Large multistate health plan enables performance in value-based program using shared analytics

Client background

A large multistate health plan covering over 15 million lives.

The business challenge

Before our client launched their current state value-based reporting platform, they attempted to reuse existing network level cost and utilization reports by running them against custom populations of members. The legacy reports required highly labor-intensive queries to produce datasets that were then manually processed through a reporting software package only used for formatting purposes. The reports lacked critical functionality for an ACO as they did not include a market comparison, did not support leakage reporting to identify where members receive treatment outside of the ACO, and contained no drill-through into underlying detail. All of these capabilities are critical to allow ACOs to understand their members’ utilization patterns and opportunity areas for improvement. With a rapid interest in expanding value-based programs, the pilot solution no longer met our client’s business needs.

Established quality reporting was at the network level and offered no flexibility into specific ACO results. To meet ACO financial quality incentive business needs, auditor certified quality reporting at an ACO population level was required.

The Baker Tilly approach

Baker Tilly worked with our client and a vendor to create a comprehensive reporting and analytics solution designed to scale with our client’s quickly growing value-based program needs and helped them meet their business objectives in the following ways:

  • Collaborated with our client’s Network, Enterprise Operations, Quality, and IT teams as well as an analytics vendor to build several types of custom reports. These reports were designed to allow our client and their providers to view reports at an ACO contracted entity level and offered drill-downs into the underlying physician level of detail and then further into individual members and claims.
  • Worked with client IT teams to design and test data extracts from various sources (membership, claim, lab, etc.) to feed downstream reporting systems.
  • Collaborated with vendor engineers on technical design, development and testing of each dashboard report, including design of underlying data structures and data transformation business rules, analysis path definition and user security privileges. Also supported vendor in building quality measures from certified healthcare quality organizations such as NCQA and AHRQ.
  • Coordinated activities with quality auditors to assure quality report results met national compliance standards for accreditation.
  • Trained end users by security access level on specific report and analytics functionality to ensure successful user adoption.

The business impact

The rollout of the current reporting and analytics platform has allowed for detailed insight at an ACO and member level for over 60 ACOs on a single consolidated platform. Monthly, over 10 quality and member level detail reports are delivered to each ACO and quarterly, over 60 cost, utilization and leakage reports are delivered. Each report is dynamic, allowing for adjustable filters and offers reliable point-in-time reporting for those users that may need to look back at historical trends.

Our client has formed informal joint operating committees with their ACO partners, and these collaborative teams use the reporting platform to analyze results and opportunities to drive toward an overall higher quality of care for each member at a low cost.

  • Cost, utilization and leakage reports provide insight in the following ways:
    • ACO performance benchmarked against a geographic control group and prior year results provide transparency into performance areas with improvement potential
    • Quarter breakouts and granular place and type of service categories support provider insight around seasonality of services and target areas to focus on
    • Summary reports with deep drill-down capabilities and defined analysis paths that allows teams to answer questions such as:
      • Which patients are most expensive in a designated time period?
      • Which hospitals outside of the ACO are members frequently visiting for  certain clinical categories?
      • How is the ACO performing compared to the relative market?
  • By leveraging the results of the HEDIS, AHRQ, CAHPS, and eCQM vendor partner’s quality measurement capabilities, our client and their provider partners now have:
    • Annual quality scorecards with over 25 quality measures that may be used as inputs for financial incentive calculations
    • Monthly patient care gap reports that target individual preventative care to drive overall better health outcomes for members
    • Quick and easy identification of quality performance trends over time
    • Visibility into EMR sourced clinical data
    • The ability to answer quality measure specific questions such as:
      • Which patients are eligible for mammograms?
      • Which patients have the highest rates of re-admission?
      • Which physicians have the highest number of members on antibiotics?
  • Monthly integrated opportunity analytics reports at the member level of detail help identify patient candidates for providers to take specific action by providing:
    • Member attribution information: Allows ACOs to manage patients at the PCP level
    • Member risk scores: Allows comparison of current health of a member relative to others within the ACO population
    • Member opportunity scores: A custom methodology used to prioritize patients for care management intervention
    • Chronic conditions and preventive screening information: Insight into which members qualify for certain care pathways
    • Summary counts of patient admissions, ER and specialist visits: Includes drill-down functionality into each visit to identify members as frequent utilizers

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