Healthcare Provider Analytics and Reporting: Expanding Beyond VBC Use Cases

We will release our newest report, 2019 Healthcare Provider Analytics Market Trends Report, in the next few days. This report reviews the current market for provider analytics and evaluates offerings from 23 different vendors.

Key Takeaways

  • Value-based care is the dominant business driver for adoption of analytics solutions by providers.
  • Reports and dashboards are still the main way that users experience and benefit from analytics technologies.
  • Advanced analytics capabilities are seeing increased interest, but mostly from large HCOs.
  • Deriving actionable plans from the data that goes into analytics solutions remains a challenge.

In recent years, providers invested in analytics technology to support the transition from fee-for-service (FFS) to val­ue-based care (VBC). Vendor offerings that support the variety of pay-for-performance (P4P), pay-for-reporting (P4R), and risk-sharing programs with payers have helped them better understand the interaction of costs, quality, and utilization in the populations they serve. But the applica­tions for analytics are broader than just VBC. Provider healthcare organizations (HCOs) are seeking to leverage these technologies more broadly to support a range of clinical, financial, and operational performance improvement goals and programs.

Acute and Ambulatory Use Cases

Provider-oriented analytics availability mirrors EHR penetration. Providers in acute and ambulatory settings have many choices for analytics across multiple use cases. Providers in post-acute settings and others with low EHR penetration have relatively fewer choices. While vendors have devised a number of ways to extend their offerings to underserved settings, not all providers take full advantage of such capabilities.

EHR vendors are often, but not always, providers’ first choice for analytics. Most EHR vendors sell analytics offerings almost exclusively to their existing EHR customers. Independent vendors – not owned by an EHR vendor or a payer – are a strong alternative to EHR companies for value-based care use cases. Claims analytics companies have deep experience with claims data sources or rely heavily on claims-related data to fuel analytics and reporting. Applications from many of these vendors emphasize cost and utilization control and feature deeply descriptive insights into risks, costs, quality, and utilization. Providers have historically been reluctant to adopt these offerings, but that is changing.

Mainstream Analytics

This report characterizes current analytics solutions as either “mainstream” or “advanced.” Most HCOs have experience with mainstream analytics – often cloud-hosted and reliant on relational databases that store historical data from the EHR, claims, and other sources. The resulting applications characterize and summarize performance along multiple dimensions. While this technology approach is well-established, mainstream analytics still faces challenges. Chief among these are data quality and variability. Diligence is required on the part of vendors and HCOs to ensure this data is accurate, high-quality, and up-to-date.

Data complexity challenges are only increasing because new data sources are on the horizon. The All of Us program (formerly known as the Precision Medicine Initiative) promises to unleash a torrent of novel and voluminous data types. In addition, the vast trove of unstructured data in EHRs will soon contribute to a better understanding of patient cohorts and risks. Social determinants of health (SDoH), data from smart health monitoring and fitness devices, and a variety of patient-reported and publicly-available data sets are also beginning to be used in provider analytics.

Mainstream analytics has yet to supply a variety of predictive and prescriptive insights; for that, HCOs are looking at advanced analytics.

Advanced Analytics

Advanced analytics consists of interrelated technologies, the most common of which are artificial intelligence (AI)/machine learning (ML), natural language processing (NLP) and extraction, and big data technologies. These technologies and techniques are not widely deployed in healthcare, but are used to varying degrees by most of the vendors profiled in this report. The expectation is that as these technologies mature, advanced analytics will offer more and better predictive and prescriptive capabilities. Many vendors now offer optional services to help providers take better advantage of advanced analytics technologies. Increased organizational familiarity with AI technologies and algorithms should naturally increase user trust as the technologies mature and become more widespread.


Many provider organizations, with experience gained from their VBC efforts, want more benefits from analytics. Whether it is from their legacy point and departmental reporting solutions, mainstream, or advanced analytics, provider organizations see analytics and reporting as a reliable way to pursue performance improvement goals across their enterprises.

Stay up to the minute.

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A New Take on Engagement: Aetna and Apple Launch Attain

apple-aetna attain appOn Tuesday I had the pleasure to be at Aetna – CVS Health’s grand announcement for Attain, an Apple Watch-based app that will be released later this Spring. Aetna and Apple co-developed this application – Aetna providing the healthcare expertise and Apple its user interface chops.

Attain is yet another health, wellness and medication adherence app (as if we don’t have enough already) but with a few twists:

  • Initially, Aetna will promote Attain directly to members, bypassing employer HR departments.
  • It’s a watch-based app built on the theory of “Nudges” to change behavior(s).
  • Wellness goals will initially be set based on age, gender, weight. However, over time Attain will self-adjust and personalize health and wellness goals based on an analysis of member usage patterns to provide meaningful, attainable goals.
  • Attain with Apple Watch benefit is a “loss-framed incentive” program. Most wellness benefit programs are simple gain-incentive based.

How it works: Aetna members will be notified of the opportunity to buy an Apple Watch on a monthly payment plan. By using the Attain app on their watch and accumulating points, those points will be applied to paying down the monthly installment. Meet your monthly goals, and no payment needs to be made. Fall short, and the loss-framed incentive kicks in and the member must pay a portion of the monthly bill.

Note that both Aetna and Apple were very proactive and firm regarding the steps they will take to ensure the security and privacy of member health data. Aetna will continue to improve security, migrating to gesture-based authentication. Aetna will never use collected data for underwriting, nor will data be used or sold for secondary purposes. Apple, likewise, will only collect de-identified data for improving the app experience if the consumer opts in.

But there are a few areas where this initiative falls short:

  • There was no discussion as to how Attain will address chronic conditions such as hypertension, diabetes or mental health.
  • The event did not address how Attain might become a platform with open APIs and developer kit to enable others to build disease-specific modules for Attain.
  • Surprisingly, no mention of how Attain might alert a member to care gaps and assist in scheduling an appointment.
  • They also did not discuss how providers might be able to leverage Attain to better manage their patients in a value-based contract. (In a private discussion with an Aetna executive, he did state that they are working with some of their provider JV partners on the opportunity Attain may bring – but it’s early.)

While hoping for discussions on the above, it is clear that Attain is very much a v1.0 product and future enhancements, including the above, are likely if the app proves successful over course of this initial launch. In a recent report from Rand Europe, there is reason for hope.

Aetna has always been a leader among payers in experimenting with new ways to engage their members. No other payer comes close. I really like what Aetna and Apple are doing here together as it truly breaks the mold of traditional approaches and go-to-market strategy to engage members in their health. It is a great first step and truly representative of a healthcare organization seeking to improve the health of the population it serves.

In stark contrast is what we will all see in a couple of weeks at HIMSS’19. No health IT vendor has even come close to this level of commitment to patient/consumer engagement with such an easy-to-use, engaging app. And frankly, responsibility for this shortcoming does not rest solely with vendors, but also their provider customers. IT vendors typically build what their market desires (or demands). Despite all the talk of consumer/patient engagement, I’m calling bullsh*t on the providers and the vendors that serve them for not stepping up to the plate and taking consumer/patient health and wellness seriously and making the investments necessary to truly move forward in a meaningful way.

So providers and the vendors that serve you – what’s next? Please don’t tell me it is yet another scheduling app that just generates more revenue for you, or an easier way to pay co-pays, or a static filing box of medical records. Seriously, what’s next in the game plan to truly engage patients in a way that is reflective of expected 21st century customer experiences and is truly patient-centric?

Once again, it is that time of the year for our annual pilgrimage to HIMSS. While many attendees focus on the sheer size of the exhibit hall or packing their schedule full of meetings, we wanted to highlight the other major part of the event: education sessions. Below are this year’s recommendations from the Chilmark analyst team, organized according to our domains of research.

We plan to attend many of these sessions, so if you would like to meet up afterward, please feel free to email anyone on the team to coordinate meeting at the session to discuss the topic further.


Communicate Value and Build Support for Enterprise Analytics

Tuesday, Feb. 12, 4:15pm – 5:15pm, Convention Center W304E


  • Chris J. Donovan, Executive Director, Enterprise Analytics, Divisions of Finance, Cleveland Clinic
  • Andrew Proctor, Senior Director, Business Intelligence, Medical Operations Division, Cleveland Clinic

Why AttendDescribes the experience that Cleveland Clinic has had since they embarked on an enterprise analytics endeavor since 2014. This session will provide insights into how to achieve strategic leader buy-in and the ‘why’ of particular use cases vs. focusing on the technological ‘how.’

Leveraging Data Analytics to Complement Value-Based Approaches

Wednesday, Feb. 13, 8:30am – 9:30am, Convention Center W308A


  • Nathan Riggle, Director of Analytics, Mercy ACO

Why AttendACOs are investing in various advanced analytics solutions with mixed results. This session will explain how to use data to develop the right growth strategy and clinical pathways to truly realize the benefits of these investments in valued-based contracts.


Five Best Practices for Improving Transitions in Care with HIE

Tuesday, Feb. 12, 10:30 – 11:30am, Convention Center W315A


  • Andrea Gelzer, SVP and Corporate CMO, AmeriHealth Caritas Family of Companies
  • Joe Miller, Director, Strategy and Innovation, AmeriHealth Caritas

Why Attend: This session should provide ideas about the value of HIE from a payer perspective.

Improving Care Coordination with Nationwide Data Exchange

Tuesday, Feb. 12, 1:30pm – 2:30pm, Convention Center W230A


  • Arthur M. Lauretano, CMO, Circle Health
  • Jitin Asnaani, Executive Director, Commonwell Health Alliance

Why AttendThis should be a good update on CommonWell, including its integration with Carequality. Hopefully, they will also talk about how TEFCA will affect both CommonWell and Carequality.

Care Management

Empowering Consumers with Data to Improve Chronic Disease Conditions

Tuesday, Feb. 12, 1:30pm – 2:30pm, Convention Center, W315A


  • Joshua Riff, CEO, Onduo
  • Mark Talluto, VP of Strategy and Analytics, Blue Cross Blue Shield Association

Why Attend: Self-directed care management utilizing digital health apps to address chronic conditions is still in its earliest stages. This session will talk about some of the new technologies that payers are using and the strategic partnerships they are forming help payers meet the needs of their members.

Bending the Cost Curve with Whole-Person Care

Tuesday, Feb. 12, 4:15pm – 5:15pm, Convention Center W300


  • Teddy Shah, VP, Advisory Services, Optum
  • Jeffery Arnold, Medical Director, Santa Clara Valley Health and Hospital System

Why Attend: Safety-net providers have a large number of Medicaid patients that often have unique requirements. This session will address how Santa Clara Valley Health and Hospital System in CA has implemented specific strategies to address the social, clinical and behavioral needs of their high-risk Medi-Cal beneficiaries.

Population Health Management

Public Health Extension of the Primary Care EHR

Tuesday, Feb. 12,  1:30pm – 2:30pm,  Convention Center W311E


  • Nivedita Mohanty, Chief Research Officer, AllianceChicago 
  • Fred D. Rachman, Chief Executive Officer, Alliance of Chicago Community Health Services

Why AttendVarious public health systems have not been linked to primary care EHRs limiting the efforts of broader population health efforts. This session will examine some of these issues and the progress that is being made by an organization in the greater Chicago area.

Population Health As Ecosystem Engineering

Tuesday, Feb. 12, 10:30am – 11:30am, Convention Center, W204A


  • Richard Biehl, MS-HSE Program Director, UCF College of Engineering & Computer Science

Why AttendBuilding a population health infrastructure is a complicated endeavor that requires a different approach than provider organizations are used to since there is a focus beyond the ‘four walls’ of their facilities. This session will examine how a new ‘ecosystem’ approach for population health contrasts with the traditional ‘system of system’ approaches.

Patient Engagement

Opening Keynote: Will Consumer-Directed Exchange Disrupt the Healthcare Marketplace?

Tuesday, Feb. 12, 8:30am – 10:00am, Convention Center, Valencia Ballroom


  • Aneesh Chopra, President, CareJourney
  • Seema Verma, Administrator, Centers For Medicare and Medicaid Services

Why Attend: Seema Verma, Aneesh Chopra, and Hal Wolf (moderator) will discuss how consumer-directed efforts are impacting healthcare delivery. If CMS is going to make any big announcements at HIMSS, it will be during this session.

Elevating the Patient’s Digital Experience

Tuesday, Feb. 12, 12:00pm – 1:00pm, Convention Center W311A


  • Aditya Bhasin, VP Software Design & Development, Digital Solutions, Stanford Health Care

Why Attend: This session will take a look at Stanford Health Care’s efforts to use digital health to transform the patient experience across their organization. It will provide a review of what has and hasn’t worked so far as well as recommendations on how other provider organizations might learn from their experience.

Payer-Provider Convergence

Providing Payer Insights to Clinicians at the Point of Care

Tuesday, Feb. 12, 12:00pm – 1:00pm, Convention Center W315A


  • Nancy Beavin, Interoperability Leader, Humana Inc

Why Attend: Basic primer and update on how payers are trying to delivering insights into EHRs at the point-of-care. This session will address some of the most pertinent challenges to this topic including bidirectional information exchange and provide an overview of how Humana has tried to tackle this issue to date.  

Unifying Provider and Payer Data to Propel Value-Based Care

Thursday, Feb. 14, 8:30am – 9:30am, Convention Center W208C


  • Claudia Williams, CEO, Manifest Medex
  • David Kates, CTO, Manifest Medex
  • Erica Galvez. Chief of Staff and VP of Programs and Partnerships, Manifest Medex

Why Attend: This will provide a good update on how Manifest Medex is working through the challenges of trying to create a unified patient record across a large geographic region (CA) with multiple payers and numerous providers organizations. It will also provide some insights into how this HIE is being used to support various value-based payment initiatives across California.

Other Session Topics:

If You Build It, Build It Well: User-Centered Design and Agile Development Provides User-Delight

Wednesday, Feb. 13, 4:00pm – 5:00pm, Convention Center W307A


  • Subha Airan-Javia, Associate Professor of Medicine, UPenn; Chief Medical Officer, TrekIT Health, University of Pennsylvania Health System

Why Attend: The chronic usability problems of healthcare applications must be addressed. This session is about one organization that is trying to incorporated mainstream ideas for healthcare users.

Leveraging Technology to Improve Prior Authorization

Wednesday, Feb. 13, 2:30pm – 3:30pm, Convention Center W204A


  • Heather McComas, Director, American Medical Association
  • Tyler Scheid, Senior Policy Analyst, American Medical Association

Why Attend: This session will provide highlights on the growing problem and specific challenges that physicians face with prior authorizations. Beyond just identifying specific challenges, this session will also provide an overview of the technology solutions to achieve higher rates of automated prior authorization.

What other sessions and events are you looking forward to? Tell us in the comments below and maybe we can see you there!

What Are Bundled Payments and Are They Here to Stay?

Key Takeaways

  • Current vendor solutions are limited and generally require additional advisory services.
  • Few available solutions offer workflow integration, especially across post-acute care settings, to assist in the execution of bundled episodes.
  • Larger HCOs will weather the shift to bundled payments more easily than their smaller counterparts, especially as bundled payments begin to scale across multiple service lines.

Bundled payments have been looming on the horizon for healthcare organizations (HCOs) at varying degrees of intensity for at least the last thirty years. As healthcare costs have continued to rise, payers and providers are increasingly viewing bundled payments as a viable alternative to fee for service (FFS) payment structures.

Recognizing that this trend is here to stay, we authored the upcoming report, Bundled Payments: Current Strategies and Tools, to help HCOs understand the impetus behind bundled payments as well as provide a detailed perspective on how healthcare information technology (HIT) vendors are prepared to support this payment modality transition.

The Drive for Bundled Payments

Bundled payments are positioned to serve as a transition between FFS and capitation. By definition, a bundled payment links multiple provider payments into one care management and payment system during a specific episode of patient care during a defined period of time. There are two types of bundles: prospective and retrospective.

A retrospective bundle incorporates a reconciled budget with the payer or “convener” as a financial integrator of the fees paid out instead of putting the responsibility upon one provider. This arrangement is built upon a FFS system and is retrospective because providers first receive their usual FFS payments, and then they receive an additional payment after their total costs are assessed and if cost savings were generated. However, cost assessments can take a year or more to complete after services are initially provided.

A prospective bundle pays a fixed price for a set of services covered in the bundle before all of the services are rendered. An average cost per episode of care is determined based on historical data and/or regional costs and payment is delivered to providers when an episode is initiated, rather than waiting until the entire episode has been completed. Adjustments to payments are made after the fact to account for outliers, excluded episodes, and other factors.

Retrospective payment bundles are the most widespread bundled payment system primarily due to the abundance of participation in the Bundled Payments for Care Improvement (BCPI) Initiative and the Comprehensive Care for Joint Replacement (CJR) model. Retrospective payments for bundles are also easier to understand, administer, and execute, which is why they comprise the majority of bundled payment financing arrangements to date.

A CMS-led Initiative

CMS is still navigating how to implement this payment structure while not alienating providers, and BPCI was an attempt to find a middle ground that is palatable to providers while capitalizing on the cost savings bundled payments offer payers.

Unfortunately, determining this middle ground has led to CMS sending conflicting messages to the industry. In late 2017, CMS rescinded rule changes that required mandatory bundled payments for providers to test the effect bundled payments would have on cardiac and orthopedic care. CMS noted that responses from providers to the mandatory bundled payments cited concerns over both the process by which costs for episodes were determined as well as the ability for smaller HCOs to comply with the process.

Despite these setbacks, CMS is not withdrawing support from bundled payments as a whole and has instead created the BPCI-Advanced, a voluntary iteration of BPCI with the same goal of aligning incentives among health care providers. Early adoption of the BCPI-Advanced program has been robust although it remains to be seen how many of these providers might exit early next year. Additionally, HHS Secretary Azar indicated last month that mandatory bundles are coming in the near future for radiation oncology and possibly other providers as alternative payment models.

Commercial payers have shown interest in bundled payments, but have been slow to introduce the practice. Although we have seen increased adoption from some payers, the general consensus is that these organizations will wait until the concept is proven before devoting resources to the change. We might have to wait until bundled payments are once again mandated by CMS before commercial payers adopt the model.

Provider Reservations

While the attitude of providers towards bundled payments could be best described as “wary,” there is still opportunity for healthcare providers to lower their costs while improving the standard of care. Yet, success with bundled payments requires close coordination between multiple providers over a varying timespan, something that many providers struggle with.

In order for bundled payments to work for both patient and provider, an HCO needs to have the ability to identify who is eligible for bundled payments early in the treatment cycle through monitoring and tracking. They also need to have a network and processes in place to engage affiliated and community providers that are necessary to the bundled payment process. Not surprisingly, many HCOs are hesitant to invest the organizational resources necessary to establish this level of collaboration.

Specialty physician groups that are only focused on engaging in one or two retrospective bundles will be able to change more rapidly but over the longer term, it will be harder for smaller HCOs to effectively scale bundled payments across multiple services lines within their organization. Another advantage larger systems have is systems and processes for dealing with post-acute care needs that are critical for succeeding in bundled payments.

In general, large HCOs with wide networks and established reporting and monitoring processes are better equipped to handle the transition to bundled payments and effectively scale these program although several specific factors (e.g., episode type, target price, exclusion criteria, risk adjustment) will affect how a provider performs.

The Tools for Bundled Payments

Our report focuses primarily on identifying the IT environment that supports, and will support, bundled payment plans. We were able to identify a number of key issues that software solutions must address, including patient tracking, care process redesign, and physician engagement. As of the writing of this report, no vendor offers a comprehensive solution to the myriad reporting and management challenges that bundled payments present.

We did identify commercially available solutions to deal with cost and quality reporting requirements inherent in the bundled payment process. Unfortunately, HCOs are going to have to develop piecemeal processes that incorporate multiple systems until vendors are able to provide a robust comprehensive solution. We expect that as bundled payments garner more support and interest, HIT vendors will recognize the market opportunity and develop systems to specifically address these issues.


The question is not whether bundled payments are going to see greater utilization, but rather to what extent will bundled payments affect healthcare payers and providers? Providers especially will need to have a plan and processes in place to reduce risk to their revenue streams as bundled payments become more ubiquitous.

Our report, Bundled Payments: Current Tools and Strategies, outlines how providers can navigate these changes and identifies IT solutions that may assist them. It provides detailed insight into what bundled payments are, how to execute them, and the challenges associated with their orchestration. Furthermore, it contains comprehensive vendor profiles and evaluations of the solutions they offer, which we hope will assist providers as they prepare for this transition.

On January 30, 2019, we are hosting a webinar on this topic. To attend or just be on the list for the recording, please click here to register.

How will Proposed Changes to CMS Telehealth Reimbursement Affect Adoption?

Key Takeaways

  • CMS-proposed rule changes extend Medicare Advantage and Part D plan coverage for telehealth services starting in 2020
  • Proposal includes enhancements to the Star Ratings methodology, which include updating the cut-point determination methodology as well as adjustments for Star Ratings in times of uncertainty, such as hurricanes.
  • Under the proposed changes, starting in 2019 in Medicare FFS, CMS will reimburse for virtual check-ins, evaluation of patient submitted photos, and prolonged preventive services regardless of patient location and care facility.

What the Rule Changes Mean

doctor cares for medicare patient via telehealthOn Friday, October 26, the Centers for Medicare and Medicaid Services (CMS) announced several rule changes that affect how telehealth services will be covered under Medicare Advantage (MA) and the Medicare prescription drug program (Part D). These changes are in direct response to the Bipartisan Budget Act of 2018, which eliminated historical restrictions on telehealth reimbursement, and are intended to “improve quality of care and provide more plan choices for MA and Part D enrollees.”

Also included in the proposed rule changes are adjustments to methodologies and processes that should improve access to care, as well as recover funds from payments improperly applied to insurance companies. We view this as a positive development, especially as it relates to current and projected physician shortages. Greater reimbursement should allow for providing some basic services through telehealth applications, it is going to equip providers with the ability to “do more with less.”

Our recent report, Telehealth Beyond the Hospital, provides a detailed analysis of the telehealth market as a whole, but we felt it prudent to prepare a supplemental post to give a brief examination of how these rule changes could potentially impact the provision of healthcare services.

Easing Reimbursement via Classification

Telehealth services have previously seen limited implementation by MA plans because they have been traditionally classified as services covered by “supplementary medical insurance.” These new rule changes shift the classification of telehealth services to the “basic benefits” category. We have witnessed lagging adoption rates of telehealth technologies over the last several years, and view the inclusion of these services into the basic benefits category as a necessary step to increase their rate of use.

CMS expects that the inclusion of telehealth services in the basic benefits category will spur more MA plans to offer these benefits beginning in 2020, and increase their support of these services in subsequent years. This isn’t happening in a vacuum, and is in line with the broader push to promote telehealth services as viable alternatives and supplements to traditional care options. The move towards parity between physical visits and telehealth services has shown to increase reliance on telehealth services before: Michigan has seen a “77.5% increase in Telemedicine encounters after supporting service parity in telemedicine.”

This isn’t happening in a vacuum and is in line with the broader push to promote telehealth services as viable alternatives and supplements to traditional care options.

Driving Near-Term Adoption: Patient Satisfaction and Ease of Access

Recent surveys have shown that patients are growing more and more amenable to remote care options, especially if it reduces their out-of-pocket costs. The opportunity cost of non-reimbursed care is one of the primary barriers to provider adoption of telehealth services, and by removing this barrier we will hopefully see further alignment between providers and patients on this issue.

We see this alignment as a part of the greater industry shift towards value-based care (VBC). As we noted in our Patient Relationship Management (PRM) Market Scan Report, engagement was one of the areas where adoption of these new technologies for VBC was exceeding expectations. Increased reimbursement for telehealth should continue this positive trend and hopefully allow for the realization of some PRM benefits.

We predict that the CMS rule changes will encourage diversified managed care organizations (MCOs) to expand their current commercial telehealth contracts to their MA business and also potentially drive the adoption of telehealth offerings among that trend.

Impact on Providers and Vendors

These new rule changes have a large potential upside for all players in the telehealth market, but it is important to note that telehealth adoption has been incremental over the last several years and there is no reason to predict a stark diversion from that trend.

We predict that the CMS rule changes will encourage diversified managed care organizations (MCOs) to expand their current commercial telehealth contracts to their MA business and also potentially drive the adoption of telehealth offerings among that trend.

Vendors looking to capitalize on this incremental market growth are going to have to navigate the differing needs of commercial and Medicare providers. For commercial providers, telehealth is seen primarily as a cost-savings and efficiency tool. For Medicare providers, they are looking most closely at telehealth as a way to promote post-acute care management and patient engagement. To effectively sell to Medicare providers, vendors are going to have to tailor their tools and pitches to hit on the appropriate pain points.


As the costs of chronic condition management skyrocket, looking for innovative telehealth solutions is of paramount importance.  Reclassification as basic services and simplification of the reimbursement process will certainly help vendors supplying these solutions overcome potential buyer uncertainty on the ROI of their products.

The most important takeaway from these rule changes from an HCO perspective is that the future of value-based care is arriving quickly. HCOs need to prepare for this future by refreshing their care delivery strategies, especially as it relates to primary care. The primary care environment is changing, and HCOs need to closely examine what they need to provide in terms of physical locations, providers, and services for their patient populations. They then need to craft strategies to meet these evolving requirements.

How to Succeed with a Provider-Sponsored Medicare Advantage Plan

By Matt Cox (Chief Marketing Officer, Lumeris) and Nigel Ohrenstein (Senior Vice President and head of Market, Lumeris)

doctor consults with Medicare Advantage patient

Health system and health plan leaders across the country are asking the same question: how will our organizations survive and thrive in a value-based world? As the shift to lower-cost settings accelerates and the population becomes older and sicker, organizations are seeking new ways to manage costs, generate income and control quality.

For many organizations, launching a Medicare Advantage (MA) plan paves the way for value-based care models that reward delivering better care at lower costs by combining clinical and financial expertise. As enrollment in MA continues to outpace traditional Medicare enrollment – with national MA penetration growing from 30 to 50 percent in the next 10 years – organizations must have a strategy that enables success in the future.

Benefits of a Medicare Advantage plan

MA is increasingly viewed as a potential growth area for organizations. While launching a plan certainly carries risk, it also offers significant upside for providers and payers to successfully manage the health care needs of members.

With an average annual premium of $10,000 per member according to a Lumeris study, MA enables provider-sponsored plans to manage the risk of a population. Access to comprehensive claims data can be used to identify high-risk patients and areas of high utilization, supporting an organization’s population health efforts and steering patients in-network. With aligned incentives, organizations can innovate and invest in care delivery with tools and workflows that support high-value, appropriate care.

Further, MA’s sophisticated risk adjustment methodology supports premium payments that reflect the expected cost of providing medical care to each member, including those with complex conditions. Proper risk adjustment requires providers to capture diagnoses accurately and completely to support reimbursement.

Finally, with Star ratings, well-managed MA plans that earn 4- to 5-Star ratings can attract more members and revenue through enhanced benefits. Highly-rated plans receive performance bonuses that bring in an extra five percent a year, which are used to provide additional benefits to members.

Consider creating a plan built around a collaborative model: one that aligns incentives, bolsters the provider-payer-member relationship and enables delivery of high-quality, cost-effective care.

Building blocks for a provider-sponsored plan

Establishing a provider-sponsored MA plan is a significant undertaking. Given the large investment of time and money, organizations considering launching a plan must ensure they have several foundational elements in place. Consider creating a plan built around a collaborative model: one that aligns incentives, bolsters the provider-payer-member relationship and enables delivery of high-quality, cost-effective care.

Organizational and market strategy

Before launching a plan, organizations must evaluate their tolerance for risk and ability to capitalize said health plan. A strong brand reputation in the market is obviously crucial, but additive resources and significant infrastructure are also required. Organizations should also consider market dynamics, population growth and reactions from key players – competing systems, provider groups and other payers – and how these factors impact their strategy as a differentiated plan offering in the market.

Operational experience

Considerable infrastructure is required for claims processing, actuarial analysis and utilization management, among other payer functions, which can be leveraged from working with a collaborative payer or operating partner. In MA, expertise in Star ratings, risk adjustment, sales and marketing, compliance and plan design add further complication to successful operations. To build the right foundation, provider-sponsored plans must focus on enabling the provider-payer-member relationship, often requiring innovative processes on everything from data transparency and aligned incentives, to coordinated care management programs and shared governance.

Engaged network

Core to a collaborative model is ensuring organizations are aligned. Managing a health plan requires organizations to focus on improving patient outcomes and monitoring the entire population, not just the patient in front of them. Fostering the right network and governance, aligning incentives to create mindshare, sharing best practices and information, and supporting new workflows and behaviors are all critical to success in value-based care delivery.

Partnering for success

Before launching a collaborative MA plan, organizations must assess capabilities to identify gaps in knowledge, expertise and operations. For most organizations, working with an operating partner is more effective than building internal MA competencies from the ground up. Finding a partner with skill and experience in launching a collaborative plan can enable organizations to gain a competitive advantage more quickly. It can improve the likelihood of success while limiting risk and enable providers to focus on their core strength of delivering high-quality, high-value outcomes.

One example of bringing these necessary capabilities together is the newly announced collaboration between Cerner, a global leader in healthcare technology, and Lumeris, an award-winning health plan and value-based care managed services operator. Under the relationship, the companies will provide a suite of offerings under the name Maestro Advantage™, designed to enable health systems and health plans to drive success in value-based arrangements through population health service organizations or provider-sponsored plans. The offerings combine Cerner technology and Lumeris operational services aiming to streamline redundant processes that burden members, payers and providers, including lengthy claims processing and reimbursement cycles, and obstacles to sharing data and records across any electronic health record in the network.

This post originally appeared on September 19, 2018, as the second in a series of sponsored guest blog posts on our Convergence conference blog. 

Future Winners in Accelerating Shift to Value

Last week, CMS released its proposed rule (beware – in good government fashion it’s a whooping 607 pages) for the Medicare Shared Savings Program (MSSP) Accountable Care Organization (ACO) program. CMS is taking a big leap forward with this rule on the path to value-based care. The big leap? Moving existing MSSP ACOs from all upside contracts (no risk), to taking on an ever-increasing portion of risk (downside, e.g. reimburse CMS if targets not met). This is a real wake-up call for providers, especially hospital-led ACOs, who have by and large failed to meet targets in current MSSP ACO contracts.

What Got Us Here

The advent of ACOs is a byproduct of the Affordable Care Act (ACA), wherein the Obama administration was seeking new payment models to shift Medicare spending from fee-for-service to value-based care (VBC). To get providers comfortable with the concept, various ACO models were deployed with MSSP the most popular – currently 86% of all Medicare ACOs.

Within the MSSP ACO a provider organization could choose one of three tracks, but only Track 1 carried no downside risk. Logically, nearly all providers chose Track 1 initially and today 82% of MSSP ACOs are still in this track. Unfortunately, in 2016 this track was a money-losing proposition for CMS, as hospital-led MSSP ACOs racked up losses for CMS that were higher than the savings from physician-led ACOs.

Provider readiness to take on true risk has always been the rub…With these proposed rules, CMS is going beyond meeting providerswhere they are but pushing them forward on the path to value.

Fast Forward

At the recent Leavitt Partners conference, attendees were briefed on the political climate in Washington. Despite all the political rhetoric, there are three core healthcare principles that are non-partisan:

  • Fee for service (FFS) is the problem.
  • Integrated care is better than disparate care.
  • There is a strong need for valid measures to score value.

This event also emphasized that the federal government must take the lead in pushing the industry to VBC, again for a couple of simple reasons:

  • CMS is the largest payer in the country, representing over half of all healthcare spending. Money talks.
  • Unlike employers, CMS has beneficiaries in every region of the country, encouraging and enforcing nationwide measures of value.

The MSSP ACO proposed rules are just another step, of what will likely be many, which CMS will have to take in its attempt to bend the cost curve. Rather than wait for providers to voluntarily accept and migrate to true risk – something we saw little of in the former MSSP ACO rules – the proposed rules foist that risk upon providers. Granted, providers are given one to two years in a “glide path to risk” in the new rules, but risk is definitely in their future; by contract year five, an MSSP ACO will take on enough downside risk to qualify as an Advanced Alternative Payment Model (APM) under MACRA.

In summary, CMS proposes ending the current Tracks 1 and 2 replacing them with a new 5-level BASIC track. The first two levels of the BASIC track begin with no risk to providers but annual auto-advancement to higher risk-reward layers will advance providers into risk sharing. Former Track 3 will become the ENHANCED track. The current 3-year agreement period changes to 5-years minimum and national inflation metrics will be replaced with regional metrics.

Somewhat depressingly, the total calculated projected 10-year savings for the new MSSP rules is a paltry $2.2B.

Winners and Losers Aplenty

The proposed rules are likely causing a lot of angst in the executive offices of many a hospital, but these rules will have winners as well.


Table 1: Winners and Losers in Proposed MSSP ACO Rules*

From our vantage point, provider readiness to take on true risk has always been the rub. The recent NAACOS survey found that 71 percent of Track 1 MSSP ACOs scheduled for renewal this year were unlikely to do so if they had to assume risk. This is likely an inflated number – when push comes to shove, far more will renew – but this is a barometer of provider sentiment and overall readiness even among those with some experience with the program.

Across the country, healthcare is anything but consistent. As Gary Loveman, former executive vice president of Aetna, pointed out at our Convergence conference last year, one has to meet providers where they are. With these proposed rules, CMS is going beyond meeting providers – but pushing them forward on the path to value. For most providers who take this path, it will be challenging, and trusted partners with previous experience in risk-bearing ACO enablement will be essential.

Without a doubt, something has to be done to bend the cost curve – and, to its credit, CMS is taking action. However, will the action that CMS is taking here with the MSSP ACO program be enough to fend off its critics, especially if projected savings are so minuscule? We’re really unsure, but one thing we are certain of is that CMS is the only entity in this market that has the ability to do something on a nationwide scale. If not CMS, then who?


* Reducing the Risk – Vendors Enabling the ACO, Chilmark Research Market Scan Report, March 2017

The Growing Role of Social Determinants Data in Healthcare

By Paul Nardone, 2018 Research Intern

Key Takeaways:

  • Healthcare stakeholders recognize a social determinant of health when they see it, but organizations differ on which measures are important. Agreement about a core set of SDoH would help implementers better utilize this data type.
  • SDoH and patient health are correlated, but determining causality remains challenging. Lack of knowledge about causality hampers providers’ ability to translate SDoH data into effective interventions.
  • Leading public health stakeholders are using SDoH to fund organizations not traditionally involved in healthcare delivery to improve social drivers of cost.
  • Data brokers are selling SDoH data. Widespread usage by payers and providers, coupled with interest from social media giants, could trigger increased market and regulatory scrutiny.

Marshalling aggregated EHR and claims data for use in applications is an ongoing challenge for most healthcare enterprises. Social determinants of health (SDoH) are a relatively new and amorphous data type that show great promise for contributing to a range of applications.

As healthcare shifts from volume to value, SDoH present opportunities at both population and individual levels. Patient cohort discovery in PHM programs could become more precise and accurate using relevant SDoH. SDoH offers the potential to “better predict potential healthcare outcomes across disparate populations.”

Implementers will need more experience with [SDoH] data before it becomes a routine inclusion in HIT applications. Otherwise, SDoH risk becoming just another unruly data source.

Providers and payers hope to achieve a better understanding of risk, better patient engagement, and more effective use of existing treatment resources. Questions remain about what qualifies as a SDoH, where to source such data, and how to use it. More experience will be needed before SDoH delivers broad-based benefits at both a patient and population level.

What is a Social Determinant of Health?

The CDC defined SDoH as “conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.” While most organizations generally agree with this definition, different organizations report drastically different measures as important to health status.

A quick look at existing lists of SDoH confirms that there is no consistent, widespread acceptance for a single set of factors. For instance, the Kaiser Family Foundation reports 48 social determinants related to individual health, ranging from years of schooling to access to a full-service grocery store. Meanwhile, LexisNexis offers 442 measures that relate to patient health.

No governmental or commercial authority has established a definitive list with strong industry support. The CDC, Canadian government, and WHO have all produced reports outlining their take on which SDoH should be tracked, accompanied simply by policy and practice recommendations. For now, providers and payers are bombarded with different views of the sources, uses, and value of SDoH. Agreement on which SDoH are important would help implementers understand how and where to use this relatively new data type.

How Do SDoH Relate to Patient Health?

Despite uncertainty about which SDoH are relevant, many stakeholders believe that SDoH can help improve population and patient health. However, while most people accept that there is a correlation between SDoH and health outcomes, determining causality between specific kinds of SDoH and specific health outcomes remains challenging.

The correlation between an individual’s years of schooling completed and their probability of smoking provides a perfect example. While more years of education correlate to a lower probability of smoking, more education does not cause anyone to smoke less, and smoking does not cause anyone to drop out of school. Research shows that the differences in smoking behavior at age 24 are accounted for by differences in smoking behavior at age 17, implying that some third factor drives both the probability of smoking and the years of completed education. As a result, interventions intended to decrease the probability of smoking by increasing the years of education an individual completes would be ineffective.

While providers accept that SDoH are often correlated to health outcomes, lack of knowledge about causality hampers efforts to translate those correlations into effective interventions. In addition, SDoH data is not guaranteed to contribute in all contexts. A 2017 study showed that using SDoH does not enhance predictions about a patient’s need for social services beyond what EHR and claims data already provide. Implementers could use guidance on whether certain kinds of SDoH enhance an application.

SDoH Contributions to Public Health

SDoH is connecting healthcare stakeholders with organizations not previously thought of as directly involved in healthcare delivery. For example, after determining that better access to fresh produce, stable housing, and preventive screenings improves patients’ health, UnitedHealthcare awarded $1.95 million to organizations that could help. One recipient, Feeding Wisconsin, used the funds to expand support for local food banks.

Both the U.S. and Canadian governments have initiatives that mirror what UnitedHealthcare has done, but on a national level. Canada’s budget document, Growing The Middle Class, “detailed an unprecedented investment of $8.4 billion over five years in housing, education and child welfare for Indigenous peoples, and $2 billion to end longstanding boil-water advisories on reserves,” specifically citing SDoH as a reason for the investment. The U.S. initiative, Healthy People 2020, seeks to address SDoH by promoting economic stability, education, social and community context, health access and education, and built environment through funding provided by the Office of Disease Prevention and Health Promotion. These large initiatives fund smaller groups and programs that already have traction in addressing SDoH.

Accessing Relevant Social Determinants Data

Sourcing relevant SDoH data requires payers and providers to engage in a different process from the collection of traditional health data. In recent years, data brokers such as LexisNexis, Experian, and Axciom have been controversially selling SDoH data derived from a variety of consumer data sources. These companies collect vast amounts of data and create patient “health scores” similar to credit scores. Using these health scores, payers and providers can identify at-risk populations and prescribe personalized treatment options for individual patients.

Consumer understanding of the existence of this data remains low. SDoH data has not historically been considered directly pertinent to healthcare and is not subject to HIPAA. The recent usage could trigger more market or regulatory scrutiny of SDoH.

The number and variety of organizations offering social determinant data is increasing. The social media giants have an interest in further monetizing the data they have collected. Absent evidence that such data helps providers to make more informed decisions about patient health, market acceptance is not assured.


Ultimately, the interest level and desire to leverage SDoH in health IT is increasing rapidly. HIT vendors are responding slowly by including this data type in different products, but still in narrowly defined ways. Wider availability of a variety of SDoH is also fueling interest and experimentation. Incorporating SDoH into existing stores of EHR and claims data at the patient or cohort level introduces another layer of complexity for developers. Implementers will need more experience with this data before it becomes a routine inclusion in HIT applications. Otherwise, SDoH risk becoming just another unruly data source.