On the Road to Payer-Provider Convergence
Market and government forces are driving alignment and convergence of payers and providers
February 14, 2017
Kevin Rill, Head of Solutions Architecture
Throughout last year, we shared stories about the people using our Theon® platform to improve the quality of care while reducing costs and improving physician satisfaction. So far we’ve met:
Today, I would like to introduce you to Cary. Cary is an accountable care organization (ACO) administrator. The ACO, established in 2012, is located in a highly competitive urban area and includes hospitals, employed and affiliated physicians, home health centers and hospice care. The ACO has at-risk populations and shared savings programs with multiple commercial health plans and the Centers for Medicare and Medicaid Services (CMS) for Medicare and Medicare Advantage members.
Cary’s responsibilities include measuring and tracking organizational performance for medical costs, utilization and quality. She is tasked with providing clear direction and strategies to focus performance improvement activities. Cary is expected to unify people throughout the ACO (physicians, leadership, financial, IT) to take responsibility for improved outcomes in each of their cost and care settings. Her success - and compensation - is directly tied to the cost and quality outcomes as measured by the ACO’s contracted programs.
The programs Cary juggles range from fee-for-service reimbursement to the latest MACRA-specific alternative payment models to custom contracts with eight commercial health plans. The ACO has nearly 500 participating physicians and oversees the care of more than 160,000 lives.
Until recently, Cary’s ability to keep a pulse on organizational performance was hindered by the multitude of applications she had to use. Each health plan had its own application, contract and metrics for each quality measure. Bouncing between these applications consumed a great deal of time every day, increased frustration, and inhibited her ability to measure, track and compare performance across the ACO.
This is exactly the type of situation in which the Theon® platform shines.
You see – the Theon® platform merges everyone’s data, populations, and the details of all value-based contracts to enable administrators like Cary to manage them all through one single interface.
Within weeks of choosing our platform, Cary easily accessed data-driven insights to help her best achieve shared savings goals across all payment programs.
No more bouncing between programs searching for each health plan’s requirements for each quality measure. In fact, like other administrators using the Theon® platform, Cary soon realized a full 60- minute reduction in administrative burden every day.
With the Theon® platform, Cary finally had the birds-eye view she needed. With a few clicks, she drills down into the supporting data to get to the root of problems. Through analytics that span every care and cost measure within the ACO, Cary sees:
Variances in care across providers and provider sites
Patterns of quality performance – above and below average
Actual inpatient and outpatient costs
Utilization inefficiencies (many related to high-cost patients)
Referral and prescription patterns
With a focus on improving quality through delivering preventive services, Cary quickly identified key areas to deliver short-term success and long-term sustainability.
For example, Cary targeted NCQA quality measures (HEDIS® ) common to commercial health plans and the ACO. She also knew improving quality meant making effective changes to the delivery of care -- changes that required easy, concise communication with providers. Thankfully, the Theon® platform enables administrators to push information directly into the EHR so clinicians, at the point of care, clearly understand open care opportunities and can take simple steps to close and report them.
As compliance and reporting improved, the commercial health plans boosted their HEDIS® reporting and increased Medicare Star ratings, while the ACO made significant strides toward achieving shared savings. Such progress represents a winning partnership.
Through the Theon® platform, Cary easily identified the three top open care opportunities across the ACO:
Adult BMI (body mass index) assessment & follow up
Colorectal cancer screening
Adolescent well-care visits
Additionally, the Theon® platform revealed patterns of HEDIS® compliance within each provider group, enabling them to focus their efforts and resources accordingly.
The result: by focusing on the quality measures identified through the Theon® platform, the ACO achieved shared savings of more than $12 million, a 25+% improvement over the prior year.
Cary’s story is another example of how Geneia’s technology with a heart is helping organizations achieve immediate and long-term success in value-based arrangements as well as deliver more patient-centric, preventive care. For the first time, a single-platform technology like the Theon® platform has brought together every quality measure across the ACO to deliver data-driven insights that drive unity and shared savings.
*Cary’s experience is an illustrative example based upon the actual experience of a Geneia client. This information is provided for illustrative purposes only. Cary is fictional and not intended to represent any specific person. Any direct similarities to any real person are purely coincidental and unintentional.
Traditional health plan A&R reporting is insufficient to effectively manage value-based care contracts.
Health plans using an advanced analytics platform can achieve a triple win.