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Health Plans

Advanced analytics drive success with ACOs

August 5, 2016
You can't manage what you can't measure.
Dr. Jennifer Chambers

Jennifer Chambers, MD
“As healthcare continues to evolve at a rapid pace, it is important for health insurers to remain focused on finding better ways to improve the quality of care, while putting downward pressure on the rising cost trend. We have done just that over the past four years by collaborating with area providers to implement accountable care arrangements throughout the region.

Not only has our model been enthusiastically embraced by physicians and their patients, but this holistic approach to medical care is working as we had hoped.”– Jennifer Chambers, MD, Capital BlueCross, Chief Medical Officer

According to the survey conducted for the Deloitte 2015 Study of Medicare Advantage Health Plans and Providers, nearly all health plans have some type of value-based arrangements in place.

  • 72 percent of health plans have one or more patient-centered medical homes for their commercial population,    
  • 62 percent have accountable care organizations (ACOs) with shared savings
  • 45 percent have ACOs with shared risk,
  • 45 percent use global capitation, and
  • 41 percent use bundled payments.

Like health plans across the country, Capital BlueCross too has created accountable care arrangements with our physician partners.

In fact, we were among the first health plans to launch ACAs. In May 2011, two physician practices, Heritage Medical Group and Physicians’ Alliance, Ltd. (PAL, initiated our ACA program. More than five years later, Capital BlueCross has worked closely with our trusted ACA partners to achieve the Triple Aim, and increasingly the Quadruple Aim, which includes physician satisfaction. To refresh your memory, our ACAs are improving the quality and cost of healthcare and outperforming their peers for the following measures:

  • Acute inpatient admissions are 4.7 percent lower for employer group customers and 7.2 percent lower for Medicare plan customers.
  • Readmissions are 8 percent lower for employer group customers and 14.8 percent lower for Medicare plan customers.
  • Emergency department visits are more than 8 percent lower for employer group and Medicare customers.
  • Medical and pharmacy costs are growing at a lower rate.

Utilization and cost have improved as has quality.

ACAs are meeting or exceeding agreed-upon quality goals relating to chronic disease management, helping patients who have chronic conditions such as diabetes, coronary artery disease and heart failure experience improved health. They also are exceeding the regional average for Healthcare Effectiveness Data and Information Set (HEDIS [1]) measures for some of the leading chronic diseases.

As I consider how Capital BlueCross and its provider partners together achieved such a high level of success, I am reminded of a swan swimming on a pond; the swan appears to glide effortlessly, yet just below the surface, it’s kicking its feet quite hard. This analogy is particularly apt to describe our early years with the ACAs. Before we implemented Geneia’s Theon® analytics platform in 2014, our provider partners and our medical staff were overburdened with paper reports and legacy software systems that were never intended to support ACAs and true population health management.

Take HEDIS®, for example.

Before the Theon® platform, Capital BlueCross shared what surely seemed like reams and reams of paper reports with our physician practices. Even when we supplied monthly reports, the information often was out-of-date so providers were frequently chasing gaps in care they had already closed. Nor did the paper reports include the 360-degree view of each member’s healthcare, meaning care provided outside of the physician’s office likely was not included.

Now, the Theon® solution readily displays gaps in member care. The practices know where they stand with particular HEDIS measures and can focus their efforts. They also have the opportunity to complete an online submission with the medical record to close certain gaps with supplemental data.

Perhaps that’s why our physician partners have responded so positively to our analytics platform. In the words of PAL’s President, Michael W. Warren, MD,

“You can’t manage what you can’t measure. With Geneia, we’re giving our physicians a tool that easily fits into their existing workflow and easily yields information and insights to help us meet the needs of patient populations while personalizing the time and care offered to higher need patients.”

1HEDIS® is a comprehensive tool used by most health plans to measure performance on important aspects of care and service.