ACO Identifies $1.1M Annual Gap in Risk Score Benchmark Leveraging CareJourney Market Intelligence

Challenges

This member struggled to understand why their ACO population’s risk score was consistently lower than average. They were confident that their patient population was not significantly healthier than average, and wanted to make sure their financial benchmark appropriately accounted for the acuity of their patients. Ultimately, they sought to improve performance in MSSP by leveraging CareJourney’s risk score benchmarking analytics to understand the inputs driving their population’s risk score.

As a smaller ACO, this member didn’t have the resources to audit the risk scores for all of their assigned beneficiaries. Therefore, they leveraged CareJourney’s risk score bench- marking analytics to better understand the variation drivers for their population risk score.

How CareJourney Helped

Leveraging historical claims data, CareJourney compared the ACO’s risk score, HCC prevalence and coding practices to regional and MSSP population benchmarks to identify where their patients looked different from a risk score perspective.

CareJourney helped this ACO identify that their population appeared to have a lower prevalence of Heart Failure compared to the rest of the state, which didn’t align to their expectations. Upon further analysis, they identified there were two high volume provider organizations within their ACO with significantly lower recapture rates of heart failure. Their patients with heart failure were not being seen on a regular basis. As a result, these patients were missing out on important care to manage their condition, and their acuity was not accurately being captured. Not only does this negatively impact patient care, but the ACO wasn’t receiving the appropriate budget for their population.

Impact

CareJourney concluded that every uncaptured beneficiary with heart failure corresponds to roughly $3,700 in PMPY benchmark to help manage their condition appropriately. If the ACO was similar to the state in terms of heart failure prevalence, it would translate to an increase in their MSSP benchmark by $1.1M.

The ACO also plans to leverage CareJourney to inform their internal HCC audit and compliance efforts to understand where they may be at risk for overcoding.