“Costs were reduced through increased tracking and reporting, primary care physician education and care management efforts.”

Challenges

The Medicare Shared Savings Program rewards Accountable Care Organizations (ACOs) that deliver high-quality health care while lowering costs.

Achieving the shared savings goals requires better management of healthcare for individuals within the ACO’s population by focusing on care coordination and preventive health services. Timely, accurate information is critical.

Our client did not have either.

The ACO needed data to understand who in the population is receiving care, the providers that engage with this population, as well as details of how, where, and when the patients interact with providers.

Armed with the right data, the care management team can proactively work with patients to ensure they are getting the right treatment and help keep them from ending up in hospitals. For more, read the story as published by the ACO here.


Our Approach

CSG designed a data warehouse and ETL process that extract the requisite information to build the picture of the patient population, the care providers, and the insurance companies (payers).

Patient activity data comes from various hospitals and other systems across the network to generate a definitive roster of patients and providers (e.g. doctors, clinics, hospitals) in the network. Additional claim and patient information also collected from payers such as CMS (Center for Medicare & Medicaid Services), United Healthcare, Humana, and others.

The data warehouse integrates the data that the ACO Care Management Team uses to work with patients. For example, they can see a record of admissions and discharges by date by person, the types of visits (e.g. doctor visits, wellness visits, outpatient episodes) and data about the level of risk that a patient will be readmitted.

Since the information is used in a variety of ways, the information can be accessed and analyzed in a variety of ways. In some cases, reports are generated that are sent to other organizations and to physicians. Analysts work with the data using Tableau as the data visualization tool.


Customer Success

The solution provides the ACO with a single, up-to-date version of truth (facts) about the Medicare & Medicaid population (patients), how they interact with the system (via the payer claims data), and enables the ACO to proactively work to improve health outcomes and lower costs.

ACO’s are scored across 32 quality measures from the Centers for Medicare and Medicaid Services. Our client’s ACO achieved their goal which results in shared savings that are distributed among ACO participants.

The ACO increased the overall quality score to 97.99% from 92.6% (versus the national average of 90%).

Care Managers use information from the data warehouse to help patients stay independent and out of hospitals.

“Costs were reduced through increased tracking and reporting, primary care physician education and care management efforts.” – Chief Nursing Officer