The Missing Tool for Many ACO REACH Entities: Funds Flow Analytics

One of the key components of the Centers for Medicare and Medicare Services (CMS) Realizing Equity, Access, and Community Health (ACO REACH) program is capitated payments. For many healthcare organizations, participating in ACO REACH is the first time they have fully committed to a partial or global capitation payment arrangement to manage a patient population. And it’s drastically different from the old fee-for-service way of doing business.

To succeed in capitated payment arrangements, organizations must have accurate, comprehensive, and timely visibility into claims from network providers and reimbursements from payers and CMS – the “funds flow” through a healthcare delivery organization.

In the context of ACO REACH, funds flow specifically refers to the way financial resources are distributed and managed to support the cost and quality objectives for the accountable care organization. It requires a deep understanding and ability to manage several key components that contribute to total cost of care and achieving quality metrics for aligned beneficiaries. To get that level of detail requires seamless integration between the organization’s analytics and capitation software.

FUNDS FLOW OPTIMIZATION BEGINS WITH ANALYTICS

Analytics tools improve organizations’ ability to understand and track key cost and quality metrics essential to achieving goals in advanced alternative payments models like capitation.

• Payment Distribution: Identifying how payments are allocated for primary and specialty care, with the ability to see trends and look for situations that fall outside normal distribution patterns, digging deeper to find the root cause.
• Payment Adequacy: Determining whether capitation payments in a current payment agreement are adequate to support the services for proper treatment, engagement, and disease management in your ACO population.
• Financial Risk Management: Uncovering critical population risks to ensure your ACO REACH entity can provide appropriate care to meet quality metrics without exceeding per-capita payment amounts. 
• Provider Incentives: Evaluating provider performance against program cost and quality targets, and against peer providers, to reward the providers helping the organization meet ACO REACH goals.
• Cost and Utilization: Managing utilization by steering aligned beneficiaries to the appropriate care settings at the appropriate time helps ACO REACH entities provide optimal care and meet quality goals without exceeding per-member-per-month payments.

IMPROVE YOUR FUNDS FLOW ANALYSIS CAPABILITIES WITH CEDAR GATE

To efficiently manage funds flow, organizations need a technology stack that integrates analytics with core administrative processing and care management tools, leading to more strategic and equitable funds distribution.

With Cedar Gate’s composable ACO REACH tech stack, payment technology designed specifically for capitation administration integrates seamlessly with powerful analytics through a shared enterprise data management system. The ACO can analyze claims files (CCLF, CRF) and capitation payments (837 transactions) to determine financial performance and profitability, providing a sound financial basis to translate insights to action – identifying priority cohorts and placing patients into care management workflows.