1. Performance Networks Troy Trygstad May 21st 2018
Value-Based Contracting and Value-Based Decision Making – What Payers Are Asking For?
Performance Networks
Troy Trygstad
May 21st 2018

2. Disclaimer
“The views of the presenter are based on his experiences. They may not be shared by anyone in the audience.”

3. Value= : something that can be bought for a low or fair price
: the amount of money that something is worth
: usefulness or importance

4. Benefit
Value =
Cost
(to stakeholders…)

5. What matters in the new system?....
Value (historical pharmacy model)
: something that can be bought for a low or fair price
: the amount of money that something is worth
: usefulness or importance

6. What matters in the new system?....
Value (historical pharmacy model)
: something that can be bought for a low or fair price
“which pharmacy would you like to use?....”
“we offer free medications….”
“we need you to increase your fills to get more help….”

7. Value (emerging pharmacy model)
: something that can be bought for a low or fair price
: the amount of money that something is worth
: usefulness or importance

8. What matters in the new system?....
Value (emerging pharmacy model)
: the amount of money that something is worth
: usefulness or importance
“we believe you’d benefit from getting this service….”
“we work closely with a pharmacist who….”
“we need you to change the health trajectory of your patients….”

9. Performance Networks (Assuming Outcomes Based…)

10. Value is in the Eye of the Beholder
Health Services Researchers
Total Cost of Care
Hospitalizations
Clinical End Points
Biomarkers
Patient Satisfaction
Demonstration of Process

11. Value is in the Eye of the Beholder
Employers
Lower Premiums
Employee Retention
Productivity

12. Value is in the Eye of the Beholder
Consumers
Convenience
Out of Pocket Cost
Simplicity
To Feel Healthy

13. Value is in the Eye of the Beholder
Taxpayers
Cover Poor, Elderly and Disabled
Cover Pregnant Women and Children
Invest in Programs that Produce Health
Cut, Cut, Cut
Pay Teachers

14. Value is in the Eye of the Beholder
Medicare Part D
Stars, Stars, Stars
Grow Enrollee Base
Don’t Create Adverse Selection
Comply with Regs

15. Value is in the Eye of the Beholder
MAPD
Stars, Stars, Stars
Grow Enrollee Base
Don’t Create Adverse Selection
Comply with Regs
Reduce Overall Cost of Care

16. Value is in the Eye of the Beholder
Medicaid (MCOs)
Win the Bid
Win the Re-Bid
Make Care Management more Cost-Effective
Don’t Create Adverse Selection
Comply with State Plan
Reduce Overall Cost of Care through fewer Units

17. Value is in the Eye of the Beholder
Medicaid (Administrators)
Comply with State Plan
Reduce Overall Cost of Care through fewer Units
Avoid Cutting Services
Something Different than we do now

18. Value is in the Eye of the Beholder
Commercial
Win the Business
Manage Unit Cost
Create or Otherwise Feign Differentiated Product

19. Value is in the Eye of the Beholder
ACO/APM
Manage Referrals
Reduce Part B Costs
Get a Handle on Actionable Data
ACO/MIPS/APM Measures

20. Value is in the Eye of the Beholder
Manufacturers
Access to Markets
Access to Prescribers
Access to Data
Outcomes associated with Expensive Medications

21. Value is in the Eye of the Beholder
Office Manager/CFO
Revenue
Happy Doctors
Happy Customers
Happy Lawyers
Outcomes

22. Value is in the Eye of the Beholder
Patients
Access
Comfort
Coordination
Supports
A System that Listens to Them

23. Transformation Moves at the Speed of Risk

24. Risk of What? Performance on What?
Loss of Revenue?
Loss of Bonus?
Loss of Patients?
Total Cost of Care?
Loss of Public Trust?
Loss of Qualifying Entity Status?
Legislative Ire?
Prescription Fill Rates?
HgA1c?
Loss of Cardiology Group?
Re-Hospitalizations?

25. “Outcomes” Leverage (we’re not there yet…)

26. Community/Outpatient Pharmacy
What If?
Community/Outpatient Pharmacy
Specialty Pharmacy
A1c <7 NADAC + $15
A1c 7-8 NADAC + $12
A1c 8-9 NADAC + $10
A1c >9 NADAC + $7
SVR Cure ASP + 6%
SVR No Cure ASP - 35%

27. Payment Reform Marches On…. What about Us?
mmHg
A1c
LDL
Patient Satisfaction
Re-Admission Rates
Bundled Payments
Autofill
90 Day Scripts
Pill Splitting
Formulary Management
340b

28. Back to Value….

29. Back to Value….

30. Back to Value….

32. Complaints and disagreements should be submitted to …