Hello, everyone, and thank you for joining today's webinar, Key
Data Insights Dr.
Value for your hospital services strategy.
My name is Brittany Terman with Optum, and I will
be your host today.
Before we begin, Please note the following housekeeping items.
At the top right of your audience console are multiple
application tools that you can use to customize your viewing
experience.
If you have any questions during the webcast, you can
click on the Q&A tool at the top right of
your screen to submit a question.
Would you capture all questions?
And we'll be providing follow up to questions as appropriate.
If you experience any technical difficulty, please click on the
Help tool.
It covers common technical issues.
You can expand your slide area by clicking on the
maximize icon on the top right of the slide window
or by dragging the bottom right corner of the slide
window.
We do have some complimentary related resources available for you
to download with today's session.
Please look to the top right where it says related
resources for those downloads.
In addition to those complementary resources, we also have a
Contact Us form located at the top right of that
webinar console that you can leverage if you'd like to
receive outreach from your Optimum Value Advisor.
This presentation does use streaming audio.
You may listen to the audio through your computer, speakers
or headphones.
To ensure the best possible system performance, please be sure
to shut down any VPN connections and connect directly to
the Internet.
Presenting today, we have Doctor Brian Ruddick, our physician Director
of Optum Physician Advisor Services.
We also have Doctor Robert Woznik, our physician clinical relationship
manager of Optum Physician Advisor Service.
With that, I'm going to go ahead and hand it
over to Doctor Brian Ruddick to get us started.
Brian.
Thank you and good morning, everyone.
This is Brian Ruddick.
I'm a Physician Director in the Optimum Physician Advisor Services
Group, focusing on areas of medical necessity and analytics.
I'm an emergency medicine physician by training and I've been
with Optum a little bit more than 16 years.
All right and good afternoon from this side of the
country.
I'm Rob Wozniak and Internal Medicine doctor by training.
I've been with Optum now for 14 years, the last
7 or so in this present role of advising on
regulatory questions and physician education.
You are optimization and to try to identify trends and
opportunities for our clients.
And a large part of that role is reviewing some
of the reports that we'll be presenting to you today.
So why don't we kick off our agenda here with
a quick review of our commitment to protecting your data,
because we know that the security of your data is
top of everyone's mind.
And then we're going to move on to some of
the reports that are available to our clients to try
to highlight some of the additional value Optimum Physician Advisor
Solutions Opus can bring to you at no additional charge.
And we are offering, as was said earlier through this
webinar a function so you can request these reports and
see just how they might be able to assist you
today.
Along those lines, we're going to cover the Tapper which
is our replacement to the old pepper reports that CMS
used to give.
Then we're going to turn to some of the benefits
and features of the commercial clinical trends analysis.
We used to call this a claims analysis and finally
end up on the newly created clients scorecard, which is
designed to give you a quick one page view of
essential performance metrics and trends as it relates to your
Opus submissions, your Optum physician advisor submissions.
But first and foremost, because it's probably the most often
asked question I received when it comes to data.
And I just want to be clear that Optum operates
independently from United Healthcare, ensuring that there's no, there's no
favoritism, there's no bias.
And we do this by maintaining strong legal and ethical
and financial safeguards, which overtime has earned the trust amongst
our clients, but as well as those who directly compete
with United Healthcare in the blue box on your screen.
It goes over the Optum data philosophy that we have
a responsibility to protect our client, patient and member information.
And we protect health information, patient privacy with these comprehensive
safeguards practices and policies.
And on the left, we detail a few here, technical
safeguards, of course, firewalls and encryption, etcetera.
We have physical safeguards that you would expect from us
as well as administrative safeguards which I largely surround the
notion of only, only employees that need access to protected
information have access to that protected information.
And we employ all of these safeguards in an effort
to promote data separation, which extends to our partner and
affiliate organizations including United Healthcare, Optum and the Greater United
Health Group.
All of our governance process also serves to facilitate appropriate
access.
So with that out of the way, we wanted to
start today with a poll question and you know this
is going to lead us to the Tapper here, but
which is a replacement as you know of our of
of the Pepper data which is presently on hiatus.
So if you could key in your results on the
console in the next 30 to 45 seconds here, but
you could see the question, what was your primary use
of Pepper data when it was available to you for
risk assessment?
You know, kind of giving an eye towards what Medicare
is keeping tabs on opportunity identification, a focus on readmission
challenges or did you simply not regularly review the Peppers?
So if you could key in your choices there?
And while you're doing so, Brian, if I could ask
you a question, can you explain to the attendees, how
are we here at Opus able to recreate the Pepper
report given that it's currently on hiatus?
Sure.
Well, Rob, as you know, when CMS took the pepper
down in the end of 2023, they actually did not
remove the raw data file called the standard analytics file
SAF.
So our analytic team was able to use this data
to recreate the pepper.
Our version of the report is actually called the Tapper,
which stands for Target Area Payment Patterns Electronic Report.
OK.
Well, thank you.
And we have a number of responses here.
Let's see, all right, so risk assessment and I think
that that's the primary reason that CMS gives us this
data.
You know, you want an idea that if you're doing
things as an institution, if you're, if you're billing is
largely different than similar hospitals to yourself, well then that's
something that you might want to focus on.
So I do think that that's the primary intent of
the Pepper report.
So that makes complete sense to me.
Focusing on readmission challenges of course is also always important.
And you know, of course it can impact your DRG
penalty as well.
And not using the pepper because it wasn't all that
user friendly.
It was in this Excel spreadsheet that was sometimes a
little intimidating to go through.
So I totally understand all of those, all of those
responses here.
So, Brian, if I could hand it off to you,
Are you ready to show them what our Tapper presentation
might look like?
Absolutely.
Thanks, Rob.
I'll take it from here and we'll go ahead and
dive into the the Tapper.
So just by way of introduction, as mentioned for the
Tapper, we've recreated much of the Pepper and all of
its metrics from the Medicare standard analytics file that I
mentioned.
In addition to recreating the original pepper, the Optum Tapper
offers a host of additional benefits.
We've added more target areas based on our experience, including
some that actually had been removed from the pepper.
We can roll up to the system level so clients
can view results across their entire health system.
Also, we have more relevant benchmarking.
If you recall, the pepper used to compare hospitals performance
versus those of other hospitals in the same state back
jurisdiction and and nationally.
But we know that not all hospitals in the same
state are comparable.
So instead in the Tapper we are comparing you to
similar hospitals based on size, location and academic affiliation.
Essentially we're comparing like hospitals based on their their demographics
as opposed to just location.
Since we have full control over the output, we can
adjust the Tapper accordingly to respond quickly to the ever
changing metrics and industry questions.
And additionally, we continue to look for opportunities to adapt
and add more value for the client hospital.
Hospitals are not required to push their data to Optum.
We can generate the report on demand for any US
based short term acute care hospital, assuming you have a
Medicare provider ID.
So to sum it up, why is the Optum Tapper
valuable to you?
It's a unique analytics report.
It's actionable in that it can assist you to lower
audit risk, prepare for audits, and identify revenue and quality
opportunities.
There's no cost to you and no data needed from
your hospital.
So let's take a look at the Tapper, right?
So this is the first slide of the Tapper.
You can see on the bottom left that this sample
clients observation rate is well above those dotted Gray lines
indicating that their medical observation rate is well in excess
of even the 75th percentile of similar hospitals to themselves.
Remember how I talked about our more relevant benchmarking, So
you can see at the top of this slide directly
under the title of medical observation rate trends.
There it is very small font where it reads using
strata academic, urban and greater than 500 beds.
So given that this sample hospital is a large urban
academic hospital, so we can say that at least for
their traditional Medicare population, they are placing significantly more medical
patients in observation than are similar hospitals to themselves.
On the bottom right of the slide you can see
what percentage of OPS patients are remaining in OPS for
specific hour buckets.
Typically we focus on the long stay OPS bearing in
mind that the intent of the two midnight rule originally
was a large largely reduce or eliminate long stay observation.
Here you can see over time a modest improvement from
16% of all OPS cases being long stay OPS down
approximately 12% in the most recent quarter.
And on the top of of this slide, you can
see the top principal diagnosis for observation along with how
long they are remaining an observation as well as what
base TRG the principal diagnosis would map to.
Together with information on your hospital specific blended operating capital
rate along with a relative DRG waiting just to give
a notion of monetary opportunity if these OPS cases were
instead found to be inpatient appropriate.
I'm going to go to the next slide of the
Tapper.
But the Tapper provides so much more than just a
simple observation analysis like the pepper.
It is roughly divided into DRG validation and coding as
well as IP medical necessity.
So this slide is an example of DRG validation and
coding.
It's showing that all of your traditional Medicare medical discharges,
what percentage are discharged with the CC or MCC attached.
You can see here that this facility, this facility is
significantly below the median.
Perhaps this is because their traditional Medicare population is modestly
healthier than the median hospital with their demographics.
Or perhaps there are documentation challenges and their physicians aren't
appropriately documenting towards CC's and MCC's.
Also, it could be that the CDI department needs more
resources.
Nothing on this slide will tell you the exact answer
though.
Like anything with the pepper or now with the Tapper,
it serves to focus your internal auditing activity to try
and get to some of the root challenges that you
might be experiencing.
In this case, I would ask this hospital to consider
an internal audit sampling of the unique cases in the
denominator, which would include cases discharged without ACC or MCC,
in order to try and understand the causes of them
being below the 25th percentile.
So for this side in the Tapper, the same, the
same here holds true for this DRG validation and coding
category, simple pneumonia with ACC or MCC attached.
You can see here again that this particular facility seems
to have fewer simple pneumonias with ACC or MCC attached
as compared to similar hospitals in the US given that
it is added below the 50th percentile and most of
the fiscal quarters that we're showing you, this is the
same facility we were just looking at in the previous
slide.
So are they below the 50th percentile due to the
lack of CCMCC attachment or could the issue be too
many inpatient COPD's which would dilute the denominator?
But the focus of internal auditing activity for simple pneumonia
and COPD for this hospital would be exactly what this
slide would drive a facility to focus on.
The next chapter slide focuses on sepsis, and here's an
example of the opposite.
This hospital appears to be greater than the 75th percentile,
consistently encoding into DRGS 870 to 872 for sepsis.
So what does this mean?
Is this hospital possibly overcoding sepsis and might be at
risk of drawing unwanted auditor attention?
Yeah, you know, and they're right.
And I think this highlights somewhat of what you were
saying before.
Nothing in Pepper or Tapper says you're doing anything wrong
or right.
All it does is focus your attention on where you're
doing things differently than other similar hospitals to yourself.
Now, is it possible that this hospital, for instance, is,
is, you know, using sepsis to criteria to pick up
sepsis as opposed to the more restrictive sepsis 3 criteria?
Well, yeah, of course.
And, you know, if they're being compared to hospitals that
are, you know, utilizing SOFA criteria to pick up sepsis,
sure, they're going to look a little bit higher because
it's, it's a little more forgiving.
So it doesn't mean that anything is wrong or right,
but it would point you in a direction of looking
at some of those.
In quarter 4/20/24, they had 100, 30 of their 167
infectious etiologies as 78% of them were discharged with sepsis
as the primary diagnosis, not as an MCC, but as
the primary diagnosis to to look at a sampling of
those cases and make sure of those 130 and make
sure that you stand behind the DRG that was picked
up in those cases.
Thanks, Brian.
Great.
Thanks, Rob.
Move on to the next slide here in the Tapper.
So you can see here that this side of focuses
on 30 day readmissions to the same hospital and this
particular facility is again at or below the 50th percentile
for readmissions when compared to similar hospitals in the US.
Although this appears to be a good place to be,
we do have one more readmission slide which dives into
this topic a bit more.
And this slide is the second readmission slide which focuses
on the six core diagnosis that Medicare looks at for
readmissions for this sample hospital.
Despite the previous slide showing that it is at or
below the 50th percentile for readmissions, Medicare is still calculating
a financial penalty for this facility in three out of
the six core diagnosis where the hospital has exceeded the
allowable amount of readmissions as per threshold set by CMS.
This adds up to a total financial penalty factor of
0.47% times total revenue.
So our Tapper report, of course, has many more categories,
categories than just simple pneumonia, sepsis and readmissions.
We just wanted to touch on a few to give
examples of what kind of information could be available to
you.
Please feel free to reach out to us in order
to schedule a presentation after this webinar.
So now we're going to move on to the next
analytic tool that we can provide called a clinical trends
analysis.
OK, fair enough.
So yes, clinical trends analysis, you know, what we just
went over has to do with traditional Medicare alone.
So it's very insightful in terms of traditional Medicare.
And sometimes there can be some crossover from, you know,
behaviours for traditional Medicare with Medicare Advantage and commercial plans,
but there's going to be a leap there.
Essentially what a clinical trends analysis does first.
Well, First off, I should say it requires Opus to
have permission to access your claims and remittance data, your
830 fives and 8:30 sevens.
Some clients elect for Opus to have an ongoing feed
and then we can refresh that typically every six months
to present the most recent claims analysis.
Other clients at 1st May elect to just give us
one time access.
But either way, there is a bit of an IT
lift where we're going to engage with contacts at your
hospital in order to establish a connection to the data.
So clients look to claims analysis for two main reasons
really, they may want to evaluate their actual return on
investment utilizing open services.
We can show specific cases in a time frame, how
many we recommended to change to inpatient, how many we
recommended to maintain inpatient, how many we recommended observation on.
The real power though in the claims analysis, at least
in this regard, is that it could match actual reimbursements
for those inpatient recommendations.
So when we're making any kind of return on investment
calculation, it's an actual return on investment, giving you a
clear picture of what was actually paid and what the
value is of utilizing OPUS for second level review and
denial support.
But it's not just that, it's not just OPUS focus.
It also gives you a holistic evaluation of many key
metrics that are closely tied to utilization review.
We have specific tabs for observation rates and short stay
inpatient rates, ER performance in addition to denials and overturns.
And the back half of the presentation includes information on
cases referred to OPUS, of course, but also information on
all.
Cases build and paid in that specific time period.
You know another thing that it can do is show
you discordance.
So where maybe we reviewed a case as inpatient, but
the bill went out as observation or if you know
vice versa, we recommended observation and the bill went out
as an inpatient.
There can be benign reasons for both, of course, but
it's also something if the numbers high of recommendations for
inpatient yet the bill that you send out is observation,
you know, that could raise questions about are there some
holes in the process here?
But let me show you a few screenshots of what
it looks like just to give just to give a
little bit of a visual of, of what this can
do.
So this is the, the payer analysis.
And you could see the payer categories on the left.
Manage Medicaid, for instance, is the top one.
Managed Medicare is second from the bottom.
If this wasn't made anonymous, next to these would be
the specific payer of that account.
So it would be, you know, United Healthcare, Manage Medicaid
and Humana Commercial and you would know specifically and precisely
which parent payer we're speaking about that.
On the left you see the number of cases total,
let's just focus actually on the top line for simplicity,
9875 total cases.
Of those, you could see the number that were billed
and paid as an inpatient, the number that were billed
and paid as observation.
All the way over to the right you can see
the observation rate.
This is just a simple calculation of the 4236 /
9875 giving you an observation rate for that top payer
of 42.9%.
But I think the key is here that we know
not all inpatients are reimbursed the same, right?
Not all observation patients are reimbursed the same.
So what we try to do is compare like hospitalization.
So we take relatively short stay inpatients, 2 day inpatients.
So out of these 5630911100 in this top line were
shorter stay inpatients and compare it to moderate length observation
patients 3369.
We do this to get an idea of the average
inpatient payment for those shorter stay inpatients which for this
managed Medicaid payer is $11,070 and this is what was
actually paid in this time period.
And we compare it to the average moderate length observation
of 3384.
This yields a payment differential or a delta between these
similar type cases of nearly 8 thousand $8000.
Now the the key here is that on the upper
right you can see observation rate.
You can't see that I've selected 34%, but we can
titrate a target observation rate to whatever we so choose
here.
I chose 34% here.
And what this tells you under opportunity is that if
we're just able to bend this observation rate for this
specific managed Medicaid payer for the specific dates here over
these two year period ending in November of 2024, given
the delta between inpatient observation payments, there's a potential opportunity
for this specific healthcare system of nearly $7,000,000 in increased
reimbursements.
And what it would tell me is that that would
be a payer that I would very pretty much want
to focus on for second level review.
I would be saying we should drive referrals of those
patients to us to see if there's any ability for
us to see if there's inpatient medical necessity on those
cases, because each one that would be missed is actually
a pretty big delta between the observation payment and the
inpatient payment.
But you know, more than that, we also have an
ability to evaluate your overall observation rate trends, which I
know it's, it seems similar to what Brian was going
over just now on the Tapper.
But again, the Tapper is only for traditional Medicare.
Now we're seeing all the payers because we again have
access to your claims and remittance files.
This slide can give you a sense of where you're
seeing a lot of observation cases and the bottom right
also can tell you how many you're referring to us
for second level review and how many were recommending inpatient
on.
Much like everything in a clinical trends analysis, this is
static what we're looking at here, but in the actual
presentation for you, I can click on whatever you would
like.
If you wanted to focus on specific payer buckets for
example, you know maybe commercial and you know, etcetera.
And we could see how the observation rates change for
the different payers.
We could see what clinical categories they're most commonly, you
know that the clinic people categories that most often have
observation cases to a cardiology frequently is leading the way
as it is here.
But anyway, there's a lot of insight that can be
cleaned to where your observation rates are high and also
how many percentage wise are you sending per second level
review, which again can indicate if you see high observation
rates, you know, and you're sending very few to second
level review.
Sometimes that can indicate an area where you might want
to consider sending more cases.
But whenever we talk about observation, like Brian was saying,
I agree with the notion that the you know, the
original to midnight rule and now more recently the 42
O one with Medicare Advantage.
You know, the main rationale for that before that for
the rule to be in place was to largely decrease
or eliminate long stay observation.
And if we take that as a truism, I would
say, well, this hospital here has a very high proportion
of observation patients remaining in observation for greater than two
midnights, nearly half of them.
Now will some of them have social reasons to making
them not appropriate to change to inpatient?
Of course, you know, but are there some in that
nearly half of observation pay patients who are remaining in
observation for that length of time, was there medical necessity
to change them to inpatient?
Here I've highlighted Medicare, but again, just to highlight to
you, I could focus as well on any payer bucket,
although usually when I'm looking at this, I do focus
on Medicare and manage Medicare specifically because is there are
rules of the road to follow there.
And the last slide here is, you know, this is
where most hospitalizations start the ER and you know, this
also can give some insight if you have a higher
observation rate than you might anticipate.
One of the questions would be are you putting proportionally
more patients from the ER into observation than similar hospitals
to yourself?
It could give you insight as as to where to
intervene on elevated observation rates.
So anyhow, I will move on here.
And I think our last report we just wanted to
quickly touch on today is our new client scorecard.
And we're pretty excited about this largely because it just
gives you a 1 page, you know, snapshot of your
utilization of OPUS and our performance.
And Brian, I'm going to let you handle this one
because I know that you had more than a hand
in this group of reports creation.
Would you mind just taking a couple minutes here quickly
to review some of the high points?
Of course show the screen here.
So as Rob said, this is our scorecard, this is
the concurrent slide and it's basically the scorecard is A2
page high level review of client hospital performance on cases
that Optum has reviewed for them.
So this first page shown here focuses on what we
call concurrent cases, which the patient is still in the
hospital and the payer has not yet seen the case.
We review these cases with the goal of getting admission
status correct as soon as possible in the patient's day,
whether that be inpatient or outpatient observation.
So the top left of this slide shows case referral
volume data for all of the concurrent products we offer
to hospitals.
And as you move to the top right of the
side, we show average turn around time data for our
case reviews as well as average percentage of cases which
are complete or what we call clean when they are
referred to us.
And the remainder of the page of page one of
the scorecard shows a breakdown of case recommendation results, return
on investment and payer segmentation data.
So this is page two of the scorecard.
It's the scorecard denial slide and the second page focuses
on denials including both concurrent denials known as peer to
peers as well as retrospective written denials.
The second page specifically focuses on denial volumes, turn around
time, overall overturn rates by product as well as by
individual payer.
So we wanted to end up here.
If you are interested in receiving any one of these
analysis, there's a form on the ON 24 console if
you want to request the Tapper which we went over
earlier on or the clinical trends analysis that Rob went
over or both.