Clinical Episode Payment Models
CLINICAL EPISODE PAYMENT MODELS
ELECTIVE JOINT REPLACEMENT
MATERNITY CARE
CORONARY ARTERY DISEASE
Accelerating and Aligning Population-Based Payment Models
DATA SHARING
FINANCIAL BENCHMARKING
PATIENT ATTRIBUTION
PERFORMANCE MEASURMENT
Primary Care Payment Models
Data Sharing Requirements Initiative
Maternity Episode
Payment Models
Primary Care Payer
Work Product Glossary
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.
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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.
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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.
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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.
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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).
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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.).
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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).
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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).
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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.
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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).
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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.
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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.
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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.
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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.
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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.
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Measurement Track: Multi-stakeholder Alignment and Design
Capability: Identify organizational incentive-based performance
Definition:
Incentivize organizational stakeholders to collaborate and be held responsible for their role in moving towards an accountable care model.
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Measurement Track: Multi-stakeholder Alignment & Design
Capability: Create accountable care organization (ACO) for defined payment population
Definition:
Initiate a shared risk and incentive model for a specific patient population to facilitate movement toward value-based care payment models.
Measurement Track: Multi-stakeholder Alignment and Design
Investing stage supports investing in multi-stakeholder performance and consensus-generating groups that allow for facilitation, relationship-building, and multi-stakeholder ownership of and accountability for the achievement of health goals.
Measurement Track: Data and Infrastructure
Capability: Sending, receiving, and reconciling data from multiple/aggregated sources
Definition:
Ability to send and receive clinical, claims, and other various data (including SDOH). May also include Health Information Exchange (HIE), usage of APIs to share data between disparate systems, and other interoperable data exchange types.
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Measurement Track: Data and Infrastructure
Capability: Access to electronic health records (EHR) across and between organizations
Definition:
Ability of multiple types of users across the organization to access clinical data to develop corresponding analytics for care management and reporting.
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Measurement Track: Data and Infrastructure
Capability: Develop integrated electronic health records (EHRs)
Definition:
Inclusion of multiple care types – primary, specialty, behavioral health, acute, etc. – within the EHR for comprehensive member/patient and provider/coordinator view.
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Measurement Track: Data and Infrastructure
Capability: Create chronic disease registries with electronic health records (EHR) and claims-based data
Definition:
Participation in clinical registries is a critical component of quality outcomes reporting.
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Measurement Track: Data and Infrastructure
Capability: Develop quality, outcomes, financial, and utilization reporting
Definition:
Includes regular data sharing, of multiple types of data (e.g., clinical, claims, social determinants of health (SDOH)) between organizations throughout the performance year to support accurate and timely analysis for impactable interventions.
Measurement Track: Data and Infrastructure
Capability: Implement performance reporting by individual alternative payment model contract
Definition:
Ability to utilize data captured to see performance measures and metrics of a specific provider contract.
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Measurement Track: Data and Infrastructure
Capability: Leverage quality, financial, and utilization reporting
Definition:
Ability to utilize singular source of data captured for quality, financial, and utilization reporting individually and across contracts.
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Measurement Track: Quality
Capability: Encourage adoption of pay-for-reporting
Definition:
Track and encourage participation in pay-for-reporting programs which provide incentives for providers to report quality, cost, or other data to a commercial or government health plan, regardless of performance. Utilize these programs to familiarize providers with the types of measures which ultimately will be tied to payment rates or bonuses in the future and begin to take actions to remediate poor performance. Review performance data received from the Quality Payment Program and other CMS models which have elements of pay-for-reporting.
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Measurement Track: Quality
Capability: Medical policy transparency
Definition:
Make all medical policies available to the provider community online and in other formats as needed. A member/patient-focused version of the medical policies is available for their review as well.
Measurement Track: Quality
Capability: Improve outcomes through sharing and discussing quality metrics
Definition:
Application of quality performance results with provider groups to drive process and outcomes improvements across clinical, cost, and utilization metrics, and drive improvements with contracted metrics between providers and plans or CMS.
Measurement Track: Quality
Capability: Develop standardized medical policies across population
Definition:
Configuration of medical policies’ guidelines to be applicable for entire population instead of specific sub-populations. Eases burden on providers to determine applicability of medical policies for specific patient types.
Measurement Track: Quality
Capability: Identify low-value care
Definition:
Services that provide little or no benefit to patients, have potential to cause harm, incur unnecessary costs to patients, or waste limited health care resources. The identification of these types of services/care should be a data-driven process.
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Measurement Track: Quality
Capability: Develop organizational quality management program
Sub-capability: Quality improvement assessments
Definition:
Processes that include testing acceptance/adherence to new/revised practices, determining how the new practices are affecting the delivery of patient-centered care, and assessment of how much patient care is improving.
Measurement Track: Quality
Capability: Develop organizational quality management program
Definition:
Standardize processes and structure to reduce variation, achieve predictable results, and improve outcomes for patients, health care systems, and organizations. Structures may include technology, culture, and leadership.
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Measurement Track: Quality
Capability: Enhanced utilization, financial, quality, and outcomes reporting across sub-populations
Definition:
Aggregated from multiple populations/sub-populations to identify multi-dimensional ties between quality, financial, and utilization results.
Measurement Track: Quality
Capability: Aggregate quality reporting incorporating utilization, sites of service, and patient outcomes
Definition:
Inclusion of multiple sources and types of quality data for well-rounded measurement that captures the impact that quality initiative(s) had on all aspects of care.
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Measurement Track: Quality
Capability: Incorporation of patient-reported outcomes into performance reporting
Definition:
Measures developed to include outcome data collected directly from patients (e.g., patient-reported blood pressure or A1c through monitoring devices and programs).
Measurement Track: Quality
Capability: Collection of patient-reported outcomes (PROs)
Definition:
Report of the status of a patient’s health conditions that comes directly from the patient to a provider or the health plan, without interpretation of the patient’s response by a clinician or anyone else. Examples of patient self-reported data collection tools include Patient-Reported Outcomes Measurement Information System (PROMIS), Medicare Health Outcomes Survey, and FOTO Patient Outcomes.
Measurement Track: Quality
Aligning stage supports benchmarking quality performance results and executing on strategic initiatives to improve outcomes toward person-centered care. Supports aligning to core measure sets across industry/stakeholder groups.
Measurement Track: Quality
Investing stage supports establishing evidence-based quality goals with ongoing data collection for measuring improvement and progress toward goals.
Measurement Track: Payment Reform
Capability: Continuous improvement outputs based on insights and target performance
Definition:
Improvement initiatives are generated from understanding the actual performance to defined metrics and associated targets.
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Measurement Track: Payment Reform
Capability: Financial incentive alignment across organizational leadership and providers focused on accountable care
Definition:
Compensation and/or incentive opportunities align organizational goals to the level of individual provider/practitioner across clinical delivery and leadership teams to optimize improvement capture.
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Measurement Track: Payment Reform
Capability: Collaboration across organizational leadership (e.g., financial, contracting, and operations) to align metrics and performance management
Definition:
Review the existing bundled alternative payment model portfolio and develop performance metrics which take into consideration requirements for quality, cost, and other factors. Performance metrics should be included in organization-wide scorecards or other performance management programs to align incentives and goals. A selection of these measures may also be considered for use in provider compensation models.
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Measurement Track: Payment Reform
Capability: Leverage reports to identify opportunities to capture shared savings
Definition:
Document detailing focus areas for meeting defined target metrics to achieve shared savings’ potential.
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Measurement Track: Payment Reform
Capability: Develop financial risk management platform
Definition:
System to organize, track, and monitor organizational financial capture of bonuses to target opportunity for defined performance metrics.
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Measurement Track: Payment Reform
Capability: Management of population-based payment models
Definition:
All or much of a person’s overall care or care for related conditions is encompassed within a single payment. Encourages providers to deliver well-coordinated, high-quality, person-centered care within either a defined scope of practice, a comprehensive collection of care, or a highly integrated finance and delivery system.
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Measurement Track: Payment Reform
Capability: Create risk adjustment methodologies (risk methodology, benchmarking, etc.)
Definition:
Incorporate social and clinical risk adjustment, including risk methodologies and benchmarking, with clear goals and ability to track desired outcomes.
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Measurement Track: Payment Reform
Capability: Use/application of risk adjustment
Definition:
Adjusts payment incentives and quality performance through risk methodologies. Incorporates social and clinical risk inclusive of goal measurement while monitoring for adverse outcomes.
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Measurement Track: Payment Reform
Capability: Management of performance risk sharing
Definition:
Share bonuses or upside/downside payments across a group of providers, health systems and/or care delivery services.
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Measurement Track: Payment Reform
Capability: Enhance provider contracting (generating transparent model, payment model design)
Definition:
Enable data sharing between payers and providers. May include one-time infrastructure payments for care delivery transformation.
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Measurement Track: Payment Reform
Capability: Enhanced reporting of delegated and collaborative community services on member patient outcomes and plan/provider performance
Definition:
Promotes accountability and transparency of health equity interventions.
Measurement Track: Payment Reform
Capability: Network performance and reporting management
Definition:
Demonstration of a defined provider network’s performance to a set of pre-defined metrics with targets.
Measurement Track: Payment Reform
Capability: Leveraging multiple reports (integrated clinical, claims, quality, and financial data)
Definition:
Reporting includes information captured from electronic health records, claims-based records, quality analysis, and financial sources.
Measurement Track: Payment Reform
Learning stage supports baseline performance and commitment to develop an understanding of alternative payment models and movement toward accountable care.
Measurement Track: Payment Reform
Capability: Implement pay-for-reporting
Definition: Gaining experience in alternative payment models through payments for reporting data or penalties for not reporting data.
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Measurement Track: Health Equity Advancements
Capability: Utilize member, patient, and family portal data appropriate to the population
Definition:
Includes capturing member/patient feedback data which connects back to Data and Infrastructure Measurement Track to assess the success of the interventions to change the behavior, health, and medical costs of the member/patient.
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Measurement Track: Health Equity Advancements
Capability: Coordinate cross-organization approach to address gaps in equitable access to services
Definition:
Collaborative approach to coordinate reporting and promising practice sharing to have greatest impact/change. Cross-functional efforts to define processes, roles, and responsibilities within the organization and community resources to help close gaps in access for specific members/patients.
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Measurement Track: Health Equity Advancements
Capability: Develop population health approach utilized across the health care ecosystem
Definition:
Comprehensive analysis of equity gaps impacting all including low, moderate, and rising risk populations while defining the extent of an issue by barrier (e.g., housing, food, transportation).
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Measurement Track: Health Equity Advancements
Capability: Develop community engagement and partnerships
Definition:
Includes active collaboration and alignment of community needs assessments between hospitals, Federally Qualified Health Centers (FQHCs), Certified Community Behavioral Health Clinics (CCBHCs), community action agencies, etc., to define initiatives at a community level to address population needs. Engagement and partnerships may be informally or formally organized under a charter, mission statement, or other governance structure.
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Measurement Track: Health Equity Advancements
Capability: Develop community resource directory for local community
Definition:
Consolidated collection of local resources available to internal organizational stakeholders to facilitate referrals and better support individuals’ social needs (e.g., meal delivery, housing, transportation).
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Measurement Track: Health Equity Advancements
Capability: Develop assessment approach for care access barriers
Definition:
Partner with community advisory boards and other governance structures to identify and mitigate barriers to care (e.g., transportation, childcare, etc., medication adherence) to improve community-enabled resource priorities and efforts.
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Measurement Track: Health Equity Advancements
Capability: Develop population-focused complex case management and transition management
Definition:
Inclusion of patients with multiple chronic co-morbidities with modifiable risks to promote supportive, trusting relationships between providers and patients, and empower patients to better manage their condition. Interventions include focused attention on adherence to medical treatments, condition education, navigating the health care ecosystem, and provider care coordination.
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Measurement Track: Health Equity Advancements
Capability: Care management identification and stratification based on encounter data
Definition:
Proactive identification of patients for care management services based on provider-collected clinical conditions diagnosed, as well as the proactive delivery of services and items to treat these conditions in advance of a deterioration in health status.
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Measurement Track: Multi-stakeholder Alignment & Design
Capability: Develop integrated approach and referral management to address underserved populations on shared partnership and resources
Definition:
Utilize a digital referral management platform to enable timely referrals and promote coordination between community resources/partnerships focused on resolving health inequities and disparities. Monitor referral patterns and dedicate resources to provide education to clinicians on when referrals are appropriate. Utilize quality and cost data to drive referral decisions based on specialty or patient condition.
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Measurement Track: Multi-stakeholder Alignment & Design
Capability: Create appropriate partnerships and initiatives to address the needs of historically underserved populations with complex needs
Definition:
Identify and establish partnerships which supplement existing service, capability or other known gaps to more comprehensively address the needs of historically underserved populations with complex needs. Partnerships could be evaluated based on findings from the community health needs assessment, applicability to the disease states most prevalent in the community, and/or ability to provide non-traditional health care services such as transportation to address known health care disparities more holistically.
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Measurement Track: Multi-stakeholder Alignment & Design
Capability: Organize/join network of local and diverse stakeholders to identify and design community health goals
Definition:
Assemble local stakeholders to start aligning on common goals and share individual organizational promising practices.
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Measurement Track: Multi-stakeholder Alignment and Design
Capability: Analysis of community organizations and partnerships for underserved populations
Definition:
Identify community-based organizations, or similar entities, which promote improvements in the health and well-being of individuals in local communities. Analyze these organizations to understand the shared populations served and identify where partnership opportunities may exist to promote patient education, provide additional support for underserved populations, and share data.
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Measurement Track: Multi-stakeholder Alignment and Design
Capability: Ability to assess current ecosystem (alignment framework inclusion in strategic planning)
Definition:
Gain an understanding of the various stakeholders that exist across the health care ecosystem which play a role in promoting and maintaining wellness beyond the traditional health care delivery assets. Utilize patient journey maps or other tools to educate clinicians, staff, and administrators on the role they play in the broader ecosystem.
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Measurement Track: Multi-stakeholder Alignment and Design
Capability: Develop multi-disciplinary education and coaching on value of accountable care
Definition:
All stakeholders understand the importance of accountable care and understand their role in achieving outcome targets.
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Measurement Track: Multi-stakeholder Alignment and Design
Capability: Implement provider performance reporting
Definition:
Create provider scorecards, dashboards, or other tools to track and monitor provider performance. Measures utilized should address quality, cost, access, and other relevant domains that are included in, or related to, current and planned alternative payment models. Providers should receive periodic feedback on their performance, including direction on how to improve. Consider publishing performance data within the organization to encourage sharing of promising practices.
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Measurement Track: Multi-stakeholder Alignment and Design
Capability: Develop strategy for market supply and analysis
Definition:
Determine market supply gaps within network of employed and independent primary and specialty provider groups.
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Measurement Track: Multi-stakeholder Alignment and Design
Capability: Develop strategy for provider network adequacy analysis
Definition:
Establish criteria and metrics for evaluating network adequacy on an ongoing basis, including capacity, timely access, specialties, and geographic coverage. Perform a preliminary analysis to identify gaps and establish a strategy for addressing those gaps over time.
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Measurement Track: Data and Infrastructure
Capability: Population risk stratification and registries
Definition:
Utilize multiple data sources (e.g., clinical, claims, SDOH, consumer behavior patterns) combined with public health registries to perform predictive analytics to identify/stratify individuals and populations with the highest addressable risk. Utilize various inputs and weights, which are periodically refined, to develop a composite risk score to compare relative risk of members/patients across the panel.
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Measurement Track: Data and Infrastructure
Capability: Comparative and benchmarked performance reporting across all alternative payment model contracts
Definition:
Utilization of multiple data sources (e.g., clinical, claims, SDOH) to report and analyze contracts individually, compared to others, and compared to benchmarks.
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Measurement Track: Data and Infrastructure
Capability: Implement hierarchical condition category/risk stratification
Definition:
Ability to utilize claims and clinical data to analyze conditions as well as apply risk and rating for basic identification of high and rising-risk members/patients.
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Measurement Track: Quality
Capability: Transformed utilization management with AI-assisted clinical reviews with provider/payer interoperability
Definition:
Using the latest AI capabilities to pre-populate authorization submissions with the mandated data elements. Includes implementation of FHIR API standards.
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Measurement Track: Quality
Capability: Develop utilization management approach
Definition:
Framework to evaluate medical necessity, appropriateness and efficiency of health care services, procedures, and facilities.
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Measurement Track: Quality
Capability: Promote evidence-based decisions and support
Definition:
Understanding the value and purpose of effective decision-making by leveraging data analysis and information. Putting support systems in place to support compliance and inter-rater reliability.
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Measurement Track: Quality
Capability: Reporting of patient-reported outcomes (PROs)
Definition:
Effective collection and analysis of patient-reported outcomes by the provider or health plan, including measurement of health disparities; timely collection and use of alternative collection methods (e.g., mobile devices).
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Measurement Track: Payment Reform
Capability: Implement shared savings payment model
Definition:
Participate in payment models which set a benchmark target for cost within a defined population, and evaluate performance based on whether the provider achieves the benchmark (subject to quality, minimum savings rates, or other factors). In this model, providers are not subject to any losses for failing to achieve the target, which allows for a lower-financial risk environment to gain experience in these types of arrangements.
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Measurement Track: Payment Reform
Capability: Implement pay-for-performance payment model
Definition:
Participate in alternative payment models that provide incentives based on performance in quality, cost, access and other measures. To the extent possible, work across health plans to standardize the measures used in these alternative payment models, and work with operational stakeholders to establish processes for tracking and monitoring performance on these measures. Include these measures in administrator and clinician goals.
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Measurement Track: Payment Reform
Capability: Integrated financial and clinical team actively engaged to incorporate clinical perspectives with data outputs to identify insights and target performance improvement opportunities
Definition:
Clinical and financial data are reviewed together to capture understanding of cost, utilization, quality, and outcomes relative to metric targets.
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Measurement Track: Payment Reform
Capability: Implement bundled payments
Definition:
Begin participation in episodic payment arrangements that set payment for managing the care for a defined diagnosis or procedure across a preset time period. Develop processes to analyze claims data to evaluate opportunities to reduce clinical variation within episodes. Develop clinical programs that are aligned to alternative payment models.
Resources:
Measurement Track: Multi-stakeholder Alignment and Design
Capability: Coordinated patient-centric partnerships that serve as foundation for multiple commercial and governmental payer products
Definition:
Applying promising practices identified from coordinated care delivery and incorporating into a standardized approach with payer products.
Measurement Track: Data and Infrastructure
Capability: Leverage interoperable data exchange
Definition:
May include the usage of a regional Health Information Exchange (HIE) or other tools that facilitate the exchange of multiple types and formats of data between organizations.
Resources:
Measurement Track: Data and Infrastructure
Capability: Leverage clinical natural language processing (cNLP) to optimize medical record data capture
Definition:
Utilization of cNLP to assist with comprehensive clinical data capture and categorization to inform population health risk stratification, input to chronic disease registries, and identify care gaps.
Measurement Track: Data and Infrastructure
Capability: Leverage claims system that accommodates alternative payment models (APMs)
Definition:
Implementation and utilization of a claims system which can process payments beyond fee-for-service, without manual workarounds.
Measurement Track: Data and Infrastructure
Capability: Implement electronic health records (EHR)
Definition:
Implementation and usage of an EHR to capture medical records and other clinical data for usage in reporting.
Measurement Track: Data and Infrastructure
Capability: Leverage employer and administrative services only (ASO) reporting
Definition:
Develop reporting specifically for self-insured entities, such as employer groups, where the health plan serves in an ASO capacity. Reporting should provide insights on utilization trends and patterns, areas of high expenditures, common health conditions, and cost containment strategies. Additional insights may be provided in areas such as employee engagement (e.g., utilization of preventative services), benchmarking, and pharmacy (e.g., use of generics vs. branded drugs).
Measurement Track: Data and Infrastructure
Aligning stage supports participation in broader data-sharing activities and patient/consumer engagement in their own care.
Measurement Track: Quality
Capability: Develop inclusive and equitable medical policies
Definition:
All policies include rationale for the mandate based on industry standards and evidence-based promising practices.
Measurement Track: Quality
Capability: Coordinate clinical quality and performance metrics across governmental and commercial health plans enabling synergistic improvements in health outcomes
Definition:
Develop comparisons of quality results from different organizations and/or populations to look for promising practices that can be applied to other organizations/populations.
Measurement Track: Health Equity Advancements
Capability: Identify care management activities and stratification based on clinical, claims, social drivers, urgency of needs
Sub-capability: Develop provider/payer coordinated plan of care
Definition:
Initial collaboration in development of patient plans of care that span the continuum of care, prioritize efforts, and support ongoing cross-functional communication on updates to support alignment.
Measurement Track: Health Equity Advancements
Capability: Enable online appointment and resource scheduling
Definition:
Giving patients the option to self-schedule appointments from a computer or mobile device to improve convenience, experience, and satisfaction.
Measurement Track: Health Equity Advancements
Capability: Omni-channel communication including mobile and digital designed with cultural diversity
Definition:
Focuses on offering and delivering a personalized and culturally sensitive communication experience using multiple communication tools including phone, email, mobile apps, and online platforms.
Measurement Track: Health Equity Advancements
Capability: Administer wellness and preventative screenings
Definition:
Used to screen for potential illnesses and maintenance of health. Screenings are inclusive of mammograms, colonoscopies, blood pressure, diabetes, cholesterol, weight loss, depression/anxiety, alcohol use, etc.
Measurement Track: Health Equity Advancements
Capability: Development of a health equity plan
Definition:
Includes engagement with community organizations to develop a list of priority activities, timelines, and responsibilities that addresses gaps voiced by community representatives with multiple community and state stakeholders.
Measurement Track: Health Equity Advancements
Capability: Investment in digital community resource directories
Definition:
Shared, electronic list of community organizations with which care team members/patients may partner to serve patients/individuals. Having shared digital community resource directories provide accurate and consistent information across all members/patients of the care teams. Ideally, organizations create or leverage regional and national platforms that allow for referral monitoring and are continually updated with the latest information on available services and resources.
Measurement Track: Health Equity Advancements
Capability: Interdisciplinary coordination and site of care
Definition:
Deliberate collaboration between multiple health specialties to provide holistic approach to care. Focused attention on most appropriate level and site of care based on performance and cost containment strategies. Integrated care leads to less confusion for the patient and better adherence and outcomes.
Measurement Track: Health Equity Advancements
Learning stage, the organization can assess and evaluate health disparities impacting the population against a baseline.
Measurement Track: Health Equity Advancements
Investing stage, the organization can expand into baseline health disparities identification and provides and supports patients with access to community resources initiatives while successfully measuring outcomes.
Measurement Track: Health Equity Advancements
Aligning stage, the organization supports alignment of multiple internal and community resources, supports patients in accessing resources, and continues monitoring ongoing health equity initiatives and disparities.
Measurement Track: Health Equity Advancements
Transforming stage, the organization supports improved equity across all its components, supports community initiatives to improve access to clinical care and reduce the impediments to care, and demonstrates improved outcomes and access to care across all populations.
Measurement Track: Multi-stakeholder Alignment & Design
Capability: Develop regional collaboration approach to drive alternative payment model movement
Definition:
Establish forums for organizations across the health care ecosystem, including providers, health plans, community-based organizations (CBOs), state/local governments, and employers, to come together to collectively address health care challenges.
Measurement Track: Multi-stakeholder Alignment & Design
Capability: Build qualitative indicators for multi-stakeholder network success
Definition:
Identify success indicators and set short-and long-term goals.
Measurement Track: Multi-stakeholder Alignment & Design
Capability: Conduct community health needs assessment focused on historically underserved populations with complex needs
Definition:
Targeted assessment focused on historically underserved populations with complex needs in the community to identify potential gaps and required interventions.
Measurement Track: Multi-stakeholder Alignment and Design
Capability: Develop network development strategy to improve adequacy gaps
Definition:
Create a strategy and actionable interventions to improve network adequacy using identified gaps from provider network adequacy analysis.
Measurement Track: Multi-stakeholder Alignment and Design
Transforming stage supports transparent multi-stakeholder alignment and forward-thinking infrastructure that advances accountable care models and arrangements.
Measurement Track: Multi-stakeholder Alignment and Design
Aligning stage supports multi-stakeholder participation in advancing accountable care models and arrangements with measurable progress.
Measurement Track: Multi-stakeholder Alignment and Design
Learning stage supports identifying opportunities available to educate multiple stakeholders on the existing accountable care landscape.
Measurement Track: Data and Infrastructure
Capability: Enhanced usage of enterprise software
Definition:
Utilization of enterprise software such as data warehouses to capture, store, and analyze multiple types of data at once (e.g., clinical, claims, quality, financial data).
Measurement Track: Data and Infrastructure
Capability: EHR incorporates digital integration with community and social services
Definition:
Ability of EHR to capture and communicate with community or social services tools and systems for sharing of data and referrals.
Measurement Track: Data and Infrastructure
Capability: Enhanced member/patient portals
Definition:
Usage of the portal to further capture and communicate enhances/additional services and activities such as online scheduling or provider bidirectional messaging.
Measurement Track: Data and Infrastructure
Capability: Implement enterprise software approach
Definition:
Implementation and usage of several enterprise-wide software/tools such as data warehouse, clinical decision support, security, and privacy to enable the collection, analysis, and reporting needs in other Measurement Tracks.
Measurement Track: Data and Infrastructure
Capability: Leverage employer and administrative services only (ASO) reporting
Sub-capability: Insights identified in employer and ASO reports utilized for improved quality, outcomes, and utilization
Measurement Track: Data and Infrastructure
Capability: Analytics rules engine with multidimensional identification and stratification modeling
Definition:
Building on the initial Analytics Rules Engine to utilize multiple data sources (e.g., claims, clinical, social determinants of health (SDOH)) in the performance of advanced reporting and identification of members/patients from historically underserved populations with complex needs for care management and interventions.
Measurement Track: Data and Infrastructure
Capability: Leverage analytics rules engine
Definition:
Consumes raw data to apply and execute a defined logical rule set to create meaningful output that can be further analyzed to develop actionable next steps.
Measurement Track: Data and Infrastructure
Capability: Implement singular source of data capture
Definition:
Relevant source systems used to capture important data elements have been identified and are under the purview of the data management structure. Instances where the same data is being captured in multiple locations (e.g., different fields within the EHR) are being identified and a process exists to standardize the inputs received for use in reporting.
Measurement Track: Quality
Capability: Ongoing monitoring of low-value care
Definition:
Incorporating low-value care monitoring and analysis into ongoing quality performance reviews and comparisons of volumes of low-value services by provider/practice.
Measurement Track: Quality
Capability: Leverage quality standards and benchmarks for top performance
Definition:
Using top performance benchmarks and quality standards to show gaps in performance and to align quality improvement plan targets.
Measurement Track: Quality
Capability: Utilizes insights from reporting to support provider specific and system improvements
Definition:
Application of blinded quality performance results comparisons between individual providers to drive provider-specific process improvements.
Measurement Track: Quality
Capability: Leverage gold carding in utilization management
Definition:
Develop artificial intelligence (AI)-assisted utilization management programs and gold carding standards of performance and allow top performing practices a reprieve from authorization submission to increase clinical review efficiency and accuracy, as well as reduce administrative burden.
Measurement Track: Quality
Capability: Clinician leadership receives quality outcomes and participates in results’ interpretation and improvement efforts
Definition:
Ensuring clinical stakeholders participate in outcomes discussions to determine interventions and next steps.
Measurement Track: Quality
Capability: Develop approach to address low-value care
Definition:
Approach may include focus on appropriateness of care that is anchored in improving outcomes (evidence-based promising practices).
Measurement Track: Quality
Capability: Enhancements to utilization management to reduce barriers to care
Definition:
Includes continual re-evaluation of prior authorization list to eliminate low-value/non-standard sub-categories and electronic submissions.
Measurement Track: Quality
Capability: Develop medical policy review approach
Definition:
Collection and clinical review of medical records and related information for specific conditions/procedures against predefined guidelines and requirements.
Measurement Track: Quality
Capability: Develop organizational quality management program
Sub-capability: Measurement framework
Definition:
Awareness of the organizational approach/framework on quality measurement that will be used for consistent monitoring and comparison year over year.
Measurement Track: Quality
Capability: Develop key performance indicator management and alignment
Definition:
Aligning on what key performance indicators the organization will focus on as well as tools to monitor results with actionable interventions.
Measurement Track: Quality
Capability: Encourage provider-specific reporting incorporating quality, utilization, financial outcomes, and benchmark comparisons
Definition:
Ensuring that quality reporting includes multiple sources of measurement and comprehensive assessment within a defined provider network/group with comparisons across providers to identify promising practices and successful intervention methods.
Measurement Track: Quality
Capability: Engage and collaborate with provider leadership in reconciling perceived conflicts between clinical quality and governmental and health plan performance quality metrics
Definition:
Ensuring that provider/clinical stakeholders are included in quality measure definition/specification development, analysis, reporting, and resolving potential conflicts early in the performance review period in order to positively impact outcomes (e.g., different definitions and targets for diabetes management across HEDIS, provider, and health plan).
Measurement Track: Data and Infrastructure
Transforming stage supports advanced data collection, sharing infrastructure, and activities to measure progress on payment reform, quality, affordability, and equity.
Measurement Track: Data and Infrastructure
Investing stage supports investment in improved data collection, analytics, and measurement outcomes.
Measurement Track: Data and Infrastructure
Learning stage supports development of data management and governance necessary for infrastructure to support analytics and insights development.
Measurement Track: Quality
Transforming stage supports using standardized system-wide processes and tools to predict populations with gaps in care needs to drive interventions and improve patient experience as well as drive high-quality care and improved outcomes for all.
Measurement Track: Quality
Learning stage supports recognition of standard quality metrics and current state of quality performance.
Measurement Track: Payment Reform
Capability: Manage financial reconciliation
Definition:
Process of making financial payments consistent with payment methodology, typically at the end of a defined period, e.g., annually.
Measurement Track: Payment Reform
Capability: Development of contract management platform
Definition:
System to organize, track, and monitor contracting terms, performance metrics, and payment methodology across contracts with payers and providers.
Measurement Track: Payment Reform
Capability: Reporting of monitor targets and performance
Definition:
Includes stratified and risk adjusted performance measures.
Measurement Track: Payment Reform
Capability: Enhanced physician education and coaching (including provider network collaboration)
Definition:
Intersects with Multi-Stakeholder Alignment and Design Measurement Track. An important component of contract performance is first understanding the value proposition of accountable care, and educating physicians in the tenets of accountable care (e.g., emphasis on team-based care, strong physician/patient relationships, primacy of prevention, focus on outcomes, understanding and addressing social determinants of health).
Measurement Track: Payment Reform
Capability: Develop provider dashboards and portals
Definition:
Reporting tools displaying defined provider specific metrics and key performance indicators often accessed through a secure website.
Measurement Track: Payment Reform
Capability: Provide administrative and financial support
Definition:
Support resources available to capture and track alternative payment methodologies across commercial and governmental businesses.
Measurement Track: Payment Reform
Capability: Enhance product and price transparency (episode-level pricing)
Definition:
Share pricing for episode level products and services per governmental standards and in a manner that enables informed decision-making between patient and provider.
Measurement Track: Payment Reform
Capability: Develop shared savings/losses payment model
Definition:
Participate in alternative payment models which set a benchmark target for cost within a defined population, and provide shared savings or losses based on whether the provider achieves the benchmark (subject to quality, minimum savings/losses rates, or other factors).
Measurement Track: Payment Reform
Transforming stage supports understanding of the impact population-based payment methodologies have on organizational financial performance and health.
Measurement Track: Payment Reform
Aligning stage supports increasingly advanced payment models which better align incentives of providers to address cost and quality outcomes to improve affordability.
Measurement Track: Payment Reform
Investing stage supports alternative payment model framework for outcome reimbursement.
Measurement Track: Data and Infrastructure
Capability: Population risk stratification and registries
Sub-capability: Analytics reporting includes insights generated from the addition of clinical, financial, and business considerations
Measurement Track: Data and Infrastructure
Capability: Population risk stratification and registries
Sub-capability: Value based contract insights identified across sub-populations utilized to improve quality, outcomes, utilization, and performance
Measurement Track: Multi-stakeholder Alignment & Design
Capability: Cohesive digital referral and management platform
Dr. Judy Zerzan-Thul is the Chief Medical Officer at Washington State Health Care Authority, Co-Chair of the LAN Executive Forum, and a general internal medicine physician. She leads the state of Washington’s Medicaid Transformation Project, where she collaborates with stakeholders to advance health equity and the innovative use of data. As Chief Medical Officer of the Washington State Health Care Authority, she administers the state’s Medicaid program. She also works to advance the LAN’s strategic objectives to drive equitable health outcomes and lower the total cost of care.
Dr. Zerzan-Thul specializes in value-based payment models and healthcare financing. Prior to her role as the Chief Medical Officer for Washington State, Dr. Zerzan-Thul was the Chief Medical Officer at the Colorado Department of Health Care Policy and Financing. She led the implementation of the Affordable Care Act (ACA) in Colorado. She has extensive experience designing and implementing health plans and benefits for Medicaid programs. Dr. Zerzan-Thul’s background also includes leadership positions in the Medicaid Medical Director’s Network. She has also served as a committee member and advisor for national organizations, including the Agency for Healthcare Research and Quality, the National Quality Forum, the National Committee for Quality Assurance, the National Academy for State Health Policy, the Patient-Centered Outcomes Research Institute, and the Centers for Medicare & Medicaid Services.
Dr. Zerzan-Thul holds a Doctor of Medicine from Oregon Health and Science University and received a Master of Public Health in Health Policy and Administration from the University of North Carolina. She completed the Robert Wood Johnson Clinical Scholars Program at the University of Washington/VA Puget Sound Health Care System in 2007. From 2008 to 2010, she was a non-residential Health and Aging Policy Fellow for the office of Senator John D. Rockefeller IV of West Virginia, where she supported public policy for the Affordable Care Act.
