Data-Informed Population Health Reduces PMPM

ACO SUCCESS BASED ON PERFORMANCE

助理检察官会因为表现和在高风险环境中工作而接受奖金或处罚。ACO的成功需要使用可靠的信息技术来识别临床、财务和操作领域的机会，以降低PMPM成本，获得更高的质量分数，并改善患者在再入院等领域的结果。^1,2MemorialCare’s goal was to continue advancing its care management programs to enhance performance and ensure it was engaging with the right patient population to prevent and mitigate negative impacts from COVID-19.

MISSING DATA IMPACTS IMPROVEMENT EFFORTS

MemorialCare的服务范围广泛，包括医疗需求变化很大的患者群体。其提供者根据每个患者的需求为每个患者提供高质量的护理;然而，它缺乏一个工具，使组织能够轻松地整理数据和执行分析。这使得确定有护理空白的患者数量变得非常困难，并且难以确定患者参与的正确患者，确定PMPM成本驱动因素，并评估护理对合同履行的影响。可变的结构和患者需求在分配护理管理和改善绩效所需的提供者支持资源方面带来了挑战。MemorialCare需要一种数据和分析解决方案，能够更有效地识别受益于护理管理的患者和PMPM成本的驱动因素，并使组织能够最大限度地利用高风险和高风险患者参与护理管理的影响。

REDUCING PMPM COSTS IMPROVES ACO SUCCESS

MemorialCare leverages the Health Catalyst® Data Operating System (DOS™) platform and a robust suite of analytics applications, including a PMPM root-cause analytics accelerator, to gain insight into performance. The improved data helps the organization support providers and care managers to ensure patients receive the right care in the right location, prevent unnecessary overutilization, and improve contract performance.

组织进行全面、深入的分析，以揭示驱动PMPM绩效的因素，识别需要改进的领域，并管理成本以实现节约和避免损失。MemorialCare使用分析加速器来审查基于索赔的数据，并评估PMPM绩效的驱动因素。组织可以可视化网络内和网络外的支付趋势视图，使其能够理解提供者、成员和专业领域如何对整体PMPM支付性能做出贡献，提供减少PMPM的机会的洞察力。

MemorialCare’s clinically integrated network (CIN) supports primary care providers in delivering needed primary and specialty care. Network and provider performance targets and improvement goals align with the goals in its various contracts. The organization allocates its care management team members to support specific regions, providers, and patients within the CIN. MemorialCare uses standard work for care transitions and ongoing care management activities. The care management team leverages patient risk-stratification data to identify high- or rising-risk patients for outreach, engaging patients in care management activities that ensure the patients receive the right care in the right location. MemorialCare uses a COVID-19 risk for mortality algorithm to identify and risk-stratify members at the highest risk of mortality from COVID-19. Care managers can visualize at-risk members and can quickly prioritize member lists for outreach.

MemorialCare analyzed its data to identify opportunities for improvement, including emergency department (ED) utilization, network leakage, and brand-name prescription use. For example:

• The data showed that patients with newly diagnosed conditions, rather than those with a known chronic condition, often sought emergency care over primary care. To address this, the care management team contacts newly diagnosed patients weekly to assess their current understanding of their condition, offer education, and support patients in accessing needed primary and specialty care, avoiding overutilization.
• An analysis of network utilization data indicated that self-directed referrals and provider-directed referrals for specialty care were areas of leakage. The care management team proactively educated both patients and providers to better manage specialty referrals to avoid costly out-of-network use
• 数据分析还显示，高药品成本和超说明书使用是降低成本的额外机会。药剂师和护理管理团队合作改善药物管理，并安全地将患者过渡到仿制药。

The care management team and providers meet monthly to review data to increase understanding of performance, continually improve processes, learn from successes, and identify future improvement opportunities.

RESULTS

MemorialCare’s data-informed care management interventions have demonstrated the desired results. Patients receive the right care in the right location, and the organization has reduced overutilization and improved contract performance. The COVID pandemic also reduced utilization of health care services. Results include:

• 66 percent of MemorialCare’s ACO individuals at extremely high risk of severe COVID-19 illness were engaged by care management.
• $2.3M in cost savings in 12 months, the result of a 9.1 percent relative reduction in PMPM costs.
• In addition to the PMPM cost reductions, MemorialCare observed reductions in other utilization measures.
  • 25.5 percent relative reduction in ED visits per thousand members per year (PKPY).
  • 24.3 percent relative reduction in laboratory and pathology tests PKPY.
  • 18.9 percent relative reduction in high-cost imaging.
  • 17.7 percent relative reduction in inpatient admissions PKPY.
  • 14.1 percent relative reduction in 30-day readmission PKPY.

“使用PMPM分析仪可以让我们了解合同绩效和PMPM的驱动因素。我们的护理管理团队能够专注于确保患者得到正确的护理，并提高合同绩效。我们在降低PMPM的同时，改善了患者的健康状况。”

Linda Violas, BSN, RN, PHN, Executive Director ACO, MemorialCare

WHAT’S NEXT

MemorialCare will continue to use its data and analytics to identify opportunities to improve the effectiveness of its care management programs while also improving contract performance.

REFERENCES

1. Peiris, D., et al. (2016). ACOs holding commercial contracts are larger and more efficient than noncommercial ACOs.Health Affairs, 35(10), 1849–1856. Retrieved fromhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC5116911/
2. 康罗伊kj(2020)。ACO持续成功的4个关键构件。MGMA.Retrieved fromhttps://www.mgma.com/resources/financial-management/4-key-building-blocks-for-continued-aco-success

ADDITIONAL READING

• Improving Population Health: Data-Driven Approach to Identifying and Engaging Patients with High Risk of Mortality from COVID-19
• Analytics Improves Population Health and Drives Efficiencies
• Analytics Improves Insight into PMPM, Reduces Liabilities in Rate-Setting Agreements
• Analytics Enables Value-Based Care Transformation
• Analytics and Provider Operations Support Generates Nearly $2M in Shared Savings