Bridging care, savings gaps with data

While accountable care organizations (ACOs) have been around for a decade,1 only a minority of the 800-some ACOs2 know how to succeed under value-based contracts.

In 2017, for example, only 34% of the 472 ACOs in the Medicare Shared Savings Program (MSSP) qualified for bonuses under the program.3 Since most of these ACOs met the program’s quality requirements,4 most of them were unable to save Medicare enough money to receive a share of the savings.

The key to success in value-based contracts is the ability to aggregate and analyze clinical and claims data in a timely manner and provide actionable information to clinicians at the point of care. This is the approach taken by South Bend Clinic (SBC) in South Bend, Ind., and it has paid off in spades: The 130-doctor, provider-owned multispecialty group ACO has enjoyed financial success in contracting with the MSSP, as well as with several commercial Medicare Advantage and Medicaid managed care plans.

Lack of actionable data

In the organization’s early days, physicians received quality and cost reports based on claims data that was often several months out of date. Providers had little ability to understand the health risks of their patient populations because they lacked the timely, comprehensive data needed to do risk stratification. As a result, population health management was hit or miss, and it was difficult for the ACO to consistently achieve its cost and quality goals.

Our ACO’s efforts to garner bonuses under Medicare Advantage contracts were also hampered by the difficulty of ensuring that all patient diagnoses in those plans were correctly coded. The Hierarchical Condition Categories (HCC) risk adjustment codes used by Medicare Advantage plans can have a major impact on their premium funding and provider reimbursement.

Analytics drove improvement

Our ability to deliver value-based care took a quantum leap forward when we acquired an advanced enterprise data warehouse (EDW) in 2017. This EDW enabled South Bend ACO to supply reports to our physicians based on aggregated claims and clinical information. The clinical data, drawn from the group’s EHR, is updated daily. As a result, physicians know that it represents the most recent data on their patients.

The EDW made it possible to provide actionable data to physicians in specially designed “face sheets” — one-page documents that include data on each patient’s care gaps and key clinical information, such as diagnoses, medications, tests and vaccinations. The software integrates each doctor’s schedule and automatically prints face sheets for the patients a provider is going to see on a particular day. The physician can then look at the face sheets in order as he or she proceeds through that day’s visits.

While this seems very simple, it has spurred physicians to proactively fill their patients’ care gaps. The face sheets also help our providers achieve quality goals, since they are calibrated to the quality measures of the insurance contract for each covered patient.

The data analytics built into the EDW have also helped the ACO improve its Medicare star ratings and HCC coding for Medicare Advantage plans. The ACO’s analytics help identify diagnoses that may not have been coded, using medication lists and comorbidities as a guide.

The analytics also generate actionable performance reports that allow physicians to drill down to specific patients. Our population health managers can discuss these reports in detail with the doctors to explain why their performance may be poorer than they expected.

Higher quality, lower costs

Since the launch of the face sheets in August 2017, our overall MSSP ACO Quality score improved from 88.48% in 2016 to 91.7% in 2017. The ACO also increased its Medicare Advantage Quality Stars from an average of 4.1 to 4.6 out of five over the same period. Year-to-date HEDIS Quality Measure Compliance in May 2018 trended 23% higher than in the same month in 2017. As a measure of HCC coding impact, the ACO’s year-to-date percent coding validation (PCV) in May 2018 trended 12% higher than in the same month in 2017.

Our ACO has beaten its cost and quality benchmarks every year since 2014. We now feel confident enough in our providers’ ability to control costs that in 2018, we chose to enter Track 3 of the MSSP, which involves both upside and downside risk. Previously, the ACO had been in Track 1, where it participated in shared savings but took no financial risk for losses.

With the MSSP making it harder to meet its benchmarks every year, our ACO will continue to eliminate waste and improve quality. The SBC ACO looks forward to continuing to find innovative ways to succeed in value-based arrangements while offering excellent patient care.

Notes:

1. “Accountable care organizations.” Health Affairs Health Policy Brief. July 27, 2010. Available from: bit.ly/2Z1gueU.
2. Muhlestein D, Saunders R, Richards R, McClellan M. “Recent progress in the value journey: Growth of ACOs and value-based payment models in 2018.” Health Affairs Blog. Aug. 14, 2018. Available from: bit.ly/2PcJxaG.
3. National Association of ACOs. “More Medicare Accountable Care Organizations (ACOs) achieve quality and cost goals in 2017.” Aug. 30, 2018. Available from: bit.ly/2U8gRAT.
4. Centers for Medicare & Medicaid Services. “Medicare Shared Savings Program: Fast facts.” January 2018. Available from: go.cms.gov/2DvGl3I.

Keys to success

Technology can play a critical role in creating a successful ACO, as highlighted by a recent U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) report on using health IT for care coordination.

The report, based on six site visits to Medicare ACOs, found:

• ACOs using a single EHR system across provider networks performed better thanks to sharing real-time data.
• A majority of ACOs in the report’s study “used data analytics to inform their care coordination.”
• ACOs that used health information exchanges found “little or incomplete data” from those sources, which complicated care coordination with out-of-network providers.1

Note:

1. HHS OIG. “Using health IT for care coordination: Insights from six Medicare accountable care organizations.” May 2019. Available from: bit.ly/313PXPd.