Accountable Care Curve – Interactive - Health Care Payment Learning & Action Network

Measurement Track: Payment Reform

Capability: Analysis to identify alternative payment model opportunities

Definition:
Establish process to evaluate readiness to enter into alternative payment models. This process should include a financial analysis and business readiness assessment to evaluate likelihood of success and identify gaps for remediation. Identify the stakeholders across the organization who will need to be engaged in this process, such as payer contracting, clinical operations, care management and information technology.

Resources:

Mark Japinga

Mark Japinga is a Research Associate at the Duke-Margolis Center for Health Policy, based out of Washington, DC, and focusing on payment and delivery reform. He has led research initiatives and written issue briefs in areas such as specialty care models, multipayer initiatives, employer-sponsored health care, and state-level transformation. Prior to Margolis, he worked in a variety of positions in and around state politics, including for the Texas Legislature, the Wisconsin Legislature, and Stateside Associates. He is a graduate of Grinnell College and the University of Wisconsin-Madison.

Maria Ramirez Perez

Maria Ramirez Perez is a Program Manager with NC Medicaid’s Healthy Opportunities Pilots program and leads the program’s efforts with Network Leads and community-based organizations. Prior to her work with NC HOP, she also co-led the implementation of NC DHHS’s COVID-19 Support Services Program which helped connect households with social supports to safely quarantine or isolate.

Maria previously worked with Legal Aid of North Carolina where she represented clients in public benefits appeals. She also led regional implementation and outreach efforts to help North Carolinians gain access to clinical care and social supports through the Medical-Legal Partnership and Healthcare Navigator programs.

Maria earned her Master of Public Health from UNC Gillings School of Global Public Health. When she is not focused on addressing healthy opportunities, Maria is trying new recipes or exploring the outdoors. She has logged hundreds of miles hiking in the southeast.

Joe Castiglione

Joe Castiglione is on the Industry Initiatives team at Blue Shield of California, where he works to scale and sustain health care innovation through industry collaboration and policy movement. His work focuses on building strategic partnerships that drive alignment on issues related to payment innovation, primary care, and health equity. Prior to Blue Shield, he led stakeholder engagement, as well as legislative and regulatory advocacy, in Washington, DC for the National Committee for Quality Assurance (NCQA). Joe lives in the Castro District of San Francisco, California. He has an MBA from UC Berkeley Haas School of Business and a BA in International Economics from the University of Texas at Austin.

Tara Smith

Tara Smith is the primary care and affordability director at the Colorado Division of Insurance (DOI), where she helps lead the DOI’s payment system reforms to reduce health costs for consumers by increasing the utilization of primary care. She is responsible for recruiting, convening, and facilitating activities of the Colorado Primary Care Payment Reform Collaborative and for developing affordability standards and strategies to help ensure commercial insurance companies’ investments in primary care drive better value and quality for consumers.

Tara has been actively involved in efforts to reform the state’s health care systems throughout her career, including Colorado’s State Innovation Model (SIM), a four-year, $65 million initiative aimed at transforming health care delivery and payment structures through the integration of physical and behavioral health, along with the implementation of the Affordable Care Act’s health insurance marketplace reforms.

Alicia Berkemeyer

Alicia Berkemeyer is the executive vice president and chief health management officer for Arkansas Blue Cross and Blue Shield. She is responsible for all programs related to provider networks, medical management, provider compensation, quality– and value-based programs, primary care, and commercial pharmacy for Arkansas Blue Cross and Blue Shield, and its affiliates. Alicia joined Arkansas BCBS in 1989 and has held several positions in claims, customer service, sales and marketing, and pharmacy. She has more than 30 years of experience in the health care industry, with a focus on value–based care, primary care, and pharmacy. Alicia played an instrumental role in Arkansas being chosen as one of only seven regions in the United States to participate in the federal Comprehensive Primary Care initiative and assisted the state in receiving significant funding from the CMS Innovation Center in the form of a State Innovation Model grant. Alicia currently serves on the Cystic Fibrosis Board, the University of Arkansas Little Rock Business Advisory Council, and the Divine Mercy Clinic Board.

Kate Davidson, LCSW

Kate Davidson, LCSW is the director of the learning and diffusion group (LDG) at the Center for Medicare and Medicaid Innovation (CMMI), within the Centers for Medicare & Medicaid Services (CMS).  In this role, Ms. Davidson leads CMMI’s team focused on accelerating healthcare system transformation by leveraging improvement science within and across models, as well as leading the multi-payer alignment strategy for the Center through the Health Care Payment Learning and Action Network (HCPLAN). Prior to joining CMS, Ms. Davidson led Policy and Practice Improvement efforts at the National Council for Mental Wellbeing, where she managed payment reform, quality improvement, and workforce development initiatives in mental health and addiction prevention, treatment, and recovery organizations, and provided training and technical assistance to human services organizations, counties, and states. Ms. Davidson began her career in healthcare as a social worker researching, testing, and scaling interventions in community-based settings.  Ms. Davidson has an MSW from Fordham University and a BA from Loyola College in Maryland.

Measurement Track: Quality

Capability: Encourage adoption of pay-for-performance

Definition:
Developing an incentive structure to demonstrate successful achievement of defined process and clinical/preventative measures, as well as earn shared savings and/or reward/bonus payments.

Resources:

Managed Care Data Checklist – Health Information Technology Evaluation and Quality Center

Measurement Track: Quality

Capability: Reporting of quality outcomes (including specialty-oriented)

Definition:
Integration with the Data and Infrastructure Measurement Track for Enterprise Data Warehouse to increase the accuracy of the quality metrics generated and reported to regulators, the practicing providers, and key clients. Includes establishing the importance of data quality in driving business decisions and initiatives undertaken by the provider organization (e.g., communication campaigns to bring patients in for preventive screenings like diabetic eye and foot exams) to improve the outcomes achieved.

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Measurement Track: Quality

Capability: Provide transparent quality benchmarking methodology

Definition:
Methodology is shared with regulators and providers, and must be adjusted for population mix, risk (including social determinants of health), and market (e.g., mammogram rates may be lower in certain communities with low access to preventative care). Also includes participation in chronic condition clinical registries identifying and tracking care and outcomes.

Resources:

Managed Care Data Checklist – Health Information Technology Evaluation and Quality Center

Measurement Track: Data and Infrastructure

Capability: Develop data strategy structure and governance

Definition:
Relevant data sets across financial, clinical, and operational domains have been identified and are in the process of being ingested into a single enterprise data warehouse or similar solution to enable data from disparate sources to be aggregated and used in analytics. A governance model has been established to drive standardized data definitions as part of a formal data management process and a formal intake process for analytics requests is established.

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Measurement Track: Data and Infrastructure

Capability: Implement member/patient portal (demographic)

Definition:
Implementation and usage of a patient portal to capture and communicate demographic data between the payer, provider, and member/patient.

Resources:

Managed Care Data Checklist – Health Information Technology Evaluation and Quality Center

Measurement Track: Data and Infrastructure

Capability: Implement member/patient portals (lab, immunization, etc.)

Definition:
Establish an online portal for members and patients to perform basic tasks such as reviewing medical information, paying bills, and other administrative functions. Where applicable, consolidate instances of online portals that exist across the care continuum (e.g., separate portals for inpatient and outpatient services).

Resources:

Managed Care Data Checklist – Health Information Technology Evaluation and Quality Center

Measurement Track: Health Equity Advancements

Capability: Enable access to telemedicine/remote monitoring

Definition:
The ability to monitor and actively manage certain clinical connection points of a patient’s health from their own home (e.g., blood pressure, weight, glucose levels) in order to capture declines in health before they are severe enough to need ER and/or hospital care.

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Measurement Track: Health Equity Advancements

Capability: Enable mobile/virtual health access outside of acute and ambulatory settings

Definition:
Ability of patients to keep track of their own health, connect with care delivery teams, and support resources by mobile communication channels and network technologies, extending beyond the times when they are in a care setting.

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Measurement Track: Data and Infrastructure

Capability: Develop technology infrastructure to support advanced consumer tools

Definition:
Ability to capture and incorporate data from remote patient monitoring devices, telehealth services, and consumer wearables (including phones, etc.).

Resources:

Telehealth: Expanding the Boundaries of Patient-centric Care – Healthcare Leadership Council

Measurement Track: Health Equity Advancements

Capability: Longitudinal care management approach inclusive of chronic disease management

Definition:
Holistic and dynamic long-term care management incorporating disease prevention and treatment. Includes digital care support and ongoing monitoring of health status outside of direct patient interventions. Patient values and preferences are incorporated into the care plan.

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Measurement Track: Health Equity Advancements

Capability: Incorporate member/patient preference to enhance communication engagement

Definition:
Assessing for preferred communication channels during each member/patient interaction and incorporating those preferences into ongoing communications. Engagement can be increased by customizing communications to the cultural norms of the members/patients (e.g., cultural food and social norms).

Resources:

Accelerating and Aligning Population-Based Payment Models: Patient Attribution – Health Care Payment Learning & Action Network

Measurement Track: Health Equity Advancements

Capability: Incorporate propensity for member/patient engagement in the care model delivery

Definition:
Integrated with Data and Infrastructure Measurement Track. Identification of members/patients with higher probability of engagement/participation in care model, which causes patients to seek better quality of care and reduce costs. Knowing the likelihood of a members’/patients’ engagement allows the provider to use lower or higher cost interventions when appropriate (e.g., use text prompts with highly engaged members/patients, versus a face-to-face case manager meeting with a habitually low adherence patient).

Resources:

Accelerating and Aligning Population-Based Payment Models: Patient Attribution – Health Care Payment Learning & Action Network

Measurement Track: Health Equity Advancements

Capability: Provide advanced consumer tools

Definition:
Decision-support tools available to members/patients to help understand essential data/background information, provide evidence-based education, and identify patient values and preferences influencing health care decisions.

Measurement Track: Health Equity Advancements

Capability: Deliver care with cultural competency

Definition:
Effectively deliver health care services that meet the social, cultural, and linguistic needs of members/patients. Contributes to the elimination of racial and ethnic health disparities. Examples include employing community health workers, training on cultural competence and cross-cultural issues, and creating policies that reduce barriers to care and promote engagement across cultures.

Resources:

View from the Field: Recruitment and Retention of African American Men in the Mental Health and Substance Use Workforce – National Council for Mental Wellbeing

Measurement Track: Health Equity Advancements

Capability: Access to nurse line

Definition:
A service for patients to ask basic health questions and address concerns about an illness or injury. Typically, available 24/7/365 as a resource to help decide where to get care and navigate to the right level of care at the right time (e.g., wait for the morning to go to members’/patients’ PCP versus going to the ER).

Measurement Track: Health Equity Advancements

Capability: Development of loyalty programs/incentives

Definition:
Rewards systems that can be used to encourage healthy lifestyle, focus on prevention measures, and navigating toward lower cost/higher quality health care.

Measurement Track: Health Equity Advancements

Capability: Conduct health risk assessments

Definition:
Instrument used to collect health information including biometrics, health status, risks, and habits to understand members’/patients’ needs and possible interventions to help them manage their health.

Measurement Track: Health Equity Advancements

Capability: Conduct member/patient surveys

Definition:
A process or systematic way to capture, document and analyze member/patient feedback or information (e.g., health risk assessments) to inform next phases for program and intervention design (e.g., establishing goals, expanding data collection and resources, etc.).

Measurement Track: Health Equity Advancements

Capability: Awareness of cultural diversity of the population served

Definition:
Includes capturing race, ethnicity, and language (REL) data to allow the customization of interventions to better engage the members/patients in the management of their health.

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Measurement Track: Health Equity Advancements

Capability: Development of health optimization and wellness initiatives

Definition:
Programs designed to support individuals to achieve the best possible health outcomes while also reducing costs, often with a preventative focus. Examples include smoking cessation, weight loss programs, and preventative health screening.

Measurement Track: Health Equity Advancements

Capability: Provider/payer integration on local, regional, and national community resources

Definition:
Active, bidirectional sharing of promising practices and collaboration on complex patient situations and population trends that need better management (e.g., increase in stent procedures, utilization of a new drug).

Resources:

Flexible Services Program – Community Care Cooperative

Measurement Track: Health Equity Advancements

Capability: Population-specific identification of gaps in equitable access to services

Definition:
Focusing on specific underserved populations or populations with complex needs and conditions that experience the highest disparities in care allows for timely interventions and reduction in overall cost/improvement of outcomes.

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Measurement Track: Health Equity Advancements

Capability: Screening for social determinants of health barriers during member/patient interactions

Definition:
Incorporating routine health-related social need screening questions (e.g., related to food stability, housing security) during each interaction to assess for potential risks and provide person-centric interventions as needed to remove barriers to care and improved health.

Resources:

Comprehensive Health Integration Framework – National Council for Mental Wellbeing

Measurement Track: Health Equity Advancements

Capability: Stratify and analyze current socioeconomic status data for potential health inequities

Definition:
Close alignment with Data and Infrastructure Measurement Track to ensure proper data is available and analyze that data to identify local populations with potential health inequities and the underlying causes (e.g., transportation, number of providers in market).

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Measurement Track: Health Equity Advancements

Capability: Longitudinal care management approach inclusive of chronic disease management

Sub-capability: Care management identification and stratification based on predictive analytics

Definition:
Incorporates identification of rising risk populations that have significant potential to decline in health based on predictive factors. Several risk scores are integrated in a composite score to identify the highest need members/patients.

Measurement Track: Health Equity Advancements

Capability: Longitudinal care management approach inclusive of chronic disease management

Sub-capability: Impact based prioritization of care management outreach

Definition:
Supports focusing on patients with modifiable risk factors that if controlled and minimized will improve health outcomes. Focusing on the most immediate and impactful interventions has a higher probability of member/patient’s adherence and health status improvement.

Resources:

Care Transitions Support Services Outcomes and Lessons Learned – National Council for Mental Wellbeing

Measurement Track: Health Equity Advancements

Capability: Identify care management activities and stratification based on clinical, claims, social drivers, and urgency of needs.

Definition:
Using multiple sources of data (e.g., medical, behavioral, and health equity risk scores, as well as recent admissions or ER visits) for a comprehensive 360-degree analysis of a member/patient’s needs and better whole-person care approach.

Resources:

Improve Healthcare Through Value-Based Payment – American Heart Association

Measurement Track: Health Equity Advancements

Capability: Identify care management activities and stratification based on clinical, claims, social drivers, and urgency of needs.

Sub-capability: Incorporate behavioral health, medication management and adherence programs in holistic approach.

Definition:
Team-based care with shared information systems to improve coordination and create individualized, person-centered care. May also include cross screening for common behavioral and physical health conditions to better integrate all care needs.

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Measurement Track: Health Equity Advancements

Capability: Care management identification and stratification based on claims-based analytics

Definition:
Analyzing healthcare claims and cost data to perform risk stratification. Data used to improve the care management approach by identifying patients and sub-populations that may need additional resources to prevent unintended hospital admissions, readmissions and repeated ED visits.

Measurement Track: Health Equity Advancements

Capability: Care management inclusive of ambulatory/outpatient level of care, specialty health conditions, and readmissions

Definition:
Care management activities include additional focus on the long-term needs of members/patients including preventative care, condition-specific education, and interventions to prevent readmission, help navigate patients to the right care, and empower members/patients to better self-manage their health.

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Measurement Track: Health Equity Advancements

Capability: Care management approach focusing on inpatient length of stay, level of care, care navigation and transition management

Definition:
Develop both member/patient support and care team education campaigns to reduce hospital admissions and Emergency Department (ED) visits, focus on short-term interventions, and identify the appropriate level of care.

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Measurement Track: Health Equity Advancements

Capability: Learning to leverage care management utilization metrics outcomes to track discrepancies and inequities for targeted populations

Definition:
Utilization metrics may include average length of stay, readmissions as a percentage of all admissions, range of ED visits/individual, days per thousand, and barriers to discharge, by population.

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Measurement Track: Multi-stakeholder Alignment & Design

Capability: Development of aligned measurement sets

Definition:
Inclusive of specialty and primary care. Takes into consideration local needs as well as national programs.

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Measurement Track: Multi-stakeholder Alignment & Design

Capability: Implement interoperable data exchange/electronic clinical quality measures

Definition:
Identify and implement mechanisms, such as health information exchanges, to improve the ability to share data across the care continuum and across independent organizations to enable greater transparency into gaps in care and establish longitudinal patient records. Consider the needs of both employed and affiliated providers in designing potential solutions to enable interoperability across the largest number of stakeholders possible.

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Measurement Track: Multi-stakeholder Alignment and Design

Capability: Align incentives across organizational leadership and provider network

Definition:
Cascading of incentives down to all providers within the organization supports knowledge of inclusion in quality measurement and performance monitoring. Promotes team-based framework of inter-disciplinary collaboration.

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Measurement Track: Multi-stakeholder Alignment and Design

Capability: Ability to conduct provider stratification

Definition:
Identification and stratification of providers serving historically underserved patient populations and/or populations with complex needs to find opportunities to target interventions at specific provider locations to maximize impact.

Resources:

Accelerating and Aligning Population-Based Payment Models: Performance Measurement – Health Care Payment Learning & Action Network

Measurement Track: Multi-stakeholder Alignment and Design

Capability: Develop patient-centric coordinated partnerships

Definition:
Collaborate across primary and specialty care on coordinated patient-centered care delivery.

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Measurement Track: Multi-stakeholder Alignment and Design

Capability: Provider performance incentive alignment

Definition:
Evaluate existing provider compensation models and identify opportunities to establish variable compensation based on metrics other than volume. Socialize plans with provider leadership to gain buy-in and pilot the use of new compensation models with providers who see greater number of patients in alternative payment models. Utilize pilot learnings to develop enterprise-wide approach to transforming provider compensation to be better aligned with the financial and clinical outcomes sought in alternative payment models.

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Measurement Track: Multi-stakeholder Alignment and Design

Capability: Enhanced provider coordination across levels, intensity, and continuum of care

Definition:
Coordinated patient-centered care delivery incorporating all levels of care including home- and community-based providers.

Resources:

Accelerating and Aligning Clinical Episode Payment Model

Accountable Care Definition

Encouraging Action Toward Accountable Care

Milestones

Interactive Measurement Tracks

Payment Reform

Quality

Data and Infrastructure

Multi-stakeholder Alignment and Design

Health Equity Advancements

Payment Reform

Quality

Data and Infrastructure

Multi-stakeholder Alignment and Design

Health Equity Advancements