11 Questions for Physicians to Ask Their Health Plan Partners about Reporting

April 11, 2017
Mark A. Caron, FACHE, CHCIO, CEO

Without a doubt, health plans have been creating value-based reimbursement relationships with their provider partners.

In 2015, nearly all health plans reported having some type of value-based arrangements in place[1]:

Keyboard Stethoscope

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


Nearly two years later, these numbers are likely quite a bit higher. In fact, a recent Chilmark Research report about ACOs found the number of ACOs has grown 13–15 percent each of the last two years. There are now more than 935 ACOs with 1,300+ contracts, covering 10 percent of the population and 25 percent of Medicare beneficiaries.

That same Chilmark Research report reported something Geneia’s physician practice clients have already learned, some the hard way: an electronic health record (EHR) is insufficient to manage and improve the cost and quality of care of patients attributed to an ACO because so much care, especially for at-risk and sick patients, happens outside of the primary care setting and in specialist offices and hospitals. Participating providers need more sophisticated technology and analytics solutions to succeed in ACOs and value-based arrangements.

That’s why we counsel our physician practice clients to pose key questions about reporting to their health plan partners, ideally before they ink value-based contracts. In our experience, there are 11 questions the physician practices most likely to succeed in value-based relationships ask their health plan partners:

  1. Usability:

    Do you provide participating physicians with an online, on-demand and self-service reporting tool that has drill-down capabilities for further exploration?

    Not too long ago, health plans held monthly meetings with participating physicians and used paper charts to review performance. Times have changed. As the result of value-based contracts, health plans now expect more of participating physicians. Therefore, physicians need more from the health plan: a reporting tool comprised of timely patient information, informed by predictive analytics, and available on-demand. 

    The reporting tools most favored by physicians not only include standard reporting on important activities like identification of the high-cost and high-risk subpopulations for engagement and evaluations of out-of-network utilization for possible redirection to in-network services, but also allow physicians to drill-down within all the reports to view and evaluate the underlying numbers.


  2. Multi-Payer Reporting Tool:

    Can I use your reporting tool with all of my ACO and value-based contracts?

    The typical physician practice has more than one ACO or value-based contract. Given the already high administrative burden on today’s physicians, it is simply unrealistic to expect physicians and their staffs to toggle between as many as 10 different reporting tools throughout the work day.

    Additionally, there is typically much similarity and overlap between these contracts. For example, all of these contracts establish benchmarks for breast cancer screenings and reward physicians for meeting them. Physicians need one way to measure and manage breast cancer screening for all of their patients regardless of the value-based plan to which they are attributed.


  3. Data Quality:

    Does the tool integrate timely data from all sources, including clinical, claims, demographic, psychosocial and more to create a comprehensive, 360-degree view of each patient?

    It’s always been true that physicians need comprehensive information to most effectively treat their patients. Not so long ago, primary care physicians treated their patients for decades and came to know and treat their families, gaining valuable insight about what we now refer to as social determinants of health.

    In a value-based environment, it is even more important that physicians managing attributed patients have a complete picture and be able to quickly access a 360-degree view. For example, primary care physicians too often do not know what happens to their patients outside of their offices. Timely knowledge of which patients are in the hospital, which have been discharged in the past 10 days and how far a discharged patient lives from a pharmacy is the kind of information primary care physicians need to prevent costly and avoidable readmissions.


  4. Timeliness:

    How often is the data updated and how frequently do participating physicians access your tool?

    Far too frequently, physicians lack access to claims information, and even when they have access, it often lags by months. For physicians to succeed in value-based arrangements, they need access to timely information to make the best decisions for their population of patients and, when needed, to course correct. The frequency that physicians and their staff access health plan reporting is a bellwether indicator of how often the data is refreshed and how useful the information is.


  5. Contract and Reporting Tool Equivalency:

    Does the tool mirror the contract and therefore help me know where I stand in terms of contract performance and success? Specifically, does the reporting timeframe in the tool mirror the contractual timeframe? Are the risk adjustment and attribution methodologies in the reporting tool the same as the ones in the health plan contract? Are you comparing me with the same set of peers in the reporting tool and the health plan contract?

    It should go without saying the reporting tool needs to help physicians understand and improve their performance in terms of meeting the measures in the contract; however, in our experience, too often there are meaningful differences between the contract and the reporting tool that impede physicians’ value-based care success.


  6. Workflow Integration:

    Does the tool automatically push notifications into my practice’s EHR?        

    Most providers working in a value-based reimbursement environment have found that an EHR is necessary but not enough, meaning they need more capabilities than a typical EHR provides but also seamless data sharing between the EHR and the reporting tool. To improve physician effectiveness and reduce physician burnout, the reporting tool needs to automatically push notifications into the practice’s EHR.


  7. Data Filtering:

    Can I filter the data to compare performance between practices and also between providers within the same practice?

    Typically, physicians do not want to be outliers in comparison to their peers, meaning comparison data can be effective in educating providers and changing their practice patterns.  One of our client’s used advanced analytics to determine their average number of MRIs per 1,000 patients for each physician and the range was three to 21. Upon further review, they learned the younger physicians tended to order more MRIs. The practice used evidence-based medicine to develop clinical guidelines for MRI-appropriateness and worked to consistently apply them. Younger physicians were also paired with more seasoned ones for mentoring. Within six months, the average MRI rate fell to six per 1,000 patients. The most advanced reporting tools enable easy performance comparisons between providers and practices.


  8. Addressing Root Causes:

    Can I use the tool to understand and address the root cause(s) of outlier performance?

    It is common to monitor and compare performance between practices and between providers within the same practice on utilization trends such as emergency department visits, MRIs and specialty pharmacy. The reporting tool needs to support this comparison and allow for further investigation of outliers.

    For example, a Geneia client learned they had significantly higher per-member-per-month costs for emergency department visits than their peers. Upon further review in our analytics and reporting tool, the practice administrator discovered one provider group was largely responsible. Further review revealed the root cause was the utilization of unaffiliated provider groups. She initiated outreach activities to both attributed providers and patients to begin redirecting services to in-network and lower cost services such as urgent care.


  9. Real-Time Population Regrouping:

    Can I group and ungroup populations and subpopulations at the point-of-care in real-time?


    Since we know certain sub-populations are higher utilizers of avoidable healthcare services and can be the ones most in need of redirection to lower cost services, the usefulness of aggregate numbers is limited. Other times, a physician may want to explore trends for one subpopulation, for example, Medicare patients with a heart failure diagnosis, to review and potentially address referral and treatment patterns. Therefore, it’s imperative to be able to create populations and subpopulations on-demand to more effectively manage the cost and quality of care.


  10. Quality Performance:

    Does the tool tell me aggregate contractual performance-to-date on quality metrics like HEDIS® and Medicare Star ratings, as well as identify which patients still have open quality opportunities?

    All value-based contracts measure provider performance on quality metrics like HEDIS® and Medicare Stars. The most sophisticated reporting tools contain timely, accurate scorecards that help providers meet these performance goals. The most effective scorecards are ones that:

    • Are created monthly – and even more often as the end of the reporting period approaches
    • Aggregate information from more than 25 diverse sources
    • Pinpoint exactly where a provider stands in relation to the contract goals
    • Identify precisely which patients still have open quality opportunities
    • Prioritize patients with more than one quality opportunity


  11. Rising-Risk:

    How does the reporting tool help me identify which of my patients are experiencing rising risk and what kind of care management programs do you have to help me engage those patients before they develop a chronic disease?

    Increasingly, predictive analytics allow health plans and providers to identify which members are likely to become sick in the next 12 to 24 months and then intervene to prevent chronic illness. For example, some health plan reporting tools can identify the pre-diabetics within a patient population, combine this information with preventive care compliance and medication adherence, and then provide prescriptive information to help providers best engage those members in care management resources.

    The savviest health plans want their participating providers to succeed in value-based contracts. After all, their fates have always been inextricably linked, and that’s even truer now as the evolution to a system that links payment and outcomes continues and health plans narrow their provider networks. Health plans that provide their network physicians with a comprehensive, sophisticated reporting and analytics tool:

  • Set up physicians to succeed in value-based contracts
  • Enhance communication and collaboration between the plan and participating providers through the use of a common tool
  • Improve health outcomes and patient satisfaction.


[1] Deloitte 2015 Study of Medicare Advantage Health Plans and Providers, https://www2.deloitte.com/content/dam/Deloitte/us/Documents/life-sciences-health-care/us-dchs-medicare-advantage-vbc-final.pdf




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