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?

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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 optimum 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 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 very 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, Mac 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 Optimum 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, behaviors 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 impatient. There can be benign reasons for both of course, but it's also something if the numbers high of recommendations for inpatient get 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 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, for 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 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 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 slide, 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.

Let's move on to Q&A here. All right, I see a few questions here, a question about critical access hospitals and and the Tapper. This is one thing we have not it's a great question now that we have not recreated at this point. I know that there were Peppers specific for critical access hospitals, you know, preview when the pepper was being delivered. I am sure that when pepper does come around to it to being there again, they they certainly will be available. But for right now Tapper specifically is for short term acute care hospitals and you know, and I don't foresee that changing in the near future.

And another question also to define CCS and MCS, I think you know from your, your presentation, Brian, on the Tapper and the focus on CCS and MCS, you know there are some diagnosis only mapped to a single DRG, we call them singlets, right? Like a syncope and collapse, for instance. You know, some diagnosis can map to multiple DRGS, either the base DRG or a DRG with ACC or a DRG with ACC with an MCC attached. And they're almost 15,000 diagnosis that are susceptible to ACC and these are complications and comorbid you know like think stage 4 kidney disease or chronic diastolic CHF or or primary pulmonary hypertension.

These would be commonly used CC's and they increase the weighting obviously of the DRG. There are there are fewer diagnosis that are MCC's. You know that MCC's major complications comorbidities, acute kidney injury with with ATN or or DKA or more are significant and these are paid obviously at an even higher augmented DRG waiting than this than the Dr. GS with ACC attached. And I hope that helps. And right, I see a few questions on here about about timing, how long does it take? I'm going to combine a few of the questions here because they're somewhat, you know, they're somewhat similar, but timing of from the time you request a Tapper, let's say, you know, you sign an NDA, how long does it take from that point to receiving the Tapper?

And the truth is because we don't require you to push anything to us, we can nearly create it on demand. So typically you would think within a week or two, depending on, you know, our mutual schedules, we'd be happy to, to review it with you, the clinical trends because there are a few questions on that as well. That takes a little bit more kind of because of the IT lift that I pointed to at the beginning. It does require interfacing, you know, and it does require some, you know, some, you know, you're getting IT people to speak to our IT people to make sure there's a strong connection that we're able to get the data cleanly over.

That can take a little bit longer, more on the horizon, let's say of four to six to maybe 8 weeks or so. So I hope that kind of clears that up as well. Any other questions out there? Well, I don't see any other questions for now. I can turn it back over to you. It looks like we have all the questions for today. I want to thank you, Doctor Wozniak and Dr. Rudik for sharing your insight and expertise with us. I'd also like to thank you, our audience, for sharing your valuable time.

We know that you're all busy and we appreciate your attendance. As you leave the webinar today, we would again like to remind you of the complimentary related resources for today's session. Those are located at the top right of the webinar console in the contact us form, which you can use to request that outreach from an opt in value advisor, which is also located at the top right corner of the webinar console. We did get some questions about whether the webinar would be available for replay, some questions about the slides. We will have an on demand version of this webinar that will come out in approximately 24 hours.

So check your e-mail, it will come to your e-mail. It will be the same link that you used to enter today's webcast, but it will be the on demand version. So thank you again so much for joining us and have a great rest of your day.