Identifying ACOs to Expand Value-Based Care Models

The client has a long history of serving as a Medicare Supplement (MediGap) insurer. MediGap is available to traditional Medicare or fee-for-service (FFS) beneficiaries. Because beneficiaries are increasingly choosing Medicare Advantage over traditional Medicare, the client was interested in better understanding the growing value-based care industry within traditional Medicare—specifically ACOs—and how they could engage with these entities to overcome enrollment challenges.  

ACOs are groups that include doctors, hospitals, and other healthcare providers who coordinate care to improve health outcomes while reducing costs. They rely on a payment model tied to quality, as opposed to the standard FFS model. Only FFS Medicare beneficiaries are eligible to participate. 

The client lacked visibility into which members were receiving care from ACO-aligned providers, making it difficult to identify and prioritize engagement with those providers.  

Additionally, while a specific client team was focused on identifying innovative solutions for its members, company leadership took a conservative approach to new initiatives. We educated leadership about the role of value-based care delivery and ACOs in the future of the Medicare program and the benefits of active engagement in reducing costs and improving member experiences and outcomes.

In the first phase of this project, we provided an overview of the alternative payment model landscape that was most relevant to the client’s strategic objectives. From there, we defined the value proposition for a subset of participants in those models and developed strategic recommendations for how the client could engage with those model participants to enhance current business lines and expand new ones in the future.

We used publicly available data on Medicare Shared Savings Program (MSSP) ACOs and Direct Contracting entities in 2 of the client’s priority states and provided a general overlap analysis of the client’s footprint over the ACO footprint. 

In the second phase, we matched the client’s membership with FFS-only claims in Inovalon’s proprietary dataset. Our goal was to identify the specific overlapping population of members who were attributed to MSSP ACOs in a specific performance year. Once the cohort was defined, we completed a deep-dive analysis of the population’s utilization and cost trends in comparison to the ACO’s overall performance to identify outliers and areas for further research. The results of this analysis were shared in an interactive dashboard combining ACO characteristics and performance benchmarks with cohort-level metrics for comparison.

Using the output from this analysis, we identified a set of top-priority ACOs for engagement and segmented them in a prioritization matrix based on their performance and level of overlap with the client’s population. Avalere presented these results and future engagement strategies to the client’s leadership team.

Through this analysis, we identified specific cost drivers, such as emergency department utilization and high rate of specialist care, of which the client was not aware. The health plan’s membership demonstrated unique utilization patterns compared to the rest of the ACO’s patient population that were driving additional health costs. 

The client can now identify the key underlying drivers of high cost and utilization through root cause analysis and develop and implement interventions to address these high costs moving forward. The client is using this information to develop partnership programs to help the ACOs better engage with patients and improve health decisions.