ROI in risk-based contracts requires data and analytics

Photos: Drs. Jamie Reedy and Ashish D. Parikh/Courtesy Summit Health

Summit Health has seven commercial and Medicare risk-based contracts covering more than 165,000 lives. 

How those responsible for managing the contracts have gotten a return on investment out of an accountable care model that requires considerable investment is the focus of the HIMSS21 session, "Building ACO Analytics: Identify Opportunities, Measurement and ROI" on Tuesday, August 10 from 4:15 to 5:15 p.m. at Caesars, Forum 131, in Las Vegas.

Data and analytics is needed before decisions can be made on investment in specific cost-reduction and care quality programs. 

"Our analytics capabilities helped us make data-driven decisions about where to expand or reduce program investments," said Dr. Ashish D. Parikh, chief quality Officer at Summit Health. 

"You can't be in a risk-based contract without data," Dr. Jamie Reedy, chief of population health at Summit Health.

For instance, analytics helped the Summit Health team evaluate its transitional care management program. The TCM program had all of the right metrics. Patients enrolled in transitional care management had lower readmission rates, lower cost of care after discharge, and higher retention by the medical group. The analysis supported a decision to invest additional resources in expanding the TCM program. 

However, when they looked at the ROI on primary care physician follow-up visits for patients who went to the emergency department, they saw no clear impact on outcomes.

The findings were used to change their approach and to focus on specific high-risk cohorts to reevaluate ED-related workflows as they incorporated additional admission discharge transfer data feeds.

Not all of Summit Health's contracts are value-based. 

"Our total revenue is a combination of fee for service and fee for value," Reedy said. "It really is a balancing act. We continue to increase the level of risk in value-based contracts, based on the pace we set."

Summit has been in both the Pioneer and Next Gen accountable care programs. It currently has only one contract involving capitation.

The transition to value began about 10 years ago.

"We got into commercial risk contracts first and then Medicare Advantage because we had unique partnerships with plans who were able to pilot payment models with us," Reedy said. "From some of our pilots, we felt comfortable at an early stage."

Scaling up on value needs a foundation provided by ACO operations teams that use data to stratify patients for home health, geriatric consults, end-of-life care, annual wellness visit outreach and more.

Performance is monitored and physicians and specialists are engaged through personalized reporting designed to help each provider understand his or her own performance and opportunities for improvement.

"We leveraged physician leadership to drive this change," Parikh said.

Acquiring a population health platform, integrating data and building internal analytics capabilities requires substantial investment. 

There needs to be a way to measure and build ROI, Reedy said. Systems should know their baseline performance and where they'll end up if they take risk.

Every acquisition and implementation decision has been evaluated in the context of whether it would provide a return on investment and help the effectiveness of population health initiatives.  

Challenges have been in using a population health platform that was insufficient for Summit's growing organizational complexity and integrating disparate data sources. Claims data, especially, presents unique data integration challenges.

In negotiating commercial contracts, Summit mandates that plans provide specific data on a prearranged schedule along with support for interpreting and integrating files. 

"We've never had to write back a check to pay," Parikh said of taking shared risk. But ultimately, he said, "Value is doing the right thing for the patient."

Twitter: @SusanJMorse
Email the writer: susan.morse@himssmedia.com