5 Ways By Which John Created a Value-Based Care Ecosystem

Abhinav Shashank
Tue 06 Sep 2016
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CMS just announced the shared savings generated for the last year, but Beatles ACO will not earn a penny. It couldn’t qualify for the shared savings payments. This was the second consecutive year without payments. Failing to provide Value-Based Care, Board was desperate to implement Population Health Management. So, they decided to make some changes in the management and elected John Doe as the new CEO of Beatles ACO. John is famous in Healthcare Industry for his innovative approaches and decision making.

John came on board and as the new acting CEO, he asked for any data that could help him understand the current working structure. He wanted to know the areas where Beatles ACO was lagging behind. He had no idea whether it was the whole network or some providers of selected regions who brought down the overall average. The IT team of Beatles ACO hands him over the claims data, which did not help understand one thing!

He talked to some of his friends in the industry and they asked him to try Datashop. He started reading about and finally decided to schedule a demo with the platform team. When the platform team arrived, John cut to the chase and straight away asked the burning questions.


“What can your platform tell me about my past performance? And most importantly how soon?”

Once you provide us the claims data, we will take 14-21 days to tell everything about the past performance of Beatles ACO. By everything we mean the following :

  • You’ll have access to contract wise performance of the ACO. So, if you have a contract with Medicare, Wellmark, and others, you’ll be able to check the individual performance of ACO on each contract.
  • The platform has all the major clauses that are there in almost every contract.
  • For a particular contract, you’ll see the required measures and your average scores against the benchmarked. For instance, Medicare contract will have measures like PMPM, ED visits/1000, Flu Vax, Breast Cancer, etc and you can view what the clause requires and where you are standing.


“Ok. So, does it help me in decision making?”

You can view the aggregate performance of the ACO and drill down to the lowest level. Just point and click on any measure and select any region to find out the performance there.

For instance, if you notice that south region hasn’t been performing well, you click on it and go deeper to see the performance of all the providers there and which provider is farthest from the benchmark scores. Even if that doesn’t help you go deeper and check out the physicians who are lagging behind.

Seeing the performance there, you can plan interventions accordingly for the provider facility. For example, if a provider facility lags in the Hba1c test for 12 months measure, you can intervene and help it improve on it.


“That’s nice, but could I expect more? What about my present performance? Can we improve on that as well?”

Of course, you can! There is a lot more you can do than just view the performance.For that, we need pre-adjudicated claims and once we have those, you can do:

  • Access real-time and predictive information on performance
  • Shed light on where they are anticipated to trend on a specific contract based on claims information.
  • Ability to track performance from both pre-adjudicated files and claims information
  • Reconciliation of pre-adjudicated claims and received claims data to find out the which claims didn’t go through and why.


“Wow! All this from claims data! Is there scope for any other advancement?”

Actually, this is just the beginning, there are limitless opportunities after this! We had claims data and we provided you with performance tips. Once we get clinical data we’ll do a lot more than just tips! It helps you in transitioning to Value-Based Care, embracing Population Health Management and a lot more.

What we do with the clinical data:

  • Any data, whether messed up or not, we standardize it by using our Data Quality tool, which generates a Data Quality Report. We clean the data and assign EMPI (Electronic Master Patient Index) to it. Furthermore, bringing the data into standardized clinical formats such as HL7 or FHIR.
  • You can schedule this at a frequency you are comfortable with. If you want the data to be updated daily, it’ll be done and if you want to do it weekly that’s also on the table.
  • All this data is added to the Data Lake and from there possibilities are endless. You can work on Population Health Management.


    • See what symptoms in the past indicate a disease
    • What is the best cure for a disease?
    • When and what surgery is needed?
    • How can the treatment be improved?
    • And most importantly, overcome the gaps in care!


“You said Population Health Management. Do you have a mechanism for care coordination too?”

Yes, sir! As a matter of fact, we do! With the help of pre-built risk models, we assign a risk score to patients and track the high-risk patients. To illustrate:

  • Datashop provides a 360° view of a patient on the patient’s profile screen, which has the data of visit history, diagnosis, lab results, risk score, types of interventions and previous health coach interactions.
  • Whenever a health coach would login to his portal, he/she would get notified about all the patients that have been discharged recently.
  • A timely intervention could be planned depending on the risk score of the patient.
  • Datashop helps in keeping a track of a patient, even if the patient has chosen to switch the Primary Care Provider. This will help the health coach in communicating the medical past of the patient with the new PCP
  • All this will efficiently and effectively help in the transition to Value-based care. Quality care would be a top priority.

John implemented the platform and within days the ACO transitioned to Value-Based Care. The Quality scores drastically improved and next year they not only met all the clauses in the contract but also generated a lot of savings.


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Tags: Accountable Care, Healthcare, Integration
Abhinav Shashank
5 Ways By Which John Created a Value-Based Care Ecosystem

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