An ACO’s ability to communicate and measure a standard of excellence for its participating practice groups is a critical component in achieving annual shared savings and improving care quality for the beneficiaries the ACO serves. Comprehensive analytics and benchmarks with actionable takeaways are fundamental to this objective. To assist in this effort, the CareJourney team has collaborated with flagship members in developing a comprehensive and transparent scorecard to evaluate TINs based on the most important and impactful spend and necessary care metrics. These metrics are aggregated and weighted (with flexibility to adjust based on a particular ACOs priorities) in a single dashboard with rankings so that ACO leadership can segment provider groups and come up with appropriate action plans for each.
To support the analysis, we first devise critical metrics at the claim line level and apply CMS logic wherever possible for ease of audit. Since CMS does not provide attribution at the TIN-level, it’s important to first understand the recommended method to attribute beneficiaries to TINs in order to understand how we ultimately assess the care each practice provides their beneficiaries.
We first assign beneficiaries to providers based on where the beneficiary has received the plurality of his/her care. CMS defines plurality as “a greater proportion of primary care services as measured in allowed charges within the ACO than from services outside the ACO. The plurality can be less than a majority of total services.” CMS uses this plurality rule to attribute beneficiaries to the ACO. Using this, we can take this ACO-level attribution to the TIN/CCN and NPI levels by utilizing claims to identify the physician and assigned TIN/CCN that has incurred the plurality of these allowed charges for each beneficiary.
Once all ACO attributed beneficiaries are assigned to a TIN, we can analyze each TIN’s billing codes for compliance with major necessary care models – particularly the Annual Wellness Visit (AWV), Transitional Care Management (TCM) and Chronic Care Management (CCM).
Annual Wellness Visits: All patients who are no longer within 12 months after the effective date of their first Medicare Part B coverage period and have not received either an initial preventive physical examination (IPPE) or an AWV within the past 12 months are eligible for an Annual Wellness Visit (AWV). An AWV is a great time for a patient and his/her provider to discuss a care plan for the year. Any patient that has gone longer than 12 months without an AWV or an Initial Preventive Physical Examination (IPPE) is flagged as having a care gap.
Transitional Care Management: Patients who have been discharged with moderate or high complexity levels from an inpatient hospital setting (hospital, SNF, outpatient observation) to their community setting are eligible for Transitional Care Management (TCM). Separate ROI analysis conducted by the CareJourney team have shown that TCM significantly reduces the post 30-day discharge cost and readmission rate. Some members have seen reductions of 30% with statistical significance, emphasizing the importance of evaluating primary care providers, and their associated TINs, on their effectiveness in tracking eligibility and ensuring compliance. Eligible discharges can be identified in claims by:
- Claim type code (discharge from IP stay, SNF, outpatient observation)
- HCPCS codes to determine moderate or high complexity
- Discharge status code to determine to determine discharge to community setting (home or home care)
Chronic Care Management: CCM occurs when a comprehensive care plan has been established, implemented and monitored for patients who have been diagnosed with at least two chronic conditions expected to last at least 12 months (or until the death of the patient). Eligible patients can be identified in claims following the Chronic Conditions Warehouse (CCW) algorithms against ICD and HCPCS codes.
While performing all of the above necessary care services comes with a financial cost, they all contribute to healthier patient populations and overall lower long-term costs for an ACO. Therefore, no TIN-level comparison would be complete without a holistic view on each group’s spending proclivities.
Analyzing a group’s PMPM or PMPY doesn’t exactly make for a fair comparison since each group’s “attributed” beneficiaries have unique and varied levels of risk. To account for this, we calculate a risk-adjusted PMPY by taking the total spend per year divided by total number of eligible patient years, and then risk-adjusting by multiplying by HCC score. We then go further and looks at each group’s trended PMPY to assess if each group is working to reduce costs over time, rewarding those with either or both low risk-adjusted PMPY and positive trends in PMPY over time.
Lastly, to close the financial loop, we calculate unnecessary care spend as outlined in the JAMA low-value care study. This study identified 26 measures of low-value care across 6 categories of services which can all be identified through claims. Practices with high levels of unnecessary care spend per attributed beneficiary are flagged for wasteful behavior.
After beneficiaries have been mapped to attributed practices and the measures outlined above have been calculated for each practice, we are then able to rank TINs within an ACO against each other. First, practices receive a rank of 1 to N within each measure; then, practices are awarded points for being in the top nth percentile of the ACO. Points are added up across the measures, and practices with the highest total points are considered the “best” of the ACO. Understanding the top ACOs’ performance allows leadership to communicate evidence of best practices to other TINs in the spirit of collaboration and mutual success. Identifying the lowest performing TINs creates opportunities for remediation with set improvement targets necessary to secure ongoing affiliation with the ACO.