 1: Analyze Utilization Step 2: Compare utilization between physicians Step 3: Analyze the variation

11 Variation Reduction Diabetes Pilot (2010) Step 1: Analyze Utilization Determine total cost per diabetic per physician Cost includes professional, lab, imaging and procedure charges

12 Variation Reduction Diabetes Pilot (2010) Step 1: Analyze Utilization Step 2: Compare utilization between physicians

13 Variation Reduction Pilot: Comparing Utilization Between Providers

14 Variation Reduction Diabetes Pilot (2010) Step 1: Analyze Utilization Step 2: Compare utilization between physicians Step 3: Analyze the variation What is the source of variation?

15 Variation Reduction Diabetes Pilot (2010) What is the source of variation? My patients are sicker My quality is better Are best practice guidelines being followed?

16 Variation Reduction Diabetes Pilot (2010) ADA guidelines for diabetes Lessons learned Frequency of lab tests Frequency of office visits Accuracy of coding Use of consultants Brief discussion on medications

17 Variation Reduction Diabetes Pilot (2010) Fast forward 6 months Compare Q3-Q vs. Q3-Q Provider charges per patient reduced by 7% Lab charges per patient reduced by 15% Radiology charges per patient reduced by 53% Total charges per patient reduced by 9%

18 Variation Reduction Pilot: Diabetes Charges/Patient 2010 vs Mean Charges/patient $670 $596 Standard Deviation $228 $155 Coefficient of Variation

19 Variation Reduction Pilot: Diabetes Charges/Patient 2010 vs. 2012

20 Variation Reduction This really works!!! We should apply to more diagnoses!!!

21 Variation Reduction: Version 1.0 Charges/Patient 2010 vs DIAGNOSIS DEPARTMENT % CHANGE PP TOTAL $$ CHANGE CHF Cardiology -6% -$53,457 Diabetes PCP/Endocrine -17% -$844,755 Thyroid Nodule Endocrinology -26% -$304,224 Otitis Externa ENT -2% -$2,373 GERD GI -20% -$178,381 Cholelithiasis General Surgery -7% -$11,408 COPD Hospitalists -20% -$9,215 HTN Primary Care -16% -$943,002 Hyperlipidemia FP/IM -19% -$1,150,376 HA/Migraine Neurology -10% -$208,054 Breast Cancer Oncology -7% -$393,622 Lateral Epicondylitis Orthopedics -8% -$27,647 Asthma Pediatrics -10% -$24,570 Asthma Pulmonology +3% +$26,238 Renal Mass Urology -4% -$62,812 TOTAL -14% -$4,187,658

22 Outline Introduction to Crystal Run Healthcare Variation Reduction Pilot & Spread Using Variation Reduction to Engage Providers Results Questions

23 Engaging Providers More Questions Than Answers Where does the variation lie? How can we get this information in real time? How can we leverage this information with our providers?

24 Engaging Providers Where does the variation lie? Professional Charges Number of visits/patient Number of consults/physician Coding patterns Laboratory/Diagnostics/Procedures Number of tests/patient Type of test ordered

25 Engaging Providers Leveraging the Tool Creation of an automated tool Ability to evaluate cause of variation Quarterly variation reduction meetings with each department Used for physician engagement Creation of best practice guideline library Reduction in cost/utilization is a nice side effect

26 Engaging Providers Quarterly VR Meetings Each department meets with one of the clinical transformation officers quarterly Diagnosis chosen the session before Champions assigned to create BPG Meet to review variation graphs 2-3 takeaways to reduce variation Review trend data for previous diagnoses Choose a diagnosis for following quarter

27 Lessons Learned GI: Abnormal LFTs Charges/Patient reduced 17%

28 Lessons Learned Neurology: Multiple Sclerosis Charges/Patient reduced 14%

29 Lessons Learned Endocrinology: Thyroid Cancer Charges/Patient reduced 4%

30 Engaging Providers Quarterly VR Meetings Development of nearly 100 best practice guidelines across 20+ different specialties Maintenance or improvement across dozens of quality measures Creation of access equivalent to 18 physicians Consistent reduction in charges per patient while growing revenue

31 Outline Introduction to Crystal Run Healthcare Variation Reduction Pilot & Spread Using Variation Reduction to Engage Providers Results Questions

32 Results Effect on Quality Hgb A1c > 9 BP <140/90 30% 78% 25% 20% 15% 10% 5% CRHC Results NCQA Goal 76% 74% 72% 70% 68% 66% CRHC Results NCQA Goal 0% 64% Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q LDL Cholesterol <100 Mammography 62% 60% 58% 56% 54% 52% 50% 48% 46% Q Q Q Q Q Q Q Q Q Q Q Q Q Q CRHC Results NCQA Goal 78% 76% 74% 72% 70% 68% 66% 64% 1st quarter 2nd quarter 3rd quarter 4th quarter 1st quarter 2nd quarter 3rd quarter 4th quarter 1st quarter 2nd quarter 3rd quarter 4th quarter 1st quarter 2nd quarter Score NCQA Goal

33 100% Results Effect on Quality NCQA Percentile 75% 50% NCQA Percentile 25% 0% Breast Cancer Screening Colon Cancer Screening Diabetes Control Screening for Kidney Disease in Diabetes Appropriate Treatment for Children with URI Use of Aspirin in Coronary Artery Disease Lead Testing in Children Pneumonia Vaccination

34 Results Effect on Access Eliminated over 66,000 visits Grew practice by 60,000 patients Capacity equal to 18 physicians

35 Results Effect on Cost 180, , , , , , , , ,000 Jan-11 May- Sep-11 Jan-12 May- Sep-12 Jan-13 May- Sep-13 Jan-14 May- 120% 100% 80% 60% 40% 20% 0% DistinctPatient Receipts per patient as % baseline

36 Conclusions Variation reduction is a powerful tool to maintain/improve quality, reduce cost, and improve access Providing physicians with real time, diagnosis specific data can lead to a rapid change in practicing patterns Standardizing follow-up intervals for chronic diseases can create the capacity to provide care for new patients and maintain or increase revenue in FFS and value

37 Outline Introduction to Crystal Run Healthcare Variation Reduction Pilot & Spread Using Variation Reduction to Engage Providers Results Questions

38 Thank You! We hope you enjoyed this presentation. To make sure that you receive invitations to future Webinars, follow A copy of the slides from this presentation can be downloaded at: OR We will be posting the recording at the same location on our Website within the next day so you can access it.