In 2023, healthcare organizations across the industry faced significant challenges as the Centers for Medicare &Medicaid Services (CMS) implemented changes to their Hierarchical Condition Category (HCC) model. For one regional Accountable Care Organization (ACO), this transition from version 24 to version 28 threatened to impact their recapture rates substantially. However, through a strategic partnership with Koan Health and utilizing the Datalyst population health analytics platform, the ACO overcame these challenges and emerged stronger, achieving remarkable improvements in their HCC recapture performance.

When Change Creates Complexity

The ACO experienced a concerning 10% decline in their HCC recapture rate compared to the previous year's performance. The new v28 model introduced updated coding requirements and altered risk scoring factors, complicating the accurate documentation of patient complexity. These modifications created substantial hurdles in accurately documenting patient complexity, a challenge that resonated throughout the healthcare industry.

The decline in performance highlighted a crucial need: healthcare organizations require innovative solutions to adapt to and address evolving CMS requirements proactively. Without such tools, maintaining accurate risk adjustment and ensuring proper reimbursement would become increasingly difficult.

Building a Data-driven Response

Recognizing the need for a robust solution, the ACO partnered with Koan Health to utilize the Datalyst platform. This strategic decision proved transformative, offering several key advantages:

• ‍Early Visibility: Datalyst provided crucial insights into v28 HCC gaps well before this data was available in traditional Electronic Medical Records (EMRs). This early access enabled providers to take proactive measures rather than reactive ones.

• ‍Focused Approach: Through sophisticated analytics, Datalyst identified two high-impact areas that would yield the most significant results for the ACO's team: Obesity and heart arrhythmia. This targeted approach allowed for more efficient resource allocation and gap closure efforts.

• Data-Driven Decision Making: The platform's analytics capabilities enabled the ACO to pinpoint specific areas requiring improvement in their HCC recapture process, leading to more strategic and effective interventions.

"The transition to CMS v28 created challenges for our organization, but Datalyst gave us the insights we needed to get ahead of the curve. Having early visibility into HCC gaps and focusing on high-impact areas allowed our team to work smarter, not harder. The platform's analytics didn't just help us recover– they helped us exceed our previous performance levels."   - Clinical Director, Regional ACO

Transformative Outcomes

The implementation of Datalyst yielded exceptional outcomes for the ACO:

• ‍Rebound in HCC Recapture Rates: The organization achieved a remarkable 12%+ increase in its HCC recapture rate, recovering from the previous decline and surpassing its historical performance levels.

• ‍Boost HCC Score: Improved average HCC Risk Score by an estimated 2.5%

• ‍Proactive Risk Adjustment: Early identification and targeted focus areas allowed the team to close gaps efficiently, positioning them for sustainable success under the new CMS model.

"This ACO's experience highlights the transformative potential of using a population health analytics platform to navigate regulatory changes and achieve operational excellence. Our client has improved its capabilities by accurately documenting patient complexity and ensuring appropriate risk adjustment. Through advanced analytics and a focused approach to closing gaps in care, the ACO has built a strong foundation for continued success in the ever-evolving healthcare landscape.”  - DT Nguyen, Founder and CEO, Koan Health

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About the Client

• Regional ACO managing 200,000 lives across Commercial, Medicare Advantage, and MSSP programs
• Non-profit health system serving more than one million patients annually
• Nationally ranked and recognized for excellence in safety, quality, patient experience