The biggest challenges for ACOs are:
For years, healthcare insurance companies (payers) have mined claims data for chronic patients and have built predictive models to identify high-risk patients. Armed with historical reports, case managers designed intervention programs that were meant to prevent complications among chronic patients and reduce ER visits and hospitalizations. While this approach has seen some success, limitations far outweigh merits. Most primary care physicians are highly skeptical of claims-based predictive models because they have no latest clinical basis, and give no consideration to the current state-of-health of the patient. Moreover, there is a complete lack of causation. Why a patient is considered high-risk? What are the clinical reasons for the high risk score? How do we lower the risk score? How does the score measure the effectiveness of my care management program?
Most claims-based analysis use coding from claims as the crux for the predictive models. Providers are skeptical of this approach, as the objective of coding is to maximize revenue and not to capture the exact state-of-health of the patient
VitreosHealth: To address this gap, VitreosHealth has built the Next Generation Population Health Predictive Models in partnership with physicians and clinicians over the last 4 years. These models mine the latest provider EHR data along with claims, financial and quality data. The models capture the patients latest State-of-Health (SOH) by chronic condition, compliance to best practices, prior patient utilization trends and socio-economic factors in determining the Risk of Hospitalization for the patient population. This approach helps systematically peel the factors driving the high risk of hospitalization to determine the drivers to design effective care management programs. To date, we have built in excess of 20 models for chronic diseases and conditions covering most of the high frequency and high cost disease conditions.
The Multi-dimensional interactive analysis tool helps analyze each patient's use of resources from multiple dimensions across the continuum-of-care, to determine the right patient attribution to a physician.
To understand VitreosHealth EHR-based approach to Next Generation population risk stratification and predictive analytics, please request a demo and read White Paper | Population Health Management: Real-Time State-of-Health Analysis.
One of the most critical problems ACOs face is, how to assign a patient to a physician or a team of physicians who would be responsible for caring for the patient across the continuum of care. This assignment is a very important decision. The most common methodology is to use historical claims and identify the physicians and specialists with whom the patient has had most visits. While this approach is useful, it is also retrospective. It assumes that the patient will need to see the same specialists in the future. This assumption is erroneous. A correct approach is to use predictive risk scores and identify what health issues a patient is likely to have in the future. For example, a 70 year old woman with no history of osteoporosis may be at a high risk for osteoporotic complications in the next 5 years, and may need to have an orthopedic and spinal surgeon in her assigned team.
VitreosHealth: VitreosHealth's predictive risk scores coupled with multi-dimensional analysis allows attribution based on a number of criteria such as
The success of an ACO depends on optimal design of the ACO Network. ACOs need to have the right number of PCPs and specialists at the right locations to ensure access to quality care for their population and at the same time avoid excess capacity. Successful ACOs need to:
VitreosHealth: VitreosHealth is the only solution in the market that uses the population State-of-Health (SOH) scores to predict the demand for specialists (cardiologists, Endocrinologists, etc.) for an ACO by specific region or by zip code. VitreosHealth application also helps in demand planning for specialist procedures and potential hospitalizations over the next 1-2 years. All this is based on the current ACO population SOH scores by chronic condition.
Gone are the days, where planning to determine the number of cardiologists your ACO needs and where to locate the specialty centers were based on population census data. We have saved our customers millions of dollars by helping them avoid making wrong investment decisions. Our demand planning tool predicts the demand for specialist resources, procedures, facility usage based on the current state of health and the risk of hospitalization data by each chronic condition.
Various recent studies have shown that out-of-network visits and ER visits can be reduced if patients have better access to care. A patient encountering a health ailment who cannot reach his PCP/specialist/nurse on phone is much more likely to call 911 or show up at the Emergency Department. Socioeconomic factors also play a big role in determining who needs more access to care. An affluent, highly educated, married male is perhaps less likely to call 911 than a single, unemployed male suffering from depression. Is it important for ACOs to segment their populations into groups that require better access to care.
VitreosHealth: VitreosHealth uses very precise socio-economic data to calculate 'access of care' scores for each patient. By combining access-of-care requirements with clinically calculated risk scores, ACOs can provide better access to those patients who need it most.
“The Vitreos Health State-of-Health scores really allowed us to embrace the Principles of Accountable Care Organization and transform ourselves with a data-driven decision making process…..Overall we were able to beat the market: For Outpatient Diagnostics, MCNT costs were up by 1.9% vs. Market up by 9.7%; and for Outpatient Surgeries costs, MCNT outpatient costs were up by 5.6% compared to the market at 15%.”
Karen Kennedy - CAO, MCNT from 1998 to 2013
A 4-Step solution towards your goal
ACO Sign Business Associate HIPAA agreements with Vitreos
ACO sends CMS claims and EHR files (if available) of the patient population to our secured
Vitreos team will normalize the data and run it through Vitreos Predictive Analytics Tool
ACO accesses the actionable reports to execute on within 15 days