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1© 2019 Express Scripts. All Rights Reserved. #ESOutcomes19 1
2© 2019 Express Scripts. All Rights Reserved. #ESOutcomes19 2
MEASURE, MANAGE, MITIGATEHow Smarter Assessment Can Transform Risk into OpportunityLynne Nowak M.D. Vice President/General Manager, Clinical, Data & Provider Solutions
Chris Lehmuth Senior Director, Enterprise Data Science
3© 2019 Express Scripts. All Rights Reserved. #ESOutcomes19
Data Governance, Architecture & Analytics
Clinical Quality, Performance &
Outcomes
Revenue & Expenses
Your challenges…
4© 2019 Express Scripts. All Rights Reserved. #ESOutcomes19
Director of Care & CaseManagement
Chief Information
Officer
ChiefFinancialOfficer
Our cast…
Chief Medical Officer &PharmacyDirector
BusinessDevelopment
Manager
5© 2019 Express Scripts. All Rights Reserved. #ESOutcomes19
HEALTHCARE DATA IS MESSY AND DISORGANIZED
6© 2019 Express Scripts. All Rights Reserved. #ESOutcomes19
CLEANSING, ENRICHING AND ORGANIZING DATA is essential to accurate and meaningful analytics
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WE DELIVER ACTIONABLE INSIGHTS THAT SUPPORT YOUR GOALS
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Demographics
Pharmacy claims
Med claims
Mobile
CM/DM
Lab results
Data Transformation
Data Logistics & Management (DL&M)
Data Enrichment
Advanced Insights
Machine Learning
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HOW CAN I PLAN FOR WHAT’S AROUND THE CORNER?
10© 2019 Express Scripts. All Rights Reserved. #ESOutcomes19
329 HR 15 MIN
14 HR 1 MIN
2 HR 15 MIN
ST. LOUIS
•Relevant•Diverse•Reproducible
•Clean-up•Summary stats•Partition
•Response/Target•Bins/Logits•Non-linearity
•Stat Method•Training
•Assess on Held-out Data
•Choose threshold
•Production Code•Monitoring
Algorithm Development
PREDICT. VALIDATE. REFINE.
Obtain data
Analyze and organize
data
Identity and convert features
Chosen configuration
Test performance
Implement scores
11© 2019 Express Scripts. All Rights Reserved. #ESOutcomes19
Exposing Clinical and Financial Opportunities
$922K Expected annual savings from addressing ER overutilization
56.6% Non-compliance with LDL-C testing for patients with heart disease
49.8% Higher PMPM savings opportunity in Mid-Atlanticcompared to Northeast
TOP AREAS OF OPPORTUNITY
5. High Risk Pregnancy4. Diabetes Diagnosis1. Hip, Knee, Low back surgery 2. Primary Admissions 3. ER Overutilization
EXPECTED SAVINGS OPPORTUNITIES BY CATEGORY:
PMPM$8.62 MEMBER
REDIRECTION
PMPM$4.60 IMPACTABLE
GAPS IN CARE
PMPM$2.53 EMERGING
DISEASE ONSET
2,136 Commercial members w/high risk of developing diabetes
31.3% Non-adherence with statin use in patients with diabetes
INSIGHTS AND OPPORTUNITIES FOR FOCUS
12© 2019 Express Scripts. All Rights Reserved. #ESOutcomes19
Population level opportunity analysis by disease stateSTRATIFY BY CONDITION
RESPIRATORY
CARDIOVASCULAR
DIABETES
$$$
$1.50 $1.52
HbA1c TestingCompletion Rate
Appropriate TreatmentHypertension
Completion Rate
Total opportunity: $3.02 PMPM
13© 2019 Express Scripts. All Rights Reserved. #ESOutcomes19
Population level risk analysis by geography
$538 $507 $572
$642 $544
$512 $579 $523
$-
$100
$200
$300
$400
$500
$600
$700
-
0.20
0.40
0.60
0.80
1.00
1.20
1.40
1.60
PMPM
Sav
ings
Opp
ortu
nity
Risk
Sco
re
14© 2019 Express Scripts. All Rights Reserved. #ESOutcomes19
OVERALL NORTHEAST MID-ATLANTIC SOUTHWEST
EMERGING DISEASE ONSET $2.53 $1.89 $2.84 $2.38
IMPACTABLE GAPS IN CARE $4.07 $3.76 $5.77 $3.33
MEMBERREDIRECTION $8.62 $6.36 $9.39 $8.00
PMPM savings opportunity by geography:
Total PMPM Savings Opportunity
$15.22
MID-ATLANTIC
$2.84
$5.77
$9.39
15© 2019 Express Scripts. All Rights Reserved. #ESOutcomes19
EMERGING DISEASE ONSET
PMPM savings opportunity summary: OVERALL NORTHEAST MID-ATLANTIC SOUTHWEST
EMERGING DISEASE ONSET $2.53 $1.89 -25.3% $2.84 12.3% $2.38 -5.9%
CAD AND CHF $0.38 $0.28 -26.3% $0.41 7.0% $0.25 -34.2%
DIABETES $1.59 $1.04 -34.6% $1.89 18.9% $1.69 6.3%
OPIOID ABUSE $0.55 $0.56 1.8% $0.53 -3.6% $0.43 -21.8%
Diabetes prevention/onset delay ($1.59 PMPM) emerged as an area of substantial opportunity, representing 63% of the Emerging Disease Onset cohort.
DIABETES $1.59 $1.04 -34.6% $1.89 18.9% $1.69 6.3%
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IMPACTABLE GAPS IN CARE
PMPM savings opportunity summary:OVERALL NORTHEAST MID-ATLANTIC SOUTHWEST
IMPACTABLE GIC TOTAL $4.07 $3.76 -17.4% $5.77 31.9% $3.33 -29.5%
CARDIOVASCULAR $1.42 $1.05 -26.1% $2.29 61.3% $0.98 -31.0%
DIABETES $0.99 $0.84 -15.2% $0.89 -10.1% $1.01 2.0%
RESPIRATORY $0.13 $0.08 -38.5% $0.13 0.0% $0.01 -92.3%
MUSCULOSKELETAL $0.50 $0.29 -42.0% $0.34 -32.0% $0.12 -76.0%
MENTAL HEALTH $0.35 $0.62 77.1% $0.17 -51.4% $0.11 -68.6%
OTHER/NON CHRONIC $0.74 $0.48 -35.1% $1.55 109.5% $0.64 -13.5
Care dedicated to members with cardiovascular disease ($1.42 PMPM) emerged as a substantial opportunity to address impactable gaps 32% of the total available opportunity).
CARDIOVASCULAR $1.42 $1.05 -26.1% $2.29 61.3% $0.98 -31.0%
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MEMBER REDIRECT ION
PMPM savings opportunity summary: OVERALL NORTHEAST MID-ATLANTIC SOUTHWEST
MEMBER REDIRECTION TOTAL $8.62 $6.36 -26.2% $9.39 8.9% $8.00 -7.2%
ER OVERUTILIZATION $1.68 $1.29 -23.2% $1.69 0.6% $1.45 -13.7%
FALL RISK $0.01 $0.01 0.0% $0.01 0.0% $0.01 0.0%
HIGH RISK PREGNANCY $1.57 $1.43 -8.9% $1.78 13.4% $2.23 42.0%
HIP, KNEE, LOW BACK SURGERY $2.55 $1.68 -34.1% $2.68 5.1% $1.77 -30.6%
PRIMARY ADMISSIONS $1.96 $1.15 -41.3% $2.37 20.9% $1.75 -10.7%
READMISSIONS $0.85 $0.80 -5.9% $0.86 1.2% $0.79 -7.1
Hip, knee, and low back surgery emerged as the largest expected single savings opportunity, representing $2.55 PMPM (over 29% of the available expected savings opportunities for member redirection)
HIP, KNEE, LOW BACK SURGERY $2.55 $1.68 -34.1% $2.68 5.1% $1.77 -30.6%
18© 2019 Express Scripts. All Rights Reserved. #ESOutcomes19
MAKE EVERY intervention count.
19© 2019 Express Scripts. All Rights Reserved. #ESOutcomes19
MOST LIKELY TO ENGAGE
HIGHEST RISK
GREATEST MODIFIABLE GAPS
Maximize every healthcare dollar
Where to find your greatest opportunities
20© 2019 Express Scripts. All Rights Reserved. #ESOutcomes19
Sally G. Fred S. Jane D.FINANCIAL RISK $72,440 $209,519 $10,396
CHRONIC CONDITIONSHTN, DM,
Asthma/COPD, Chronic Pain
COPD, CAD, HTN, CHF Asthma, Psoriasis
OPEN GAPS IN CARE 6 11 2
CLINICAL ONSET RISK Opioid Dependence
REDIRECTION RISK Back Surgery Hospitalization ER Utilization
ENGAGEABILITY High Medium Low
SAVINGS OPPORTUNITY $16,052 $8,799 $1,064
Patient level opportunity assessments
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Intervene sooner using predictive risk scores
POTENTIAL RISK SCORE:
8.90
ENGAGEABILIT Y SCORE:
MODIFIABLE RISK DRIVERS:
86%
$16,052POTENTIALANNUAL SAVINGS:
Pharmacy opportunities• Adherence to hypertension (RAS) therapy (open gap)• Statin omission in patients with diabetes (open gap)• Use of high risk medications in elderly
Medical opportunities• A1C testing in patients with diabetes (open gap)• High risk of low back surgery in next 12 months• High risk of opioid dependency in next 12 months
Name: Sally G.Age: 66
RISK SCORE:
14.48
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OPPORTUNITY SUMMARY
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SEAMLESS INTEGRATION INTO YOUR OWN SYSTEMS AND WORKFLOW
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SUPPORT FOR YOUR CLIENT GROWTH & RETENTION
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CONFIDENCE FOR RISK-BASED ARRANGEMENTS
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ALIGNMENT FOR YOUR ORGANIZATION
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