As part of its validation, Accordant commits to having its contract language meet the industry’s most valid measurement of outcomes, changes in event rates over time across the population, adjusted using a dummy year analysis. While in population health there can always be confounding variables such as new drugs and/or small sample sizes and/or unobservable variables and/or secular trends, there are no qualifications to the statement that there is no more valid pre-post measurement commonly used in the field today.

Click here for the Accordant template used to achieve their validation, which Accordant is graciously making publicly available in the hopes that other vendors will follow their lead. Note also in the link that their asterisk highlights other possibilities for error.

Accordant Template Used

Alana Healthcare focuses on chronic disease management, with the goal of improving patient quality of life and reducing need for hospital care. Alana’s intervention for Congestive Heart Failure and Chronic Obstructive Pulmonary Disease reduced PMPM hospital costs significantly more for its participants than a comparison group who had no intervention. The comparison group was matched for disease acuity, risk score, age, and prior year’s spending.

Allergychoices offers sublingual immunotherapy (SLIT) for allergy sufferers. Results from five research studies conducted at Allergy Associates of Lacrosse found that the number of physician visits, ER visits, hospitalizations, and absences from school/work all had significant decreases after two years of treatment. They also offered a validated quality of life measurement that showed statistically significant improvement in six of the seven domains measured after four months of treatment.

**Winner of the 2019 Health Value Award for Program Provider – Specialty Obstetrics**

AABC is based on best maternity care evidence. Comprehensive prenatal care is provided in a relaxed, respectful environment of informed, shared decision making. Birth centers lead to cost savings from better prepared mothers and families, reduced risk of preterm birth, and reduction of cesareans.

**Winner of the 2019 Health Value Award for Commercial Insurers**

Enhanced Personal Health Care (EPHC) is Anthem’s largest value-based care model that rewards doctors for delivering results — such as improved care coordination, reduced use of unnecessary medical services, better management of chronic diseases and lower costs — instead of the volume of services they perform. EPHC providers receive specialized support, enhanced data, resources and incentives that enable them to change the way they practice health care.

Since the launch of the program in 2012, Anthem has made tremendous progress in shifting payments to value-based care models. Since its beginnings, EPHC participation has grown to more than 87,000 (in aggregate) providers who care for more than 6.8 million Commercial members.

**Winner of the 2019 Health Value Award for Third Party Administrator**

Apostrophe ‘s Intelligent Health Benefits Platform departs from the traditional health insurance business model, delivering benefits for self-funded employers with unprecedented savings and market-leading member experience while saving companies and employees 20% or more from Year One. Apostrophe is driven by simplicity, transparency, and evolving beyond what a TPA can deliver.

Aravind Eye Care System aims to eliminate needless blindness by implementing a primary eye care model called Vision Centers. A technician provides the clinical services and is supported by electronic medical records and teleconsultation with an ophthalmologist. Aravind provided 4.1 million free or subsidized outpatient eye examinations, surgeries, and prescription eye-wear to marginalized populations. Aravind demonstrated a significant reduction in infection rates following cataract surgeries, by implementing a prevention technique.

**Winner of the 2019 Health Value Award for Program Provider – Specialty Fertility**

Using data from the Society for Assisted Reproductive Technology (SART) as a benchmark, ARC demonstrated that its patients have fewer multiple births, thereby increasing the number of healthy babies and decreasing the cost.

ARC compared the number of cycles of treatment and percentage of resultant twin births reported to the SART by all clinics nationally with those reported by clinics within ARC’s  Network. ARC examined data over a three-year time frame. The Arc Network’s cycles consistently resulted in fewer births to twins over three years. Further, the ARC member multiple birth rate as a proportion of all births declined 3% from 2014 to 2015 and a further 2.5% from 2015 to 2016, an overall decline of 5.5%. As a network, ARC Members have reduced multiple births by 5%, which is also ½% to 1% better than the national average.

Arche Healthcare is a medical device and healthcare service company addressing diabetic foot care, and the $30 billion cost of diabetes-related wounds and amputations. In an increasingly outcomes driven healthcare environment, Arche’s proprietary IT platforms offer healthcare providers, health plans and other healthcare stakeholders, seamless and compliant healthcare delivery tools to help prevent the 1st wound.

The model, informed by the latest evidenced-based research on diabetic foot health, demonstrates the results of a comprehensive Lower Extremity Amputation Prevention (LEAP) initiative and the clinical and economic impact that early risk identification and stratification can have on a diabetes population.

As is the case with “financial spreadsheet validation” according to the rules of the Validation Institute, users may change assumptions in order to model different impacts on prospective results.

Blue Cross and Blue Shield of Louisiana offers Office of Group Benefits members a comprehensive population health management program. This program combines case management, disease management and utilization management efforts with the Quality Blue family of value-based reimbursement and provider engagement programs, most notably Quality Blue Primary Care (patient-centered medical home model) and Quality Blue Value Partnerships (Accountable Care Organization model).  As of the end of 2014, there were 34,599 OGB members who were part of Quality Blue Primary Care.

Using this integrated population health approach, Blue Cross and Blue Shield of Louisiana achieved a chronic disease event rate for Office of Group Benefits members that is significantly below both the Southern regional average and the state government average.

Blue Cross is the only health plan operating in Louisiana that has achieved event rates this favorable, measured validly. Because they reflect both cost and health status, event rates are the most important outcome both for OGB as well as for its employees.

Blue Cross of Rhode Island developed perhaps the most valid and detailed analysis of their comprehensive patient-centered complex case management program ever done at a health plan. It is especially challenging because the cases are moving targets, claims decline following an inpatient stay anyway due to regression to the mean, and all eligible members are contacted, leaving none for the control group. BCBSRI was able to overcome these obstacles, and achieve validation, by putting members in 4 categories

1. Triaged out – these patients should improve on their own
2. Engaged—these are the ones who case managers managed
3. Declined—these are the members who decided their situation was under control
4. Tried to reach—these members probably needed the help but couldn’t be found.

In order, the cost improvements should match the categories, with “triaged out” having the greatest decline and “tried to reach” the smallest over an equivalent period.

Specifically the results were as follows, with cost improvement on the left axis. The cost decline in “triaged out” approached 40% while “tried to reach” declined much less than 10%. This result matched the hypothesis and lends great credibility to the claim that engaged members’ cost improvements were attributable to the program.

In the News

BlueCross BlueShield of South Carolina offers large employer groups a comprehensive population health management program. This program combines case management, utilization management, disease management, wellness efforts, patient centered medical homes and value based incentives. At the end of 2015, there were approximately 379,000 members eligible to participate in some aspect of population health management.
Using this integrated approach to population health, BlueCross BlueShield of South Carolina achieved a chronic disease event rate for the large employer group that is below the National average and the State Government average.

BlueCross is the only health plan operating in South Carolina that has achieved event rates this favorable, measured validly. Because they reflect cost and health status, event rates are the most important outcomes for both the large employer as well as for its employees.

Further, in 2017, they validated all their major lines of business for 2016, making BlueCross of South Carolina the most carefully vetted health plan by the Validation Institute, with the most favorable validly measured outcomes, in the Southeast.

Bonati-trained surgeons in a Joint Commission approved surgery center conduct targeted spine procedures. Randomly selected patients self-reported their pain level at 30 days, 90 days, and six months after surgery; between 93 and 97 percent were pain free. This compares favorably with similar surveys of patients receiving traditional back surgery.

**Winner of the 2019 Health Value Award for Program Provider – Specialty Destination Center of Excellence (U.S.)**

Edison Healthcare is the first and, so far, only company in the United States who provides a network of both domestic and international Smart Care Medical Centers which serves patients with the utmost standard of quality medical care. The Edison Healthcare ROI Estimator tool gives potential clients a user-friendly, valid and transparent resource to determine their potential savings. Edison Healthcare uses a set of transparent, credible and fully-sourced assumptions in its tool to estimate the number of plan members that will be impacted and the associated net claim savings, program fees and expenses.

In doing so, Edison Healthcare achieves the three goals necessary for certification of its ROI Estimator tool: (1) The math is correct; (2) The calculations are transparent; (3) The assumptions, all linked to authoritative sources, may nonetheless be changed by a user who prefers different assumptions, or to use its own health plan claim experience. This facilitates sound purchasing decisions and implementation.

**Winner of the 2019 Health Value Award for Program Provider – Specialty Cardiometabolic**

The Epigenex Quality Blue Primary Care Program (QBPC) program gave primary care practices web-based patient-centric health information exchange tools, which identify and help to manage chronic conditions.  Patients who had hypertension, diabetes, high cholesterol, ischemic vascular disease, chronic kidney disease, and heart failure were the focus of the program.  Practices using QBPC had lower costs for hospital admissions among chronic disease patients, and lower overall costs when compared to matched practices not using QBPC.

**Winner of the 2019 Health Value Award for Program Provider – Value-Based Provider Care Facilitation**

In the Evolent Health Complex Care Program, patients are identified through predictive analytics for being at high risk for a future, avoidable hospitalization. These models leverage robust and diverse data sources including administrative, lab data and assessments, and social/behavioral data. Members are ranked by risk percentile and prioritized for outreach.

Evolent Health performed a dummy year analysis as required by Validation Institute for outcomes measurement involving high-cost or high-risk cohorts that are likely to show regression to the mean. The dummy year analysis matches the entire exposed and control populations, not just managed members, removing self-selection bias, which may otherwise contribute to better performance of managed patients as compared to unmanaged patients.

Individual outcomes measures between the exposed and control populations were plausible, showing cost avoidance in overall medical and pharmacy spend. Using our standard of validity that an outcome must be measured using the most valid type of measurement in current common use, Validation Institute is pleased to confer Financial Outcomes Validation for Evolent Health.

Evolent’s transition-of-care program showed significant savings using the Validation Institute’s preferred dummy year analysis methodology. The validity of the result is confirmed by its conformance with the specific rule of validity that the savings should appear in exactly the categories in which you would expect savings (readmissions and post-acute care), while costs increased, due to utilization increases, in the categories in which one would expect an increase, primary care and specialist visits. The actual figures cannot be shared because they are being prepared for peer-reviewed publication. Nonetheless Validation Institute can attest that Evolent’s programs met the standards for both savings and plausibility.

**Winner of the 2019 Health Value Award for Program Provider – Value-Based Provider Care Facilitation**

Patients are identified through predictive analytics for being at high risk for a future avoidable hospitalization – the primary focus of our program. These models leverage robust and diverse data sources, including administrative (i.e., medical and pharmacy claims), encounter (e.g., lab data, assessments) and social/behavioral (e.g., social determinants of health, consumer data) data. Generally, members are ranked by risk percentile and prioritized for outreach. Members can also be referred to the Complex Care program by their physician.

The Complex Care program emphasizes the use of clinical practice guidelines to prevent condition-related complications, improve overall health and support self-management. The program was developed based on Wagner’s Chronic Care Model and Lorig’s Chronic Disease Self-Management Program and focuses on addressing the needs of patients who have been diagnosed with more than one chronic disease – Chronic Obstructive Pulmonary Disease (COPD), Coronary Artery Disease (CAD), Diabetes, Congestive Heart Failure (CHF) and asthma.

Upon enrollment, participants complete a comprehensive assessment. Based on specific needs identified during the assessment, evidence-based clinical and social recommendations are automatically triggered in a workflow tool. This tool supports the streamlining of processes and ensures consistent delivery of interventions. In addition, intervention recommendations are routinely reviewed to ensure alignment with the best available scientific and evaluation evidence. In coordination with the patient and patient’s physician, nurse care advisors develop an individualized care plan that includes patient specific goals and activities. Patients graduate from the program once all identified issues/barriers are resolved.

Registered nurses utilize a real-time performance dashboard to monitor progress against key metrics and help identify patients who are due for follow-up. Aggregate performance scores are also reviewed monthly by clinical leadership to identify best practices and potential gaps. Development of the dashboard was informed by analyses of historical programmatic data that revealed specific program activities and characteristics associated with reduced inpatient admission. Using principal components analysis, we developed a summary patient-level score ranging from 0 to 100, based on the relative influence of each metric. This score reflects quality of engagement and was used to identify patients who received the intervention in an optimal manner.

**Winner of the 2019 Health Value Award for Program Provider – General**

freshbenies provides employer health plan members four different programs, designed to reduce use of medical services and/or reduce costs.  The Teladoc program gives members access to primary care, dermatology, and behavioral health visits by phone and video.  DoctorsOnline puts 24 different physician specialists accessible to plan members.  The Advocacy program gives members services to navigate medical care, negotiate bills, and coordinate care.  Last the Rx Savings program offers discounts on prescriptions.  Employers who offered the program saw a lower total cost per member per month, including members who did not use the freshbenies programs.

Group & Pension Administrators Inc. ‘Cost Plus’ program imposes reference-based pricing, which pays medical providers based on a schedule rather than based on the provider’s charges. GPA also has a navigator concierge service which directs members to appropriate care at the best facility for their condition. GPA showed its clients reduced their outlay for medical services, using its model.

Happy Whole Human provides an online program that assesses 28 different aspects of a balanced life. The program then supplies supports and coaching to improve areas that are in need of improvement. HWH validly and accurately measures participants’ change in perceived health status, turnover intention, and presenteeism.

BROADENED AND DEEPER ENGAGEMENT
Health Partners’ Health Advocacy approach enables the delivery of comprehensive disease and case management solutions to manage care, optimize health and generate cost savings.
Through innovative identification, stratification and engagement techniques, more members receive the support and services they need for successful condition management.
Member support and services improve engagement through:

• Member activation
• Condition literacy
• Care and treatment decisions
• Self-management skills

IMPROVED CLINICAL OUTCOMES
By aligning the intensity and type of support with a member’s needs, overall health and clinical outcomes are improved.

LOWER COST OF CARE
Improved clinical outcomes translate to reduced adverse events and associated costs.

Whereas most vendors want to compare motivated participants to non-participants, and/or measure the difference between the high-cost baseline and the study year, in order to benefit from regression to the mean, Healthsense will offer to compare to a validly measured control group, including a study design that controls for motivation, using a “dummy year analysis.”

Study Design

In the News

**Winner of the 2019 Health Value Award for Direct Care Provider – General Primary Care**

The Super Clinic model matches patients to appropriate care pathways – including self-care, conservative care – for musculoskeletal conditions.  The program works with primary care practices and their skills in managing and referring musculoskeletal patients.

IMC compared per member per year costs of the program’s musculoskeletal patients and a matched community cohort.  The cost data comes from the participating employers’ medical claims systems.

After risk adjustment, the average cost per program participant was 51.48% lower than the matched cohort average cost (p < .0279). The utilization of MRIs, injections, and surgeries was lower by 49.75%, 39.44%, 78.38%.

It Starts With Me Health endeavors to support overall employee health for clients and our employees/health plan members. We heartily endorse the Employee Health Vendor Code of Conduct, which states that any health and wellness programming should do no harm to employee health, employee morale, corporate integrity or employee/employer finances.

Employee Benefits and Harm Avoidance

It Starts With Me Health will recommend health & wellness efforts that are done “with and for” employees & health plan members, not “to” them.

Our focus will be on the promotion of personal well-being of employees, identification and/or avoidance of potentially negative health outcomes for employees/health plan members, analyzing data, and assistance in improving the financial stability of the health plans of our clients.

Our choices and frequencies of suggested health interventions, testing, and educational materials will be as generally consistent as possible with expert guidelines such as Harvard Medical School, the United States Preventive Services Task Force (USPSTF), the CDC, and Choosing Wisely (an initiative of the American Board of Internal Medicine). This is done in an effort to minimize over-programming, over-spending, overwhelming, over-screening, over-diagnosis, and over-treatment. As a specific example, we will discourage our clients from implementing universal financial incentives for annual checkups.

We will recommend to our clients that potential programs and services be evaluated to ensure that employees will not be singled out, fined, or embarrassed for any reason due to our health status.

Respect for Corporate Integrity and Employee Privacy

When analyzing our data or other client vendor data, we will provide unfiltered, unbiased, & unspun data, good or bad, so that our clients can make sound business decisions about their mix of services and vendors.

We will not share employee-identifiable health data with employers.

Commitment to Valid Outcomes Measurement

Our relevant staff will understand USPSTF guidelines, employee harm avoidance, wellness-sensitive medical event measurement, and outcomes analysis.

If clients wish to engage in health improvement programs internally or via other vendors, we will recommend that we include warnings of any adverse effects that participants might encounter (e.g. with the popular “Biggest Loser” competitions, the programs should be accompanied by warnings regarding potential unhealthy eating behaviors, weight-cycling, awareness of issues with other health conditions and/or medications, and poor long-term results that can result).

In addition, we will advise our clients that for true measurement of any type of cessation or reduction program (weight loss, tobacco, etc….), vendors should be required to provide aggregate reports that outline both immediate improvement and most importantly, the true measure of success – the continued maintenance of that improvement by each individual for at least 12 months.

Our contractual language and data reports will be valid. If we must measure outcomes using other than one of the valid techniques, we will disclose the invalidity (such as “healthy volunteer bias” or the “natural flow of risk” or ignoring dropouts) that is likely to cause savings to be overstated. If we use a participants-vs-non-participants methodology, we will disclose that in the three instances in which we were tested, we were shown to be invalid.

Kinesis offers two different possible commitments, depending on one’s starting position, that Validation Institute has deemed to be valid. Due to the rate of falls in the elderly population, the comparison would need to be over at least 50,000 senior-years in both the before and after populations before a conclusion can be drawn.

If you already have a falls intervention and have been tracking falls using an objective indicator such as ICD9s, Kinesis commits to a reduction in the rate/1000 of falls, if the QTUG assessment is substituted for the current assessment and the total spent on post-assessment intervention is not reduced. (This assumes no significant change in average age or percentage of members over 80. However, changes in these variables can be adjusted for.)

Alternatively, if you do not already have a post-assessment falls intervention, Kinesis proposes that your senior population be split. Key demographics and history to be roughly equalized for this commitment are: average age, percentage over 80, gender (overall and in the percentage over 80), and history of falls. (Long-term care residents get excluded or can be included if indeed you have the opportunity to implement your own falls assessment in those settings.) If indeed you spend equal amounts of money/1000 on both groups prospectively on falls assessment and subsequent prevention for individuals deemed to be at risk of falls, Kinesis commits to a relatively lower fall rate in the Kinesis group than in the other group.

**Winner of the 2019 Health Value Award for Value Transparency Services**

Using a set of transparent and fully sourced assumptions and calculations, an employer may estimate the “HIdden Surcharge” caused by medical errors in its population. The Leapfrog Group invited DMPC to participate in the development of this model in order to help ensure this level of validity at the end of the process. They used the best available evidence and a rigorous process to build the Hidden Surcharge calculator, achieving the three goals necessary for certification of their model and financial spreadsheet validation: (1) The math is correct; (2) The calculations are transparent; (3) The assumptions, all linked to authoritative sources, may nonetheless be changed by a user who prefers different assumptions. In sharp contrast to other savings models in which none of those factors are present, Leapfrog’s model incorporates those three attributes. For more details, click on this link http://www.leapfroggroup.org/employers-purchasers/lives-dollars-lost-calculator#

With a focus on comprehensive patient health as well as an emphasis on provider education, communication and cooperation, while eliminating the distance between its patients and their physicians through community healthcare centers, MCCI Medical Group has been able to dramatically reduce heart events and outperform national heart event rate averages in the adversely selected Corpus Christi and San Antonio markets.

MedEncentive’s preferred contractual methodology for testing and reporting on the efficacy of its program to control healthcare costs adheres to  Validation Institute-endorsed rules of plausibility in study design covered in Why Nobody Believes the Numbers.

First, we match whole groups of covered (intervention) and non-covered (control) people (subjects) in randomized control trials (RCT), rather than participants vs. non-participants in the intervention group. In other words, within the intervention group, we seek to recruit participants, but we measure the entire intervention group, including non-participants, against the entire control group, consistent.

Second, we apply widely recognized experimental methodologies that are designed to isolate the impact of our program by controlling for or matching on factors such as demographics, health status, and other known variables.

Third, we are committed to demonstrating that claims of cost savings attributable to our program can be shown to be as a result of the program’s features – such as information therapy to promote health literacy – and their association with expected outcomes in areas such as hospitalizations, ER usage, office visits, medication adherence, etc.

Fourth, we actively seek and are committed to public sector, open access studies, including RCTs, that are designed, evaluated, and/or peer reviewed by qualified and independent experts in the field of population health and related disciples, such that the outcomes of these studies can be authenticated and certified according to the Validation Institute rules.

In addition to the contractual language itself, we plausibility-check to ensure compliance with the “Every Metric Can’t Improve Rule” (meaning certain utilization categories, like physician office visits and drug use, should increase in order to plausibly claim that a reduction in avoidable hospitalizations was caused by taking steps to avoid those hospitalizations), and the “Quality Dose-Cost Response Rule” (meaning that, for example, a reduction in avoidable hospitalizations can be associated with a corresponding level of participation by doctors and patients in the program that is logical).

Further, MedEncentive will write into every contract its commitment to the Employee Health Program Code of Conduct, as a key contractual term.

**Winner of the 2019 Health Value Award for Behavioral Health**

MindSciences offers three apps, each of which addresses a major health issue: smoking, eating, and stress/anxiety. The users were randomized to either Mindfulness Training or the Freedom From Smoking. The random assignment of users ensures that any traits that might influence the results were (ideally) equally distributed in both groups. MindSciences had a significantly higher abstinence rate at 17 weeks. The difference in the 17-week abstinence rate is reasonably credited to Mindfulness app’s superior performance and not to other factors (such as user selection bias).

NationsHearing has demonstrated that people with untreated hearing loss have higher risk of falls, and that treating hearing loss would, based upon peer-reviewed research, correlate to lower frequency of hospital care for falls.  Using credible data on the frequency and cost of fall-related hospital stays, the calculator gives users a reasonable estimate of the program’s impact on a Medicare Advantage population.  The Institute validates that the calculator is valid.  The Institute makes no warranties that the program will have the impact estimated by the calculator.

Nova Healthcare Administrators has developed an approach that applies data about the employer, the benefit plan, and medical claims to find opportunities for lowering cost and improving health.  Nova then follows through with customized interventions and programs that directly address the opportunity areas.

On the measure of Per Member Per Year medical costs, excluding pharmacy and Emergency Room visits per 1,000 member months, Nova demonstrated performance superior to Milliman Medical Index (MMI).

Nuspine offers an online back pain management program. Validation Institute assisted with selection, development and implementation of three measures: correlation of days’ participation in Nuspine and improvement in StarT Back scores; comparability of Nuspine results to usual care; and cost-effectiveness of Nuspine compared to usual care.

Validation Institute reviewed Predilytics’ Analytic Design Plan (ADP) for a health plan, which outlined:

· the objectives of the Medication Adherence project,
· the method for achieving those objectives, and
· the statistical and quantitative metrics that are used to document model validation.

Validation Institute reviewed Predilytics’ program evaluation which described how the models were used in a health plan’s operational call center to improve medication adherence for their members.

Predilytics’ evaluation of the predictive models and the operational recommendations reflect a well-grounded understanding of how predictive models perform and accurate assessment of the value of the insights created by these models to inform resource deployment within healthcare operations.

Within that program evaluation, Predilytics used additional statistical analysis to isolate the incremental performance of the predictive model above and beyond call center efficiency gains. Overstatement of attribution is commonplace in predictive modeling in population health, but the model was very carefully designed not to overstate attribution of the Predilytics’ intervention to the outcomes. The one aspect of this study in which overstatement might have been taking place is that the customer service representatives making the outbound calls got better at calling members over the course of the study. As a result, calls towards the end of the period were more successful. Predilytics pointed out this potential confounder to the validator and estimated the impact of it, rather than wait for the validator to point this out to them.

Consequently, the Validation Institute is able to provide validation for Predilytics, as they are well above the standard of using a methodology that is equivalent to or better than the most valid standard commonly used in their segment of the industry.

Presbyterian Healthcare Services has implemented an employer-specific care model that resulted in keeping a large local employer’s wellness sensitive medical event rate far below national benchmarks, as the graph below depicts. Additionally, PHS meets or exceeds MCG Well Managed for this group on 320 of 341 Inpatient DRGs.

Procter & Gamble combines disease management, wellness and benefits design to encourage compliance to significantly reduce avoidable medical events over a multiyear period.

Providence has dramatically reduced chronic disease event rates through a combination of disease management, gap-in-care programs and engagement with providers to understand variations in care. Providence also displays individual physician performance in managing chronic conditions on their provider directory, to inform and assist members when choosing a primary care physician (PCP).

PSC Technology Incorporated (d.b.a., PSC Healthcare) Guarantee

With 23,000 or more covered person-years (this means that at least that many people for one year, or, for example, a quarter that many people for four years) and 25% of employees and dependents over age 45, PSC Healthcare will reduce the inpatient and ER incidence for the full list of AHRQ preventable medical events plus common complications of diabetes starting in Year 3.

We are willing to adjust the ICD9 benchmark, at the request of the Client, by the change, up or down, in these ICD9s using HCUP inpatient utilization trend data for the state(s) where the customer is primarily located.

This guarantee exemplifies valid metric measurement. PSC Healthcare is focusing only on the diagnosis codes that the Agency for Health Research and Quality says can be addressed.  PSC Healthcare is measuring events across the population (thus avoiding participant bias, a common and well-understood invalidator), and emphasizes ER and inpatient event avoidance. Furthermore, PSC Healthcare includes the secular event rate trend into the event rate tally to avoid taking credit for reductions (such as in heart events) that would have, statistically speaking, taken place anyway.

A reduction in utilization of (defined) high-cost resources has been consistently demonstrated, on the total population, thus avoiding the common fallacies of the volunteer effect and regression to the mean. Further, the supporting materials show that the overall cost reduction is driven by utilization reductions in the categories of utilization in which one would expect declines, creating a “nexus” between the intervention and the outcome.

The following validation is a review of the guarantees offered by Quizzify to its customers.  These guarantees are fully disclosed on the Quizzify website, which is the sole source for the data reviewed.

The focus of validation review was on whether the Quizzify guarantees apply clear and valid measures.  Two guarantees met the standards for validation: cost and utilization; and engagement.  (Note: Quizzify may offer other guarantees which have not been validated.)

Cost and Utilization

Text of the cost and utilization guarantee Part I:

If the client splits its population, Quizzify guarantees that the medical and wellness program costs per person will trend more favorably in the Quizzify cohort than the conventional wellness cohort.  Under the guarantee, expenses for catastrophic or outlier events are excluded.  Thus, costs for a single person that exceed $50,000 (or some other amount) would be excluded; the first $50,000 would, however, be included.  An “outlier cutoff” figure will be agreed upon ahead of time by Quizzify and the client and will apply to the before and after assessments of both groups.

This guarantee is valid assuming that the two cohorts are similar except for their exposure to wellness or Quizzify programs.  By using a per person measure, the guarantee ensures that population changes do not distort results.  This is a valid and consistent method for ensuring that extraordinary expenses do not skew the results.

Text of the cost and utilization guarantee Part II:

If the client does NOT split the population in half but rather offers Quizzify as the lead program, Quizzify guarantees a reduction (vs. history) in the following two categories:

1. Wellness-sensitive medical event rates, as defined by Gowrisankaran et al. (Health Affairs March 2013, Vol. 32, No. 3 pp. 477 – 485)

2. A grouping of any 50 items of utilization that are proposed by the client as being overused in their population, such as CT scans. These items will have to be identifiable through simple diagnosis, procedure or drug codes, to facilitate reconciliation. Measures will be done per capita and will not use diagnosed patients as a denominator.

This form of the guarantee is also valid, as it cites a source for defining wellness-sensitive medical event rates.  It applies a rate to the measure.  Allowing the client to define overused procedures is also valid, limiting it to procedures that can be identified using the available data sources.  Further, the guarantee specifies that diagnosed patients will not be used as a denominator for calculating rates; rather, all rates will be calculated per capita.

Engagement

Text for engagement guarantee:

Companies measure engagement different ways. No matter what way is used, Quizzify guarantees that the non-engaged population will decline by half, up to 10% in total. Example: if the client has a 90% engagement rate, Quizzify will increase that to 95%.  If the client has a 20% engagement rate, Quizzify will increase that to 60%.  The requirements for this guarantee are:

1. The client must measure the same way (survey instrument and communication channel) in both periods and both populations, over the same time intervals and

2. The client must maintain the same incentives or penalties during the time period.

This guarantee is valid and enforceable, even if the survey instrument used has not been validated.  Using the same instrument at the same time interval for both groups ensures that results are based upon an underlying consistency.

Disclaimers of Review

This review was limited to the descriptions of the guarantees published on Quizzify’s website.  This review also relied upon the website’s statement that the ROI reporting applies valid measurement tools; a review of the ROI report was not undertaken.

Summary

Quizzify delivers wellness education to employees in unique, entertaining, and effective quizzes.  Quizzify guarantees that participants will have lower medical costs and higher engagement levels than participants in traditional wellness programs.  These guarantees apply valid measures, giving clients a clear and objective method to assess performance.

Redirect Health self-funded healthcare plan provides free healthcare for employees and their families. This plan includes various care and cost management tools, such as 24/7 access to care, in-person visits with no copay, managing specialist and hospital care, transparent and fair prices, patient assistance. An internal team guides care for all employees ensuring they receive the highest quality care, fair price, and most efficient way to pay for care. Redirect Health has shown lower medical costs for businesses and employees compared to organizations of similar size, region, and industry.

**Winner of the 2019 Health Value Award for Direct Care Provider – Specialty Musculoskeletal**

Reflexion provides a Virtual Exercise Rehabilitation Assistant for patients who have had total knee arthroplasty, as a substitute for in-person physical therapy.

In a randomized clinical trial, Reflexion measured post hospital 12-week billable services including MD clinic visits, urgent care, emergency room, inpatient rehabilitation, skilled nursing facility home health visits, outpatient physical therapy visits, calls/e-mails to physical therapy, and rehospitalizations.  In addition, the applicant measured Knee Injury and Osteoarthritis Outcome Score (KOOS) at six and 12 weeks, knee extension, knee flexion, and 10-meter gait speed. Finally, falls, pain, and rehospitalizations were measured.

All measures taken at the prescribed time points, and all patients tracked in their original assigned group even if they later changed groups (intent-to-treat).

Reflexion demonstrated results comparable to physical therapy, and for lower cost than conventional care.

Regenexx provides stem cell treatment for orthopedic conditions, ranging from carpal tunnel syndrome to joint injury. The Regenexx treatment is non-invasive, and is significantly lower cost than traditional surgical care. The calculator estimates savings that an employer could realize by offering Regenexx treatment to its health insurance plan members. 

Remedy Analytics analyzes data that contains up to 600 data fields per claim of an employer’s raw prescription claims data. The data is disseminated in order to determine the proper adjudication of every claim for comparison to the actual adjudication and calculation imposed by the PBM. Remedy technology uncovers the adjudication and calculations methods that cause the actual discounts to be artificially inflated. The pricing, adjudication and calculation model created by the PBM is often misaligned with employer expectations created in the contract. Collecting, dissecting and warehousing every claim provides a check-and-balance on PBM reporting.

In particular, the two examples below are validated as ways in which improper discounts can be adjusted using Remedy:

1. PBMs often misclassify sole-source and patent-litigation generics (which typically carry far lower discounts than established generics) as brand-name drugs. This misclassification also causes the brand-name discounts to appear larger than they are.
2. PBMs often capture automatic discounts from retail pharmacies without assistance from a PBM.

Predict & Prevent Primary Claims
“The Coaching Choice”

1. Splashlight’s predictive analytics will accurately identify and stratify the high risk and rising risk individuals using three years of historical health claims and workers’ compensation claims. They use the first two years of data to build the model and the third year to prove validity. While many vendors promise a reduction in cost of the highest-cost or highest-risk segment, they recognize that this cohort regresses to the mean, and a demonstration of effectiveness requires showing savings after making a “dummy year adjustment” to account for that regression effect. Splashlight will contract to show savings validly, taking that adjustment into account.

2. Prior to beginning their Prevent services, Splashlight provides a benchmark of predicted future medical costs for health claims and workers’ compensation medical claims. Using their validated predictive analytics methodology they then adjust for those ICD10 codes that are mutually agreed with their clients to be impactable through their prevention services. They will apply measures that are attributable to The Coaching Choice solutions which they expect to result in a reduction of overall costs by at least 5%.

3. Splashlight’s contractual language and outcomes reporting will be transparent and plausible. All research limitations (e.g., “participants vs. non-participants” or the “natural flow of risk” or ignoring dropouts) and methodology will be fully disclosed, sourced, and readily available.

4. Splashlight will measure the actual savings realized each quarter and annually and adjust their savings totals accordingly to show the total costs and savings for the client. Further they will guarantee in their contracts that their costs will not exceed more than 40% of the actual savings achieved over a three year period. If the actual annual savings have not exceeded annual costs after a six month period to adjust for delays in claims received, then Splashlight will continue to provide services at no charge for up to an additional year or until the actual savings are realized through validated measures.

5. The participant experience will be tracked for all participants with the following expectations:
80 percent of the identified population will participate in The Coaching Choice program.
80 percent of participants in The Coaching Choice program will report their willingness to recommend the program to others.
80 percent of participants in The Coaching Choice program will report their improved confidence in their ability to manage their healthcare.
80 percent of the participants in The Coaching Choice program will report that it improved their quality of life.
80 percent of the participants in The Coaching Choice Program will report positive personal experience as a result of participation.

Surgery Center of Oklahoma (SCO) offers patients a price list for surgeries, allowing them to price compare. In addition, SCO makes its quality in indicators transparent and available. SCO’s infection rate, compared to that of typical ambulatory surgical centers performing similar surgeries, is much lower; it reported a zero infection rate in 2018.

Sustainable Health Index assesses a person’s current health risk in five domains, and then provides support customized to the risk level. The program goal is to interrupt the natural flow of risk (e.g. moderate to high); similar programs have been shown successful. The Validation Institute validated SHI’s methods for measuring health status, health activation, as well as their method for estimating costs. The majority of the survey questions are from validated instruments; and SHI uses validated scoring methods. SHI then applies the health status/ risk measurement to costs estimated using credible data sources and methods.

The Phia Group achieved improved outcomes by identifying preferred hospitals for child birth, and then providing mothers a creative incentive to go to the preferred hospital. After selecting hospitals based upon their outcomes, the Phia Group notifies members of the preferred hospitals; members who have their babies at preferred hospitals get $300 per month for the child’s first year, which helps to defray the cost of diapers and other supplies. The program saved money in as short as one year.

**Winner of the 2019 Health Value Award for Healthcare Analytics Platform**

The Zero Card informs plan members about health care providers who have a bundled price for services. Compared to average PPO costs, the Zero Card bundled prices are significantly lower even after paying administrative fees and waiving the member’s deductible or co-pay.

**Winner of the 2019 Health Value Award for Program Provider – Specialty Wellness**

US Preventive Medicine (USPM), a vendor of wellness/prevention services, has achieved the greatest reduction in health risk factors of any validly measured wellness program ever published. In fact, USPM has been previously recognized by Validation Institute as the first and only wellness company to measure validly, achieve significant hospital and ER visit reduction when measured validly, and offer valid contractual metrics.

**Winner of the 2019 Health Value Award for Program Provider – Care Navigation**

PredictiMed™ Guarantee

With 23,000 or more covered person-years (meaning at least that many people for one year or, for example, a quarter that many people for four years) and 25% of employees and dependents over age 45, we will reduce the inpatient and ER incidence for the full list of AHRQ preventable medical events plus common complications of diabetes starting in Year 3.

If the customer would like to, we can adjust the ICD9 benchmark by the change, up or down, in these ICD9s using HCUP inpatient utilization trend data for the state(s) where the customer is primarily located.

This guarantee exemplifies valid metric measurement. US Health Center’s Predictimed is focusing only on the diagnosis codes that the Agency for Health Research and Quality says can be addressed, is measuring events across the population (thus avoiding participant bias, a common and well-understood invalidator), and emphasizes ER and inpatient event avoidance. Further, Predictimed incorporates the secular event rate trend into the event rate tally to avoid taking credit for reductions (such as in heart events) that would have, statistically speaking, taken place anyway.

US Preventive Medicine (USPM) is the first and as of now only wellness company to achieve a sustained and significant reduction in wellness-sensitive medical events (asthma, cardiac events, COPD, congestive heart failure and diabetes) across that portion of its entire book of business for which comprehensive claims data was available (see chart below). The reduction achieved by USPM significantly outpaced the much smaller national decline in these events, as evidenced by both the database maintained by the Disease Management Purchasing Consortium (through 2014) and the federal Healthcare Cost and Utilization Project (HCUP) database (through 2013). USPM is further the only wellness company willing to contractually commit to being measured on this metric in future contracts. This makes USPM the only wellness company to measure validly, achieve significant event reduction when measured validly, and offer valid contractual metrics.

**Winner of the 2019 Health Value Award for Program Provider – Specialty Pain Management/Addiction Reduction**

Venebio Opioid Advisor (VOA) is a validated risk index and clinical decision support tool that can predict a patient’s risk of prescription opioid overdose and provide evidence-based guidance to support safer prescribing and reduce risk. The tool uses a proprietary algorithm to develop a personalized risk profile for predicting prescription opioid overdose. increases in the number or percentage of patients identified as high-risk who leave the pharmacy with naloxone in-hand (dispensing rate). Initial findings of a study of 476 pharmacies show a dramatic shift in naloxone use when Venebio’s program was implemented.  At baseline, the patients in the high-risk category that are targeted by VOA had an overall naloxone dispensing rate of just 4%.  After less than six months of program operation, 3,175 patient interventions have been conducted in the pilot pharmacies and a total of 1,034 patients (or 32.6%) left the pharmacy with a naloxone unit.

Vera Whole Health provides on-site primary care clinic services to employers, as well as an array of services designed to engage employees and promote preventive care.

Vera compared the PMPM expected costs to the actual costs.  Expected costs were derived using the employer’s cost trends prior to implementing Vera’s services.  Actual costs included all medical costs and the direct costs billed by Vera to the employer for the onsite clinic services.  All members are included in the calculation, not just those who visited the clinic or otherwise engaged in Vera’s services.  The employer’s actual costs after implementing Vera’s program were significantly lower than expected costs.

**Winner of the 2019 Health Value Award for Specialty Drug Managers**

VIVIO Precision Care™ is a specialty drug plan powered by VIVIO qClinicals™, a continuous improvement care system that analyzes individual patient data to make specialty drug therapies available based on real-world effectiveness and individual patient needs – not a profit-driven formulary.

VIVIO Health’s savings computation method compares net acquisition cost of the original purchasing method vs. purchasing through the VIVIO Health program. This includes all discounts and rebates.

The applicant provided data on four customers’ 2018 baseline drug costs and actual drug costs. This data is then reported in total gross savings and, after noting program fees, reports return on investment and total net savings.  In 2018, VIVIO Health’s customers averaged 3.7X ROI.

Welwaze’s product, Celbrea Thermal Mapping Device, is an adjunct tool for mammography or other standard breast detection methods for breast cancer diagnosis. Welwaze strives for patients to have less unnecessary follow-up testing and biopsies. For this, Celbrea TMD helps to detect earlier stage tumors, thus reducing the frequency of later stage cancers. The calculator estimates the impact of Celbrea on follow-up testing, biopsies, and treatment costs. The calculator also estimates employers’ costs for breast-cancer related turnover.