THE CHALLENGE
When one of the largest Catholic healthcare systems in the Midwest embarked on its value-based care journey as a Centers for Medicare and Medicaid (CMS) Pioneer Accountable Care Organization (ACO) and then in the Medicare Shared Savings Program (MSSP), it was a challenge. In 2016, they missed the CMS benchmark for PMPM spending by almost $30 million, and missed the target for financial savings by $41.6 million.
The following year they got closer, but still didn’t achieve enough to share in the savings. The organization was using Cedar Gate’s Value-Based Care Analytics software, but had not been able to make use of the data in meaningful ways to impact their ACO success.
Specifically, the Catholic healthcare system wanted to:
They lacked the internal expertise to analyze their current roster of MSSP beneficiaries due to high levels of churn, and high out-of-network utilization rates among assigned beneficiaries. They also didn’t know how to identify primary care provider (PCP) participants with whom to partner on risk-based models, or how to design and engage in prospective bundles.
The organization engaged Cedar Gate to perform actuarial consulting services, and saw significant improvement in multiple areas of MSSP performance.
Cedar Gate’s actuarial insights, combined with its Value-Based Care Analytics software, helped them:
By identifying out-of-network leakage, and steering more patients to in-network providers to reduce out-of-network utilization, the organization brought back millions in revenue. Providing more in-network care also helped the organization meet its value-based care goals as an ACO.
The healthcare system contracted with multiple large, self-insured employers to create orthopedic and imaging prospective bundled agreements. These bundles create more stable and predictable costs for some of the most common surgical and imaging procedures.
With predictive models in Cedar Gate’s Value-Based Care Analytics Software, the Catholic healthcare system was able to predict performance in risk-based contracts with 99.4% success rate when compared to actual results, giving them confidence to participate in these models.
THE RESULTS
Within two years, the healthcare system went from missing the CMS benchmark by $29.9 million to exceeding it by $14.4 million, a $44 million turnaround. They achieved a total of $18.6 million in shared savings over three years. Cedar Gate’s actuarial consulting services also helped them:
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