Welcome everyone. My name is Melissa Singleton and I'm Chief Programs Officer at Home-Centered Care Institute. And I'm pleased to welcome you to today's webinar, HCC Intelligence Presents Data Analytics, The Key to Achieving Growth and Quality in Home-Based Medical Care. So I just have a few housekeeping announcements as we get started. We had some learning objectives established for today's session. And so those include, we're gonna discuss some of those challenges of shifting to value-based care. I know a lot of us are still straddling fee-for-service and value-based care, or trying to figure out how to make that leap. And an essential component is how data analytics can be leveraged for success, particularly for home-based care. And we are fortunate to be able to have some presenters here today to describe their insights and experiences in using home care data to aid their decision-making about everything from markets, performance, competitors, how they're getting referrals and partnerships and even clinician recruitment. So I'm very excited to bring that to you today. Let me, hang on one second. All right, we'll do the other way. All right, so I have too many windows open on my screen. Sorry. I'm pleased to introduce our presenters for today. So Dr. Tom Lally is Founder, Chief Executive Officer and Chairman of Bloom Healthcare. He's a house call physician with a passion for developing new and innovative ways to care for our communities, for his community's most vulnerable patients. And he's just, I think you're gonna learn a ton from him and I look forward to having him speak. And then we have Rebecca Ramsey, who's Chief Executive Officer of House Call Providers in Portland, Oregon. And Rebecca is, just brings a wealth of healthcare knowledge and leadership skills and passion to her role at House Call Providers. And she's also a former Executive Director of Population Health Partnerships for Care Oregon. And so I look forward to having you hear some great wisdom from her. And then Dr. Erin Yao is our own Director of Research and Analytics at Home Centered Care Institute. And he is kind of the, well, he is the brainchild behind Confer Analytics, which is HCCI's data analytics platform and something that you'll hear a little bit about when we get going here today. All right, I have to change that. There we go. All right. And our moderator is Dr. Paul Chang. In addition to Dr. Chang being our Senior Medical and Practice Advisor at Home Centered Care Institute, he's Medical Director at Northwestern Medicine's Home Care Physicians. You may have heard that he's personally made over 37,000 house calls in his career to more than 3,600 patients. So he's got a ton of experience to share and is humble enough to bring his questions to his colleagues to learn more himself about how to leverage data analytics. So at this time, I'm gonna go ahead and turn it over to Dr. Chang and we're gonna get started. Melissa, thank you very much for that introduction and welcome everyone. I am really, really excited to learn from Tom and Rebecca. They're really experts later on today on how household practices and other practices that cares for patients with advanced illnesses, how can they use data to grow their practice, to improve the quality of their work and to make their practices more financially viable, successful. So I'm eager to get into the meat of the presentation today. But before we get there, I do want to ask Tom and Rebecca to share a little bit about Bloom, about household providers, about where are they located? What kind of practice is it? What kind of services do they provide? Are they palliative service or are they primary care service at home? So Tom, can we start with you and then we can move on to Rebecca. Sure, Paul, thanks. And I appreciate HCCI having me here. Thank you all for attending. I'm honored. Bloom is a primary care practice at heart and we take care of our patients that are all high needs. We're 100% home-based primary care and we serve about 6,500 patients currently. We serve about 10,000 throughout the year in any given year. And we do that with an interdisciplinary and a very comprehensive approach. Our patients are only gonna be with us an average of about three years and they're gonna need a wealth of care management. They're gonna need all kinds of different services like behavioral health, pharmacy support, complex care management, all the way through to hospice. And we feel like that continuum is critically important. We do most things based on two different principles. We feel very strongly about empanelment because it means that there's a responsibility that we can create and that's incredibly important but it also allows us to leverage data and look at supply and demand and think about things like risk stratification. And if we have a patient who's higher risk, can we guarantee that they're going to be seen at increasing frequency? So we are very involved in the data portion of kind of trying to build a practice and trying to make it sustainable. We have one model of care. Everybody gets the same model. It doesn't matter who you are. Like as far as payer, we have kind of the catalog service. And then we work on the backend because we take care of all different types of patients regardless of payer source. We have to do really well in some of those contracts. So we have everything from regular fee for service and a lot of our patients are still that today to where on the other hand, we are at global risk in our high needs ACO and it's a wholly owned like employed model. And both of them work. So we are able to really make sure that the care delivery is the same. And so tools like the HCCI tool and others are critical for our success. Thank you, Tom. Rebecca, can you share a little bit about hospital providers? Yes, good afternoon, everyone. And thank you for having me here. I had the privilege of working with HCCI closely over the last several years, have been a member of the board and just have really enjoyed participating in many of their webinars. I am the CEO of Housecall Providers and Housecall Providers is in the Portland. Our home base is in Portland, Oregon. We started 30 years ago, actually went back when home-based primary care wasn't as commonly understood as it is now. And we actually serve currently about 1600 home-based primary care patients at any given time. And they range from 18 years of age to 107, I think is the oldest patient that we're caring for now. That program is the oldest and longest standing program that we run but we also have a home-based palliative care program and we operate a hospice. And we rely on data in all three of those programs. The thing that has been really powerful about using the kind of data we're gonna talk about today for us is that we're in a growth phase. We're looking at expanding our home-based primary and palliative care programs to various regions across the state and even across into Washington state. And that's something that we have other forms of data. We're involved in just as Bloom is, we're enrolled in a high needs ACO and we have a lot of claims and utilization data that we use to improve our performance with those high needs patients. But this data, and I'm gonna really focus my comments today and my slides on how we're using this data to expand and to grow and how do we look at our performance compared to other practices in some of these new regions who may also be providing home-based primary and palliative services. So, yeah, I think I'll talk more about that. I think Tom is also gonna focus a little bit more on how's he using it in value-based contracting? How's he using it in terms of sort of benchmarking his clinicians? So we're gonna try and cover slightly different areas and ways of using the data, but they're all very complimentary. So I look forward to it. Thanks, you guys. Thank you so much for giving us a little glimpse into your world and your practices. Maybe just set the stage for our discussion. Melissa and I and our team looked at the registration list for this webinar. And we have practices from ocean to ocean, from Puerto Rico all the way out to Hawaii. I think it's the first time ever that we have crossed those fears, I guess, in one webinar. So I'm really excited. And I guess maybe I'm gonna go on an assumption here that with all the different practices represented in this webinar, practices are probably in various stages of value-based care. Maybe some are advanced, some like Northwestern, like us, we are still slowly moving from fee-for-service into value-based care. And we have a lot to learn in this field about leveraging data. So Tom and Rebecca, maybe you can just tell us a little bit or tell me and our audience, why should I care about data? Why do I need this? Or maybe phrasing it differently, help me with this mindset change that's really necessary as my practice transitions from a fee-for-service, pay-as-you-go kind of practice that's been there for 30 years almost to a value-based arena. Help me with this transition. And as you see, why the importance of data? I think the easiest way to think about it is that the fundamental shift in how we as physicians or providers, and I say providers in the broad sense, how we think about reimbursement yesterday versus tomorrow. And there's a big difference. If you think about the entire pie of healthcare expenditures for an average Medicare patient and the percentage that is actually allocated or given to a primary care provider, it is about two and a half to 3%, very, very small. And if you think about the actual amount of effect of care, we order in control most of the other 97% of the expenditure. In fee-for-service, we were concerned about that 3% and about being efficient and about being in a volume-based environment. And when you think about value-based care, you're now in an ecosystem. You're not in your office. You're actually practicing among an entire ecosystem and the patients are upstream and they're downstream and they're getting here in parallel universe. And you have to know about this. And the further along you go in kind of these value-based relationships, the more accountable you become to care that might be happening outside of your control. And having insight into how to be successful and kind of managing that is a new skillset. Like you said, I didn't get taught this in medical school. I wish I did. So I've had to learn and really use data analytics and reason and a lot of time with others to become an expert at kind of the population health strategies that we have to apply. But it's so much broader than just the clinical ecosystem that we used to practice in. Thanks, Tom. I like that ecosystem. Rebecca, any comments before we move on to our presentation? No, I really liked what Tom said. And I have an interesting, I guess, perspective because I worked for many, many years in a payer environment. So I was actually leading a number of the value-based contracts that the payer was just getting into several years ago and working with providers and understanding the gap that there was in the data that we had that they didn't have. And so what Tom's saying is, I was only their end of that and recognizing, they need this data in order to perform better for us. And how do we actually not only incentivize the right things in the contracts that we're building, but how do we also help share this data in ways that are meaningful for practices, positions, teams, and the community caring for our members? So when I switched gears and became the CEO at House of Health Providers, it was one of the first things that I wanted to do was to really start upscaling our providers and care teams and our entire practice with the kind of data that I knew was available. It's just a matter of getting it, not all payers, some payers are a little bit more advanced in the ways in which they can share that kind of data. But Confer is taking CMS's data for these fee-for-service Medicare patients and some Medicare Advantage patients and putting it into views that then allow our practice to really understand what's happening with these patients in the way that Tom was talking about. So it's kind of come full circle in my career and it's been really wonderful to be able to have this tool as a way to start to teach my teams about the value of it. And then I'm also using it in some of my contracting conversations. So I'm able to actually point to our success and benchmark ourselves in our current market when I'm working with the payers on rate increases or to really move the contract along that value-based continuum. So there's a multitude of ways that we're able to use this kind of data to really advance our practice and the ways in which we're being incentivized and rewarded for the good work that we do. Thank you, Rebecca. That's a perfect segue. Melissa, next slide, please. Regarding the different metrics, the data that we can use. On the slide here, you can see just some example of the data we can collect and how we can use the data. I won't read every bullet point, but I think you all have a sense of the importance of data and how that could be leveraged depending on where you are in the value-based journey. Next slide, please. Melissa mentioned earlier that Aaron, the wizard behind Conferred Analytics, both Tom's practice and Rebecca's practice, they are users of Confer. And I want to bring Aaron in here for just a little bit. Aaron, can you give us maybe a high level of what Confer is able to do and how we can take data and help practices grow, improve their performance, do their contracting, as Rebecca mentioned earlier? Yeah, thank you, Paul. Hi, everybody. I'm a researcher and an analyst. So we not only generate data product for you, but we also publish. So you see a lot of the data products also have the academic rigor. So to summary what we have, the data really covers the whole spectrum of home-centered care, from primary care to palliative care, home health, hospice, virtual care, and home hospitalization. So that's about the sectors in home care. But if I talk about types of data, I would say that we have performance data for all these programs, right? Performance in terms of utilization, healthcare costs, et cetera. And including their patient cohort data, risk levels, chronic conditions, et cetera. And then we have another category of data, our relationship data. So referrals, partnership, and these are estimated by analyzing Medicare claims, MA data and Medicaid if needed. So, and you can use these data for many different kinds of use cases. It's already listed in the last slide. Yeah, but of course, we address new questions. So we're always ready to answer new questions. And actually, I got just today a new question from our clients, yeah. Paul, you're on mute. Oh, thank you, Aaron, for that. I think flexibility and customization are just such important features of Confer or any analytic platform. Tom, can you give us some example on how Bloom is using analytics to demonstrate quality, to make decisions about marketing and how you measure up with competitors and so forth? Sure. Yes, so we layer this on top of our data and analytics strategy. And really for us, this is a unique opportunity to see lagging indicators without having to do a ton of work. And that's incredibly difficult. And to Rebecca's point earlier, like not all payers share all of the data with you. So for you to have actual kind of third-party validated, rigorously tested kind of performance data, that's really difficult to track and to build those structures inside of an organization as you're growing. And you got a lot of other priorities. So to us, this is a really nice way for us to kind of look both internally at our performance and then kind of in expanding diagrams around like that kind of internal, kind of what we're doing in our own world of care, the geography that we care for, who others are interacting with our patients. And then we think about it like before or after in a time-based relationship. And then to Rebecca's point, we also look at it from a market expansion and recruitment. We're gonna cover more of that kind of those first parts today, but we use it in all those different areas. Let's go to the first slide. So at the individual level, this is one of the performance dashboards that Aaron was referring to. And it's just an incredibly rich dashboard that has a ton of information, but this is the state of Colorado. I am looking at home-based primary care providers. I'm using the Medicare fee schedule from 2022. And I kind of ranked them in order. I don't even remember what I used as a dropdown. It doesn't matter. Most of the providers on the list that are green are Bloom providers. They're all Bloom providers, I think. Yes, they are. And this is a way for us to actually look at Shannon Horne as a nurse practitioner. She's a phenomenal provider. She has 131 longitudinal patients that Medicare thinks are related to her based on the CMS claims data set. And we know that if we went into a demonstration model, they would, CMS would probably think there's 131 patients because it's the same methodology. We can see the average number of patients, high needs patients that she would have. We can see what her projected savings would be in a high needs plan and some of the costs of some of these folks. And you can scroll along. There's many other datas. And for us, we now have a real-time ability to kind of look up the performance between Emily and Shannon in a real-time basis. So we can go to this and it's getting refreshed with data from last year. So it's once a year, but like this for us is incredibly important for us to kind of see how they're doing because we pair this with a lot of the other data that we think are kind of more leading indicators. Like, are they seeing their patients on time? Are they closing their notes? Are they doing, you know, using the templates and specialty visits at the rate and frequency that we think. So incredibly powerful tool and a dashboard that we use to augment some of the information we have about the performance of our individual providers. Next slide, please. All right, roll it up one level. Physician House Calls is the operating company of Bloom. It was my predecessor company. We have a better name today. But this gives you a relative like idea of how we are doing against our competitors in our marketplace. This marketplace happened to be Colorado. We're larger than our second largest competitor, but we also have a better performance. And we can make sure that like, boy, are there folks that are in our area that are doing a good job, potentially either from a competitive analysis or maybe want to partner with them as a preferred partner, joint venture, or maybe even an acquisition. So we'll pay attention to this and the performance of those folks that are in our kind of geography. Next slide, please. I think this is one of the coolest ones. So I spend a lot of time just kind of hunting around all of Aaron's work. He's got so many cool things. And this was really kind of that element of time. So if you think about who is in your practice today, so these are the folks like that Medicare said, these were folks that were assigned to Bloom Healthcare. We think there's a relationship there with one of the providers from an aggregate of claims, but who touched that patient beforehand? And that's where this dashboard becomes incredibly powerful. You see Matthew Merrington was a provider who has cared for 90 or so patients before they became Bloom patients. So there was like, wait, something there. And he happens to be at a rehab facility. So it makes sense, but we better reach out to Matthew and have a relationship. And so from a sales relationship, just making sure that there's good quality collaboration from a handoff. So everything from operational efficiency to making sure that Matthew knows where to send his paperwork, it's easier for him to send it to us, to saying thank you to Matthew when he does send us patients that he thinks we would do a good job with and entrust that care to us. It allows us like an instantaneous way to look at things. And we use this to feed to our kind of sales group. We call them practice ambassadors, but they're constantly looking through this, whether to develop a relationship or just say, thank you. Next slide, please. So kind of a different perspective on the same sort of idea, but patients that are not your patients, but that are still frail. And who is, where are they getting care? A lot of these folks, you know, are not necessarily getting home-based primary care. So if we look at those dashboards that are looking for home-based primary care codes, we're not gonna catch all the patients who have diagnoses of frailty. A lot of these folks are getting seen still, you know, whether it's regular trips to the emergency room, not necessarily getting enough visits from their primary care physician, getting somewhat underserved in that typical office environment. This gives us a very quick way, and we can sort by any column, kind of whichever one we think might be the most important to us. I think I have it sorted here by the aligned number of E&M patients. Danielle Anderson is our chief medical officer at Bloom, so I would expect her to be towards the top of that. But you can start looking at where are other patients, and this can be an incredibly powerful tool, not only for your kind of local development of kind of going out and building relationships, potentially even partnerships. If you have an ACO or other type of relationship where you can have preferred partners, if those folks are doing a good job with high-needs patients, they might be able to join your ACO. Next slide. This was a use case where, you know, as we've been growing, we wanted to continue to kind of build out like the right level of structure around each division, and we had decided, boy, we want to have an entirely separate division dedicated to just the private home patients that we serve. We serve patients in private homes and in assisted livings. Assisted livings continue to grow because they're congregate settings, and there's a lot of efficiency there. But we wanted to make sure that we continued to kind of support the private home patients because we knew how much demand there was, but we didn't know exactly how much the demand was, so we turned to Erin's tool, and we started to think about the fact that we don't really know that the number of patients getting discharged, and like, boy, like, but what surrogate markers could we use? And we said, boy, we have a dashboard right here that shows us the patients who are CMS as Medicare primary who were in an inpatient hospitalization who got discharged with home health. That all of a sudden gives us an incredibly rich dataset to start predicting the demand for home-based primary care. We can start looking at that at a hospital level, breaking it down to the number of discharges per day, start making some assumptions around there, and it allows us to build the financial model to be able to actually go out and say, hey, there's a financial way for us to actually do this. We think that there's a sustainability that's built in here, and part of it is really making sure that we have the demand figured out. You don't want to be hiring a bunch of providers and having them waiting for work. That's a very quick way to not be able to deliver the house calls that you want to be able to do. Next slide, please. Another development one, and this we use inside of our ACO, when we are thinking about preferred partnerships. So we are always looking for good partners and we want to align incentives. So we don't want them to just to be kind of like on paper partners, but we want them to be aligned financially if possible. And so we go out there and we want to make sure that if we have a patient who is going through this cycle and they go to a preferred partner in a skilled facility, that they have a way to go home with home health. And so we need to think about things about who is in this ecosystem and what relationships do they have ahead of time. And we need to think about bringing in other partners or do we go into that and say, no, we're going to demand that we want our partner because we think they do a better job from a quality standpoint. You want to go into those meetings knowing what these things are going to happen. You want to be prepared as possible. And this gives you a lot of insight into what you're kind of going to be thinking about when you're building a network. And the networks that you build inside of an ACO are far less burdensome than for like a Medicare Advantage plan. But you're still building those same principles and you kind of have to know where the dots get connected to. Next slide, please. Easy one. I think this one can be used. I think I just showed it there. We use it for a lot of times when we're thinking about an MSA that we might be thinking about exploring or maybe expanding to. We'll pull this up, list it not only by state, but then by MSA. And we'll kind of be able to see what the competition looks like, who we should be thinking about from a partnership or maybe even an acquisition. Next slide. I think this one's really interesting. I put this on here. I don't know if there's not anything I do with this slide, except I think it's incredibly interesting from... I'm a data scientist at heart. I love data. It's just something that I really enjoy doing. But I think when you look at something from the same exact dashboard settings, and I just did St. Louis and Las Vegas, and I took a snapshot, and you can see that there is a local flavor to healthcare. And we've seen that. I've seen that in my own personal life when I've operated across multiple states. And certainly you can see it here based on the home-based primary care performance of these practices. And if you're a home-based primary care patient in St. Louis, it seems to be you're getting decent quality. And it looks like if you're in Las Vegas, I'm not saying that the quality is low, but the value is low, right? There's something that's off there. And you can see the red and orange is just a little bit too much of that page. And so it gives you a lot of idea of what is going on inside of the local environment and those environments around you. Next slide. And I think this is actually an incredibly important one, and I'll leave most of this growth, but you can get down to the really nitty gritty level and you can compare two practices. This is our practice, Physician House Calls is the practice we operate here as Bloom. Meadows Family Medical Center is our largest competitor. And you can see that they do some decent things, the same as us, like number of visits per patient. We like that. And then you can see there's some things that are different. And I won't go into all of the detail here, but boy, you can really tell a lot about the quality, the outcomes, you can start seeing patterns. You can break this down, like I saw at the beginning, all the way down to the provider level. But it really gives you insight that we've never had before, even as a population health practice that takes all kinds of data, we build all kinds of systems. We've got data scientists and our own employer, but we still use this tool because we think it's incredibly powerful and it augments a lot of the things that we're able to do today. Thanks. And Tom, I know that's your last slide. We did have a question in the Q&A box just about understanding the colors and how they're assessed for quality. I don't know, Aaron, do you wanna speak to that? Just the- Yeah, sure. So first of all, if you use your own data, you will not able to create the adjusted numbers. It's the PMPM or admission rate, readmission rate, because you need a sample, many, many practices so we can do risk adjustment. So there's no way that a single practice or company can create adjusted numbers. So Tom, just one comment on that. And second to our friend, this question. So the coloring is I basically use the credit score coloring scale, dark green, green, yellow, and red. So of course it's not like quartiles. It's like a very small percentage is dark green, right? And then a lot of them are in green and then a small percentage in yellow and a very small percentage in red. And it depends which one we're talking about. If it is adjusted PMPM, so that's the per member, per month's Medicare payment, right? So if it is red, it's meaning that their patients, yeah, use a lot of healthcare. And if it is readmission, if it is red, then they have the highest readmission rate in the country after risk adjustment. And for example, for readmission rate, we actually, we adjusted for many patient factors, but also at the hospitalization level, like length of stay, et cetera. And in the next update, we might add more variables in the risk adjustment. It's almost the same as the CMS risk adjustment model. All right, thank you so much. And thank you, Dr. Lally, appreciate that. Let's, oops, sorry, I went too far. We'll go ahead and turn it over to Rebecca. Yeah, thanks. I just learned some things from Tom. That's why I love these. Same here, even I developed this. I learned like a few new things. Yeah, it's always great, right? Because I'm a little bit of a data geek too, and I'm using it differently. And I think it's great when we can learn from each other, particularly in this field that's kind of specialized. So what I'm gonna present is actually hot off the presses because I had a board meeting last Friday. And one of the things that I'm trying to help bring my board along with is, what is the opportunity for growth? And looking at it from a somewhat incremental perspective and not, so really looking at the state of Oregon and our borders on either side versus looking at other parts of the country. But being able to use data to have that conversation is so helpful. And I needed them to understand sort of what are the options and where are the competitors, where are there gaps in the market? What are these competitors doing? What do they look like compared to us? What's the likelihood that we're gonna succeed in this market given not just the amount of competition but the quality of the competition. So really using this as signals to help guide our decision-making. So that's the sort of lens that I'm using as we go through these slides. So let's go to the first slide. So these are all from the sort of demand supply dashboard. And like everyone has said, there's a lot of data in Confer. And so there are many dashboards. Most of my slides here and screenshots are from the supply and demand or the performance scorecard dashboards. So in this view, what I'm looking for is this is the Portland market. I focused on one particular county. It happens to be the county, Multnomah County that's the largest and where we have the biggest presence. But we're actually the Portland, Vancouver, Hillsborough, MSA has multiple counties within it. So I filtered on Multnomah County and I wanted to get an update on what competition is looking like. We know that we have a very strong foothold in this region, but I just, I always look to see if anything is changing. So here what we're seeing, and we're going to reference this slide in a little bit, what we're seeing is that Providence, uh, health and services appears to be our biggest competitor in the home based, um, primary care or home services, um, uh, uh, field serving private homes. So I'm really focused right now on who is doing home based primary, who is providing home based primary care E and M services to patients in private homes. Then you go down the list, you see house call providers, then you see a mental health, um, organization that this is, this shows up a lot in the dashboards that I'm looking at for, for our region there. So there are clearly some mental health agencies that are, that are using some codes that are showing up, um, as potentially primary care E and M codes. Dispatch health is an urgent mobile health provider. So they're doing urgent care versus continuous, uh, primary care. We know them very well. And in fact, we partner with them. So that wasn't surprising for me to see. And then there's this HPA medical management and we have not seen them show up. So we're, we're currently looking in to see who that company is because the name that shows up in the, in the claims data, isn't always the name that they're doing business by. So you sometimes have to do a little bit of a deep dive. So this wasn't all that surprising to us. We're very aware of Providence. Um, we actually have a contract with Providence health plan. So they're actually contracted with house call providers as well as their own, uh, primary care at home program. So let's go to the next slide. So when I filter on the, um, the ALF or assisted living facility, um, market share, I see a different picture. So in this view, we appear to have the larger market share and you don't see prop. You only see 5% of Providence down here. Now we know that a good, that they do take care of a lot of people in facilities, but it's primarily their Providence ma plan members that aren't going to show up in this data set because I'm looking right now with this at, at fee-for-service Medicare patients. So I know that they serve patients in the facility setting, but it's primarily their ma patient, their ma, um, plan patients. What was really interesting about this was Tobit Inc. Again, a new player, hadn't seen them show up again in the last sort of view that I had looked at in 2021. And then healthy at home is a practice that we are very familiar with. Um, it's a very small, uh, two to three practitioner practice. We don't see them as a competitor except in a couple of the facilities that we serve. Um, and they are a practice that we are constantly reaching out to, to see if they want to, um, combine forces. So let's go to the next slide. So I was really curious about Tobit Inc. Um, and I did, I spent about an hour trying to figure out who they are. There's more to do here because I, I did not get a good answer. What I, what I found when I put their MPI and MPI lookup, and when I just Googled them was that Tobit Inc, um, is a professional medical corporation and they have two offices. One's in Los Gatos, California, and one's in San Jose. So not in the same state that we're in. I'm actually kind of curious what Aaron has to say about this. My hypothesis is that there is a, um, see, there is a senior living community. There's a series of senior living communities that probably have more presence in the, in the California market, and they may be using a telehealth provider to serve some of the patients in the, in the senior living communities, one or two in our region. Um, I have yet to find a provider in our region that is associated with Tobit. Um, and I can't find a DBA doing businesses as, um, uh, that's associated with Tobit. So this is, so Aaron, I can't figure it out. Uh, but, uh, I need a little bit of time to figure them out. This is why, this is why I love our partnership because I can, I can send him little, like, you know, little trails to help me follow to try and figure out, you know, is this, is this a new competitor? Do I need to be aware of this, this, uh, practice, or is this something that they're not really doing? They're not really providing the same service we are. All right. So let's advance to the next. Um, so then I went to the performance scorecard dashboard and you saw a version of this in Tom's slides as well. I just always want to check in to see how Housecalled Providers is doing compared to our, um, to our competitors. And what's also interesting about this is, um, is when you look at the numbers. So you can see in this, this is the state of Oregon. Um, you can see that Housecalled Providers has not anywhere near the number of longitudinal, um, patients that you saw in the Bloom dashboards. And that's in part because Bloom's bigger than we are. Um, and they have more regions in, in, in the state that they're serving. The other thing is that Oregon is very heavily managed care. So there are, there's a higher penetration in our practice of MA patients, much higher than, than fee for service, um, Medicare patients. So there's sort of two factors here. But the other thing is remember when we were back on the previous slide and I said, look, it looks like Providence really is our biggest competitor, particularly in the private home space. When you look at the number of longitudinal patients, Providence is serving, it really drops down. And so what this tells us, I think, and, and this, we, we can validate this because we know Providence pretty well is that they're, they're providing a lot of episodic care in the home. They're doing transitional care management visits. They're doing annual wellness visits. They're doing some, um, some palliative care sort of short term visits. They're not doing all that much longitudinal home-based primary care for this fee-for-service population. So that's the difference that you can see, um, when you, when you look at, when you, when you triangulate the data. Other than that, we are, um, pretty comparable. Um, our risk adjusted PMPM is a little bit lower. Um, our risk score is a little lower than Providence's. Healthy at home is also, you know, doing relatively well. Um, our, uh, our admits per thousand is lower than the two, um, major competitors. Um, and then, you know, this goes on, I just took a snapshot, but I, I can follow this and I can look at our ER rates. I can look at our readmission rates. Um, so really valuable in terms of, you know, if I'm going to go, if I'm going to go talk with another MA plan, Regents, or even if I'm actually right now, recontracting with Providence health plan, I have this data and I have some talking points here. I can point to our performance and our, our total cost of care management as I'm having those conversations. All right. So let's go to the next slide. So the next series of slides is really look, is, is really my, uh, attempt at looking at a, at a area that we're expanding to. So this is, this is Salem. It's just South of Portland. And I, I I'm ready to expand. I've got all my contracts in place that I need. And I'm interested in looking at who's already there. Now I, I, I did this last year and I'm just keeping up with it. Right. So when I look in the Salem market, the picture's really different. Um, Salem's the capital of Oregon, by the way, um, smaller town in Portland, but, um, but not small in general. The first three that come up in the private home space, one is a mental health practice. One is mobile dermatology and one is a lab or mobile phlebotomy provider. These are probably really important practices for me to be aware of because they could be partnership opportunities. They might, we might want to partner with them and care of the home-based primary care patients we care for. Let's go to the next slide. In the facility space, we now see what looks to be a true competitor or someone that's already well-established in the market, serving patients, um, in facility settings. There's a couple of them here. So I looked up compassion care, family practice, and you can go to the next slide. And this is a group of two MPs, very small practice. They've been around for several years. The provider that we have that we hired in Salem knows them. Um, you know, good, good, solid practice, um, serving just patients in facility settings. So if you go to the next slide, then I was kind of curious, what do they look like on the scorecard? And what I found was they're doing, you know, relatively well in terms of their total cost of care and their adjusted PMPM. Their risk scores were lower than ours. Um, but something is happening in the ER space. And again, I might have reached out to Erin to validate my hypothesis here, but when I see that their ER visits per thousand are triple, almost triple some of the other providers, it, it worries me. Like if I'm thinking about, you know, would I maybe want to entertain a joint venture or partnership with them? What's going on here now with a small nurse practitioner, two nurse practitioner practice trying to serve frail elders, um, in a facility setting. It, it isn't that surprising that if they don't have a team-based model or a lot of resources. I, I have a hypothesis. It's my related to the assisted livings policy. Yes. They're partnering, right? Maybe we didn't, uh, differentiate between outpatient ER versus inpatient ER. Right. I, I think there are a lot of outpatient ER in this data. Yeah. Yeah. But, but, but what I'm saying is that, yes, absolutely. We all know in this industry that, you know, that there are protocols and policies, but there are also ways of working with those, you know, that's right. Facilities. And if you have more staff and you have a team-based model, you can often really work with them to, to sort of make sure you get the call first and you have a nurse or a social worker to go out and visit the patient, et cetera. So it's just, I just wanted to use a really concrete example of where you can actually use this data and try and sort of benchmark yourself and understand, you know, particularly in a new environment, who are you up against? What, what does it, what does it look like? Uh, what are their, what are their outcomes look like? And I think that's my last slide. Yeah. Great. Yeah, it is. Um, thank you both so much. Um, Paul, did you want to, um, Oh, I, I, I love every one of those. I've viewed them before, obviously. And I, I want to just, I don't know about the audience, but I, every slide, I just want to pause and reflect and soak it in and say, you know, how does this apply to me and my practice? You know, we're just venturing into value-based care. Um, uh, so it's, it's been so rich, uh, to hear it now presented live. I loved it. Um, and not just because I know these people, but, uh, because I really, really enjoyed the information, but then, you know, also got me a little nervous. Um, I, I, Oh, Tom, I brought up, uh, uh, well, no, Aaron said, you know, uh, he got a new question from one of his clients. I'm like thinking, boy, what questions am I not asking? Um, that maybe are, are, you know, are important things that I should know about. So we're all in this learning together. I love the presentation. I don't want to say any more. I want to, I want to open up the floor and see if there are people who, uh, who's got questions. We have a question. We have a, Dr. Suri, I'm, I'm clicking allow to talk. So you are, um, able to unmute. Oh, great. Thank you. Can you hear me? Yes. Okay. Perfect. So thank you. This was really, really good. Um, I, uh, you know, like they mentioned, we are a very small practice as well. Um, you know, we're not a huge, uh, institutional practice. We are, um, uh, we do serve a lot of, it's a fully geriatric practice. We are part of an ACO. We've been part of primary care first. Uh, prior to that, we were CPC. Um, we are five providers currently. We'll, we just started a new physician. Uh, so we service assisted living, independent livings, uh, skilled and office and home visits. And I just wanted to know, you know, what is the cost of all of this for a small practice? I mean, it seems like a great thing. It's a great tool. We are getting our data from ACO. We are part of an ACO. So, and we are risk category three in the PCF right now. Uh, so cost overall cost of care is extremely important for us. Um, we are doing better than our regional partners, uh, in our practice, but it takes a lot. Like we have a whole team. Um, but you know, growth is always on everyone's mind, but you know, the cost of this kind of data is really important for us, like being a small practice. So what is that? What is the cost? Yeah. So, um, uh, the, the annual subscriptions are currently priced at $4,950 per year, um, per, per license. Um, we can send you some information about how to do that, about how to enroll. Um, and, uh, I mean, the things that we really, um, emphasize is number one being, you know, exclusively focused on home-based care. Uh, number two, I hope you've seen, you know, how accessible our development team is, um, you know, to make sure that we're getting questions and, and, uh, uh, and incorporating your feedback into the tool. Um, and that three, I, we, uh, we know that we're more affordable than a lot of the other platforms, um, and resources out there. So we hope that that makes it accessible for, um, small to midsize practices. Great. Thank you. Yeah. All right. Are there any other questions? Melissa, I'll, I'll throw in one on that, um, at the price point for us to generate internal dashboards. Um, I just know what the cost is. It's so much higher. Um, and, and we also don't have access to the CMS dataset. So there, there's a rich ability to kind of leverage this. It is something where if you just pay the subscription and you don't log in, it's probably not worth it. But, um, I would anticipate, and I started my practice, I'm a physician. I started from doing house calls and did that Fridays. And then I was able to like have my own job. And then like, you know, like we've grown the hard way in a long way. Um, so I know a lot of those different phases of like investment are very difficult. Um, I still think that would be a high value for most practices that, you know, if you have five providers and, and you've had that type of success or experience even in other, um, predecessor models where like CPC plus, and you're experienced at kind of using some of the data, um, this will be stuff that really does expand outside of that ACO universe. Cause you get like some of the ACO performance data and it's on like 25% of your practice or, you know, on, on, on some of the patients who get in. Um, so this is definitely something that, that can really help augment that. Um, and I think the way that we use it the most is to kind of look at those partnerships, um, and then the individual performance. And it would cost us a lot more to do that than to pay Aaron, um, his subscription fee. Great. Thank you. Thank you for that question, Dr. Suri. All right. So, um, I know we're coming up on time here. Um, they're just a few other housekeeping announcements. Um, at HCCI, we do these periodic webinars on different topics. Um, in Jan, if it's January it's coding month. And, um, and so we are looking forward to coming to you, um, on January 10th, three o'clock, uh, central time, sorry, should have had the CT in there. That's three o'clock central time, unlocking revenue strategies, uh, and unlocking revenue streams, navigating the 2024 Medicare physician's fee schedule for home-based medical care. There's a QR code on there, um, showing you how you can link to the registration, but we'll also follow up to all of you with, uh, um, an email that includes information, not just about confer analytics, um, but also, um, this upcoming webinar. And then always remember that we have a resource center that has, um, downloadable tools and tip sheets, webinar recordings, uh, and that we do have a hotline. Um, I want to just take this opportunity to thank our presenters, um, uh, Rebecca Ramsey from House Call Providers and Dr. Tom Lally from Bloom Healthcare. And of course, um, uh, Paul, Dr. Paul Chang, um, uh, from HCCI and, uh, Aaron, Dr. Aaron Yao. Um, thank you all so, so much. This has been just a really wonderful, um, enlightening hour. And I, I so appreciate all of you. Um, thank you everybody and have a really good night. And we look forward to seeing you at the next webinar in January. Thank you, everybody. Thank you.

data analytics

home-based medical care

quality improvement

data-driven decisions

growth

performance measurement

competitor identification

strategic decisions

value-based care