Controlling costs is a key Value-Based Care goal, a fact well-known to ACOs that share savings with CMS. Even as individual ACOs have generated tens of millions of dollars in savings, however, MSSP ACOs as a whole have only been able to reduce their Total Cost of Care (TCOC) by a fraction. That is a program vulnerability and one reason why value-based payments are increasingly incorporating population-based payment.
Plainly stated, claims data (especially 2-5 months old) isn’t a great tool for identifying patient risks, Medicare HCCs notwithstanding. The timeline for cost prevention is before events occur, not when you’re looking in the rearview mirror. Although using emergency room and inpatient admissions can help you to follow up on patients and possibly forestall future problems, you may well miss the patients who are next in queue for events but hidden from view because you can’t see the risks present in clinical data.
With Alternate Performance Pathway (APP) Reporting, ACOs can do better. Even if you’ve never collected a bit of clinical data, you have the ability to identify some of your most vulnerable patients through APP Measures. Let’s see how that can work to put you ahead of the game and boost your savings.
Use the Tail to Wag the Dog: Focus on APP Data for Cost Savings
Your ACO probably considers APP Reporting as a regulatory program, a necessary requirement for being an ACO. Many providers consider both APP and MIPS quality reporting programs to be a burden. All the more reason that you should use their benefits to enhance your potential savings!
For the majority of ACOs that have not aggregated data from practice EHRs, there has been no clinical information to fuel your cost initiatives. But by using as few as three measures, you can initiate improvements and interventions that can prevent avoidable admissions and their costs.
These three APP measures, required for APP Reporting, capture important outcomes that will be of use to your ACO:
- Diabetes Hemoglobin A1C Poor control Preventive Care (Quality ID 001)
- Screening for Depression and Follow-up Plan (Quality ID 134)
- Controlling High Blood Pressure (Quality ID 236)
Any Method of Reporting APP Measures Will Open Options for Cost Control
You have a choice of three methods for APP Reporting:
- All-patient MIPS CQM Measures,
- All-patient eCQMs, or
- Medicare patient-only Medicare CQMs.
For detail on the pros and cons of these methods, see our tips on choosing your APP Reporting approach.
All three methods will provide you with outcome data for patients with diabetes, hypertension, and depression. But some reporting methods will provide richer data for predicting risk or cost control activities. A detailed data dive is beyond the scope of this article, but here’s how each APP reporting method maps to data value for cost control:
- eCQMs generate less-rich clinical data, providing only data that will meet the measure for all eligible patients. You will get HgbA1C, blood pressure values, and depression data, but not all the clinical information needed to enhance patient risk assessment.
- MIPS CQMs capture richest data across all patients. Requiring data aggregation, CQMs allow the qualified reporting registry to pull data from many sources. This will vary across data-aggregating registries. Roji Health Intelligence pulls a large number of clinical values to calculate measure eligibility, to help clients’ health systems and ACOs participate in improvement programs and intervention, and to pursue cost control activities. The rich data is used to identify highest risk patients and those with exacerbations or progression of disease.
- Medicare CQMs provide moderate data richness for Medicare patients. If your ACO uses CMS patient eligibility lists for measure denominators, you will still need to gather measure values for the patients. The value of your data will be limited if you depend on data input for those values, but this situation is feasible mainly for very small ACOs. If you can aggregate data from systems, you can generate very rich data for the patients and practices on those systems if QRDAs are supplemented by other data aggregation files.
Three Key Areas to Start Cost Control with APP Reporting Data
While the degree of valuable data will vary across the above reporting methods , you will have clinical data for perhaps the first time to begin cost control and further quality initiatives. Here are three avenues that build your foundation:
1. Create a plan for patients with poor control in diabetes and hypertension (all methods of reporting).
What’s in the measure data?
- HgbA1C values
- Systolic and diastolic blood pressure
What are the possibilities?
- Identify patients for review of clinical treatment program based on non-improvement.
- Identify patients based on clinical and medication data for SDOH review.
- Initiate self-management programs, case management for poorly controlled patients and those with exacerbations.
- Choose patients for continual glucose monitoring, self-management programs, or case management.
2. Prevent behavioral health (i.e. depression) admissions or complications of chronic disease (all methods of reporting with claims data).
What’s in the measure data?
- Patients with indication of depression
- Patients with depression and without a plan going forward
- Patients with indication of depression and with diabetes and/or hypertension
What are the possibilities?
- Identify patients without treatment plan and with admissions or emergencies.
- With both depression and diabetes, create interventions to manage condition.
- Establish referral arrangements to community resources.
- Link patients to virtual resources.
3. Identify patient risk for cardiovascular disease and stroke (best for CQM/Medicare CQM methods).
What’s in the data?
- EHR data: Patients with metabolic disease markers (A1c, hypertension, obesity, hyperglycemia, dyslipidemia)
- Claims data: hospital and ER events, other diagnoses such as AFib
What are the possibilities?
- Identify patients with multiple indicators and utilization events for higher risk.
- Investigate unknown diagnoses, such as missing hypertension.
- Identify early indications of diabetes with glycemic values.
- Create risk algorithm based on existing conditions plus events found in claims data.
These examples are just a few of many opportunities to blend improvement of clinical outcomes with initiatives to prevent admissions, reduce ER use, and mitigate progression of disease. Yet all of them use data that will be purposed for quality reporting, plus the claims data you already have. Take advantage of required APP reporting to maximize your opportunity for ACO savings and transition to more effective cost management and better patient outcomes.
Founded in 2002, Roji Health Intelligence guides health care systems, providers and patients on the path to better health through Solutions that help providers improve their value and succeed in Risk.
