One of the core tenets of accountable care organizations (ACOs) is a focus on quality of care and achieving contracted quality measures for their members. Quality measures serve as benchmarks for assessing the clinical performance of ACOs in delivering high-quality healthcare. ACOs must accurately identify and close care gaps within each patient population to achieve optimal quality measures for each performance year.
This process requires clinical and financial healthcare data aggregation often from multiple disparate systems to perform the appropriate analysis. ACOs depend heavily on electronic health records (EHRs), and their population health analytics partner to effectively generate performance results across their provider networks.
ACOs must utilize a trustworthy solution to optimize quality performance and maximize reimbursement. An NCQA-certified partner adheres to the reporting requirements and can help ACOs optimize quality performance and reimbursement efficiently.
At the end of an annual performance year, payers reward ACOs for achieving performance targets on their quality measures. Signature Partners, an accountable care organization in northern Virginia, received disappointing news from their payer. During their year-end quality measures review, the payer reported that Signature Partners did not meet the quality measures benchmarks necessary to receive financial compensation.
To address this concern, Signature Partners used Koan Health Datalyst's quality data tracking and reporting requirements to compare the payer's results with the care they delivered. Datalyst helped the ACO find inconsistencies between the payer’s quality results and what the ACO providers delivered to their patients.
Signature Partners quickly discovered that the payer was using outdated HEDIS measures specifications and not the current version they were contracted to use. This led to incorrect members being included in the payer's final measures results and missed incentive payments for Signature Partners.
Datalyst’s ACO quality measures tracking and reporting enables clients with commercial and governmental programs to optimize quality performance, maximize reimbursements, and greatly reduce quality reporting efforts and resources.
Using the drill-down capabilities of Datalyst, Signature Partners quickly identified members that met the quality measures but were not included in the payer’s calculation using the older quality measures. The ACO analyzed clinical and claims data, and with Koan Health's help, compared payer's results with those from Datalyst, highlighting disparities.
Signature Partners found that the payer did not adhere to the current HEDIS measures specifications stipulated in its contract. With evidence from Datalyst, they submitted an appeal to the payer and demonstrated:
Armed with evidence from Datalyst, Signature Partners appealed the payer's results, providing proof that a significant number of members met the contracted quality measures based on details contained in the population health analytics software's data.
Working together Signature Partners and Koan Health quickly provided the payer with a detailed report demonstrating that their providers had exceeded the contracted performance metrics, which resulted in the payer acknowledging that Signature Partners met and exceeded their required quality measures benchmarks and a “true up” payment by the payer.
Utilizing Koan Health's quality measures payer gap comparison tool we were able to quickly identify inappropriate payer gaps in care and submit supplemental data to close those gaps, ensuring our payer quality measures benchmarks were achieved, which resulted in additional savings. - Signature Partners
The impact of this effort was substantial. Signature Partners not only proved that they had performed better than initially reported by the payer, but they also exceeded the benchmarks required to receive financial compensation.
This successful appeal and the subsequent alignment between Signature Partners, the payer, and Koan Health, marked a significant milestone in their journey toward enhanced ACO quality measures performance.
Koan Health's Datalyst platform empowers ACOs to track and report quality measures performance accurately and efficiently. As commercial payers use different quality measures the analytics software must accommodate the variations. The Datalyst software supports HEDIS, MSSP, Medicare STAR, and a catalog of custom quality measures.
The quality measures capability within Datalyst offers multiple ways for ACOs to view their quality measures gaps and assess their quality measures performance. Datalyst displays performance at multiple levels (enterprise, program/payer, group, physician, and patient) and offers extensive filtering capabilities.
By leveraging this powerful population health analytics software, ACOs can identify care gaps, streamline reporting processes, and generate data extracts for supplemental information.
For commercial payers, the payer gap comparison capability within Datalyst compares the measures and gaps supported by clinical and financial aggregated data with those presented by the payer, highlighting any disparities. Datalyst HEDIS quality measures are certified by NCQA ensuring that HEDIS quality measures results captured in Datalyst are appropriate and aligned with HEDIS quality measures specifications.
By leveraging highly accurate and transparent data, Signature Partners successfully challenged a payer's results, leading to proper reimbursement and enhanced alignment within their ACO.
Datalyst is also NCQA DAV certified, which means ACOs also can use Datalyst to generate data extracts that allow them to send aggregated supplemental data from sources such as EHRs and labs back to the payer to close their gaps in care. Signature Partners is confident in their ability to monitor and report additions to the payer to ensure accurate quality measures performance.
Through this process, Signature Partners emphasized the importance of collaborating with a population health analytics partner committed to data accuracy, transparency, and client success.
Having an analytics partner whose culture is focused on clinical and financial data integrity provides reassurance that accurate quality measures performance and correct compensation for the care delivered is reported for each ACO program they enroll in.
Interested in knowing more about Koan Health's Quality Measures capability? Send us an email and we can discuss more.
Signature Partners is a clinically integrated provider network affiliated with Inova Health System. They are a leading non-profit ACO on the East Coast. Signature Partners has been a close partner of Koan Health since 2015 and has utilized Datalyst and Koan support throughout the years to successfully manage cost, utilization, and quality measure performance across multiple payer contracts.
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