Payers & Providers

Employer Health Plan Successfully Lowers Costs and Boosts Benefits

Offering a competitive healthcare plan for employees is a business essential, and a differentiator for organizations to attract top talent, but as healthcare costs continue to rise, employers are increasingly challenged to offer affordable employee healthcare with extensive benefits. Learn how Health Catalyst embraced self-insurance to take the management of its healthcare costs and benefit design into its own hands.

Analytics Improves Insight into PMPM, Reduces Liabilities in Rate-Setting Agreements

To succeed as a coordinated care organization and better serve its Medicaid population, Health Share of Oregon leveraged analytics to obtain a holistic evaluation of the drivers of per member per month payment performance.

Integrating Data and Analytics into Provider Workflow Improves ACO Performance

Providing and documenting best practice preventative and primary care measures is critical for MSSP success. Read how USMM integrated data from disparate sources and utilized its analytics platform and applications to achieve 80th and 90th percentile performance for various ACO measures, resulting in significant contributions to Medicare savings.

Improving Accuracy of Clinical Documentation Positively Impacts Risk Adjustment Factor and HCC Coding

Improving accuracy of clinical documentation can impact risk adjustment factor and HCC coding, significantly enhancing reimbursements for health systems. Read how Allina Health leveraged its analytics platform and applications to help improve HCC coding efforts and more accurately reflect patient complexity.

Opportunity Analysis Permits Successful Execution of At-Risk Contracts

Growth in the government payer mix and an increased cost burden to the commercial population, decreases in the private payer population, and programs like the Medicare Shared Services Program, have caused joint ventures, partnerships, and co-branding efforts, better known as at-risk contracts, between payers and providers to increase.
Allina Health has three Integrated Health Partnership (IHP) contracts, an accountable care model that incentivizes healthcare providers to take on more financial accountability for the cost of care for Medicaid patients, which cover approximately 90,000 members. To achieve success in its IHP contracts, and avoid losses, Allina Health needed to reduce healthcare costs while improving patient outcomes and experience.
Allina Health has integrated several data sources, including claims and developed the infrastructure required to perform opportunity analysis. Using data and analytics for opportunity analysis has given Allina Health insight into its IHP patient population, supporting the development of interventions to decrease the total cost of care and improve outcomes.

Mission Health Receives 100 Percent of At-Risk Dollars in Payer Incentive Program

Since 2004, the US healthcare system has annually ranked last relative to 10 other developed nations in quality, access, efficiency, equity, and health outcomes. In an effort to improve the quality of care and patient outcomes in the U.S., the Center for Medicare and Medicaid (CMS) launched a series of quality incentive programs designed to generate a shift from volume to value-based reimbursement.  The health insurance industry soon followed their lead, and started writing contracts with hospitals in which a percentage of payment was based on performance on selected quality metrics.
Faced with the challenge of reporting on numerous incentive programs with differing expectations, Mission Health leveraged their enterprise data warehouse to aggregate the data needed to track the quality measures. With millions of dollars on the line with one particular payer, Mission developed an analytics application to monitor performance on the metrics in that contract.  The application was used to analyze whether performance feedback and workflow changes would lead to improved performance on the metrics, thus ensuring that they would maximize reimbursement, while improving care for patients.
Results:

Achieved 100 percent of all at risk dollars.
100 percent of the ambulatory metric targets were exceeded, some by as much as 19 percent.
All five hospitals exceeded targets for 80 percent or more of their inpatient metrics.