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 MEASUREMENT
Primary Care Payment Models
Data Sharing Requirements Initiative
Maternity Episode
Payment Models
Primary Care Payer
Work Product Glossary
Collaboratives and Convening Organizations
Arkansas’s Multi-state Multi-payer Collaborative
Initiative Description: Since 2011, Arkansas Blue Cross and Blue Shield, Blue Cross and Blue Shield of Kansas City, and Blue Cross and Blue Shield of Oklahoma (BCBS plans) have engaged in a regional, multi-payer learning and technical assistance effort. The effort started as an initiative to stay connected, share lessons learned, and demonstrate best practices related to the CPC Initiative, but now the Collaborative has spanned two additional Innovation Center models (CPC+ and PCF). The multi-state effort has continued to grow organically beyond the models and BCBS payers.
Strategic and Tactical Uses: Regional payers in Arkansas, Oklahoma, and the Kansas City area can join the multi-state multi-payer collaborative and be involved in alignment efforts for quality measures, technical assistance, and information exchange. Payers outside of the area can use the Collaborative as an example of regional payers coming together to align, and look into forming a Collaborative in their region.
Multi-payer Alignment Foundational Element(s): Performance Measurement; Advancing Health Equity; Timely and Consistent Data Sharing; Providing and Leveraging Technical Assistance
Timeframe: Active
For additional information, please email the hcplan@deloitte.com team.
Who Might Use This: 
Payers
Innovative Initiatives and Partnerships
Core Quality Measures Collaborative (CQMC) Measure Sets
Initiative Description: The Core Quality Measures Collaborative (CQMC) develops and releases core sets of quality measures for 10 focus areas. The CQMC Workgroups convene on an annual basis to update the existing core sets, conduct yearly maintenance, and dialogue with members from a variety of stakeholder groups to gain different perspectives on the measures and consider new ones.
Strategic and Tactical Uses: Organizations can compare the CQMC Measures Collaborative Core Measure Sets with other aligned measure sets in use to identify overlap and prioritize measures for multi-payer implementation initiatives.
Multi-payer Alignment Foundational Element: Performance Measurement
Timeframe: Active
For additional information, please visit https://www.qualityforum.org/CQMC_Core_Sets.aspx
Who Might Use This: Payers | 
Providers | 
Purchasers
Innovative Initiatives and Partnerships
Initiative A
Initiative Description: Initiative A was conducted between 2021-2023. It focused on X, Y, Z and was successful in X, Y, Z.
Strategic and Tactical Uses: Initiative A concluded in March 2024. It can be referenced to understand Initiative A’s X, Y, Z and applied to future efforts.
Multi-payer Alignment Foundational Element: Aligning Key Payment Model Components
Timeframe: Archived
For additional information, please visit XYZ
Who Might Use This: Purchasers | 
Enabling Organizations | 
Policy Makers
Government Regulation and Guidance
Centers for Medicare & Medicaid Services 2023 Medicaid Adult Core Set
Initiative Description: The Social Security Act (Section 1139B) requires the Secretary of HHS to identify and publish a core set of health care quality measures for adult Medicaid enrollees. The Adult Core Set includes a range of quality measures encompassing both physical and behavioral health. Beginning in 2024, reporting on the behavioral health measures on the Adult Core Set is mandatory for states. The Adult Core set will continue to be updated annually, with future updates provided in a manner to allow states to address any changes ahead of mandatory reporting periods.
Strategic and Tactical Uses: Organizations can compare the 2023 Medicaid Adult Core Set with other aligned measure sets in use to identify commonalities and prioritize measures for multi-stakeholder implementation initiatives.
Multi-payer Alignment Foundational Element: Performance Measurement
Timeframe: Active
For additional information, please visit https://www.medicaid.gov/medicaid/quality-of-care/performance-measurement/adult-and-child-health-care-quality-measures/adult-health-care-quality-measures/index.html
Who Might Use This: Payers | Providers | Enabling Organizations | Policy Makers
Government Regulation and Guidance
The Universal Foundation Measure Set
Initiative Description: In an effort to align measures that drive quality improvement and care transformation, the Centers for Medicare & Medicaid Services selected adult and pediatric measures that promote the best, safest, and most equitable care for individuals across critical quality areas – wellness and prevention, chronic conditions, behavioral health, person-centered care, and seamless care coordination. The measures will be used across CMS quality programs and prioritized for stratification and digitization.
Strategic and Tactical Uses: Organizations can compare the Universal Foundation with other aligned measure sets to identify overlap and prioritize measures for multi-payer implementation initiatives. The Universal Foundation will continue to evolve over time with population-specific “add-on” measure sets.
Multi-payer Alignment Foundational Element: Performance Measurement
Timeframe: Active
For additional information, please visit https://www.cms.gov/aligning-quality-measures-across-cms-universal-foundation
Who Might Use This: Payers | Providers | Purchasers | Policy Makers
Alignment Resources and Helpful Documents
HCPLAN’s Guidance on Social Risk Adjustment
Initiative Description: The HCPLAN’s Health Equity Advisory Team (HEAT) meets regularly to identify and prioritize opportunities to advance health equity through Alternative Payment Models. The HEAT’s Advancing Health Equity Through APMs Guidance on Social Risk Adjustment provides stakeholders with a starting point for action by offering guidance on three core components of social risk adjustment: data collection and tools, payment incentives and mechanisms, and care transformation.
Strategic and Tactical Uses: The HEAT guidance is call to action for stakeholders to incorporate social risk adjustment into APMs with short-, medium-, and long-term recommendations. The recommendations enable organizations to align on key issues such as data collection, payment incentives, and care transformation to help reduce health disparities in the health care delivery system.
Multi-payer Alignment Foundational Elements: Aligning Key Payment Model Components; Advancing Health Equity
Timeframe: Active
For additional information, please visit http://hcp-lan.org/workproducts/APM-Guidance/Advancing-Health-Equity-Through-APMs-Social-Risk-Adjustment.pdf
Who Might Use This: Payers | 
Community Organizations
Government Regulation and Guidance
Office of the National Coordinator for Health Information
Technology’s (ONC) Cures Act Final Rule for Data Sharing
Initiative Description: The Office of the National Coordinator for Health Information Technology’s (ONC) Cures Act Final Rule aims to promote secure access, exchange, and use of electronic health information. The Act accelerates the uptake of standardized application programming interfaces (APIs), requires IT developers to provide API capabilities for population health management, and increases patient access to electronic health information.
Strategic and Tactical Use: This rule helps to standardize the reporting measuring process by promoting interoperability and enabling access to patient-level data from payers, providers, and patients. Organizations should continue to track ongoing updates data sharing infrastructure.
Multi-payer Alignment Foundational Element: Timely and Consistent Data Sharing
Timeframe: Active
For additional information, please visit https://www.healthit.gov/buzz-blog/category/21st-century-cures-act
Who Might Use This: Payers | Providers
Government Regulation and Guidance
Centers for Medicare & Medicaid Services 2024 Medicaid Adult Core Set
Initiative Description: The Centers for Medicare & Medicaid Services released the 2024 Adult Core Health Care Quality Measurement Sets in a November 2022 to provide sufficient time for states to prepare for mandatory reporting. Reporting on the 2024 Adult Core Set will occur in Fall 2024.
Strategic and Tactical Uses: Organizations can look to the Core Sets as they consider their own performance measures for upcoming contract years.
Multi-payer Alignment Foundational Element: Performance Measurement
Timeframe: Upcoming
For additional information, please visit https://www.medicaid.gov/medicaid/quality-of-care/performance-measurement/adult-and-child-health-care-quality-measures/adult-health-care-quality-measures/index.html
Who Might Use This: Payers | Providers | Enabling Organizations | Policy Makers
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:
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).
Resources:
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.
Resources:
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.
Resources:
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.
Resources:
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.
Resources:
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.
Resources:
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.
Resources:
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.
Resources:
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.
Resources:
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.
Resources:
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.
Resources:
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.
Resources:
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.
Resources:
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.
Resources:
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.
Resources:
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.
Resources:
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.
Resources:
Measurement Track: Quality
Capability: Develop utilization management approach
Definition:
Framework to evaluate medical necessity, appropriateness and efficiency of health care services, procedures, and facilities.
Resources:
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.
Resources:
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).
Resources:
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.
Resources:
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.
Resources:
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.
Resources:
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.
Emily DuHamel Brower, M.B.A., is senior vice president of clinical integration and physician services for Trinity Health. Emphasizing clinical integration and payment model transformation, Ms. Brower provides strategic direction related to the evolving accountable healthcare environment with strong results. Her team is currently accountable for $10.4B of medical expense for 1.6M lives in Medicare Accountable Care Organizations (ACOs), Medicare Advantage, and Medicaid and Commercial Alternative Payment Models.
Ms. Brower joined Trinity Health from Atrius Health in Massachusetts, where she last served as vice president of Population Health. There, she built and executed the essential capabilities required to achieve strong financial and clinical outcomes within integrated care models under value-based reimbursement, particularly for publicly insured populations.
Prior to her career at Atrius Health, Ms. Brower spent 15 years in leadership roles at Urban Medical Group, a Massachusetts nonprofit healthcare organization specializing in the care of medically complex, chronically ill populations across a community-based, long-term care continuum. During that time, Ms. Brower launched a Program of All-inclusive Care for the Elderly (PACE) program and other innovative, capitated contracts for medically complex populations and served as Principal Investigator for a multi-year research project analyzing cost and quality outcomes to support payment reform.
Ms. Brower received her B.A. from Smith College and her M.B.A. from the New York University Stern School of Business.
Mr. James Sinkoff is the Deputy Executive Officer and Chief Financial Officer for Sun River Health (formerly known as Hudson River HealthCare), and the Chief Executive Officer of Solutions 4 Community Health (S4CH); an MSO serving FQHCs and private physician practices.
Sun River Health cares for over 240,000 general medicine, dental, behavioral health, mental health, agricultural, public housing, homeless, developmentally disabled, HIV and substance abuse patients and families generating nearly 780,000 patient encounters in over 43 clinical sites in both rural and urban settings in 10 counties of the Hudson Valley, 2 counties on Long Island and all of NYC. Sun River Health provides a full range of primary care, behavioral and mental healthcare services including but not limited to pediatrics, internal medicine, family medicine, OB/GYN, dentistry, urgent care, MAT and specific specialty care such as cardiology, endocrinology, and ophthalmology. Over 95,000 patients are managed under a variety of risk-based contacts as well as 11,000 MSSP ACO patients.
Mr. Sinkoff has worked in all sectors of the healthcare industry starting his career with Ernst & Young as an auditor and then as a senior management consultant to hospitals, physician practices, long term care facilities, and home health agencies. In the late ‘90s, he became the director of managed care financing for Berkshire Health Systems. Subsequently, he became the Chief Financial Officer for Fidelis Care New York (now Centene). Mr. Sinkoff was the Chief Executive Officer of Whitney M. Young Jr. Health Center in Albany, New York, before joining Sun River Health and Solutions 4 Community Health in late 2009.
As the DEO, Mr. Sinkoff oversees all aspects of Sun River Health’s service delivery system; clinical, financial and operational. He has been invited to share his thoughts on many topics including value-based systems of care, health equity, IT, interoperability, LEAN and Emotionally Intelligent management. Mr. Sinkoff is a coach to a number of clients seeking to grow and achieve their professional aspirations.
Mr. Sinkoff was an appointed member of the NYSDOH Transparency, Evaluation and HIT Workgroup. He is a member of the board and an executive committee member of the Health Care Transformation Task Force, formerly a part of the Levitt Group. He is a member serving the Robert Wood Johnson Foundation to Improve Health Equity led by the University of Chicago, the Institute for Medicaid Innovation, and the Center for Health Care Strategies. He is a member of the legislative, public policy and sub-committee on health center financing of the National Association of Community Health Centers. He is a member of the board of Amida Care, an HIV and Special needs plan. Mr. Sinkoff is the former chair of the board of the Community Healthcare Association of New York.
Victor is the Chief Medical Officer for TennCare, Tennessee’s Medicaid Agency. At TennCare, Victor leads the medical office to ensure quality and effective delivery of medical, pharmacy, and dental services to its members. He also leads TennCare’s opioid epidemic strategy, social determinants of health, and practice transformation initiatives across the agency. Prior to joining TennCare, Victor worked at Evolent Health supporting value-based population health care delivery. In 2013, Victor served as a White House Fellow to the Secretary of Health and Human Services. Victor completed his Internal Medicine Residency at Emory University still practices clinically as an internist in the Veteran’s Affairs Health System.
Dr. Brandon G. Wilson, DrPH, MHA (he, him, his) joined Community Catalyst as the Director of the Center for Consumer Engagement in Health Innovation, where he leads the Center in bringing the community’s experience to the forefront of health systems transformation and health reform efforts, in order to deliver better care, better value and better health for every community, particularly vulnerable and historically underserved populations. The Center works directly with community advocates around the country to increase the skills and power they have to establish an effective voice at all levels of the health care system. The Center collaborates with innovative health plans, hospitals and providers to incorporate communities and their lived experience into the design of systems of care. The Center also works with state and federal policymakers to spur change that makes the health system more responsive to communities. And it provides consulting services to health plans, provider groups and other health care organizations to help them create meaningful structures for engagement with their communities.
Dr. Wilson joined the Center, following his tenure in federal service as a Senior Public Health Advisor with the Centers for Medicare and Medicaid Services (CMS) Office of Minority Health, where he led strategic initiatives to implement the Biden/Harris Administration’s priorities on health equity for underserved communities, and developed a health equity business case portfolio. He most recently received the CMS Impact Award from CMS Administrator Chiquita Brooks-LaSure for advancing health equity and accessibility in COVID-19 for persons living with disabilities. Prior to joining CMS OMH, Dr. Wilson led a $250 million portfolio in the CMS Innovation Center’s Accountable Health Communities Model and the Health Care Innovation Awards. At CMMI, he spearheaded the Health Equity Working Group, which laid the foundation for CMMI’s health equity focus in its 10-year strategy refresh. He later directed culture of patient safety quality improvement projects for the NIH Clinical Center Office of the Director, by reducing medication errors in the inpatient oncology pharmacy department. He also headed recruitment and retention approaches for increasing minority screening, enrollment, and retention in preventative and therapeutic vaccine clinical trials and participation in the Community Advisory Board at NIH. For his exceptional commitment and dedication in identifying a solution for a global infectious disease threat by advancing a malaria vaccine through a clinical trial, Dr. Wilson received awards from NIH’s Director, Dr. Francis Collins and NIAID’s Director, Dr. Anthony Fauci.
Dr. Wilson brings a wealth of knowledge, skills, and abilities in advocacy, health policy, and research from national policy organizations as the National Association of People with AIDS. Dr. Wilson completed his Master’s in Health Systems Management at George Mason University and his Doctor of Public Health at Morgan State University. He also holds Public Health faculty appointments at Purdue University and the UNC Gillings School of Global Public Health, where he teaches courses in health economics and policy, cultural competence and communications for health professionals, community health assessments, and healthcare marketing. His research interests include using patient centered and indigenous models of care, health economics outcomes research, policy analysis, and community-based participatory and action research to eliminate health disparities and advance health equity in underserved and disinvested communities.
Tamara Ward is the SVP of Insurance Business Operations at Oscar Health, where she leads the National Network Contracting Strategy and Market Expansion & Readiness. Prior to Oscar she served as VP of Managed Care & Network Operations at TriHealth in Southwest Ohio. With over 15 years of progressive health care experience, she has been instrumental driving collaborative payer provider strategies, improving insurance operations, and building high value networks through her various roles with UHC and other large provider health systems. Her breadth and depth of experience and interest-based approach has allowed her to have success solving some of the most complex issues our industry faces today. Tam is passionate about driving change for marginalized communities, developing Oscar’s Culturally Competent Care Program- reducing healthcare disparities and improving access for the underserved population. Tamara holds a B.A. from the University of Cincinnati’s and M.B.A from Miami University.
Dr. Peter Walsh joined the Colorado Department of Health Care Policy and Financing as the Chief Medical Officer on December 1, 2020. Prior to joining HCPF, Dr. Walsh served as a Hospital Field Representative/Surveyor at the Joint Commission, headquartered in Oakbrook Terrace, Illinois.
Dr. Walsh is an Aerospace Medicine Specialist, who provided primary care to aircrew and special operational personnel and their families during much of his 21-year active-duty career in the U.S. Air Force. Upon retirement in 2006 he served as an Urgent Care Physician at the previous Memorial Health System in Colorado Springs between 2006 and 2008 and practiced at the Centura Center for Occupational Medicine in Colorado Springs, CO and Pueblo, CO between 2006 and 2009.
His prior positions include serving as the Chief Medical Officer, South State Operating Group of Centura Health, Corporate Chief Medical Executive for Centura Health in Denver, Colorado, and the VP of Medical Affairs at St. Francis Medical Center in Colorado Springs, Colorado.
Dr. Walsh received his B.A. at the University of Southern California, his M.D. from the Medical College of Ohio in Toledo, Ohio, and a M.P.H. from Harvard School of Public Health. He completed his residency in Aerospace Medicine at the USAF School of Aerospace Medicine at Brooks AFB, Texas.
Dr. William Shrank is Humana’s Chief Medical Officer (CMO). He leads the Integrated Health Solutions team that consists of several key clinical areas of the business. Dr. Shrank oversees Humana’s senior-focused, purpose driven, primary care organization, and guides the implementation of Humana’s integrated care delivery strategy, with an emphasis on advancing the company’s clinical capabilities. He launched Humana’s health equity department, Humana’s population health strategy (the Bold Goal), and the Humana Healthcare Research team. Across all divisions, Dr. Shrank promotes the idea of Humana as a learning organization and has dedicated his team to rapid learning – where meaningful insights are generated accurately and quickly, and enhance Humana’s ability to continually evolve to improve the health and health outcomes of those we serve.
Dr. Shrank is a member of the Management Team, which sets the firm’s strategic direction, and reports and to President and Chief Executive Officer, Bruce Broussard. Additionally, Dr. Shrank serves on the Board of National Committee for Quality Assurance and is co-chair of the Clinical Transformation Taskforce for the Health Care Payment Learning and Action Network.
Dr. Shrank joined Humana in April 2019 having previously been employed by the University of Pittsburgh Medical Center (UPMC) as CMO, Insurance Services Division from 2016 to 2019. At UPMC, Dr. Shrank was responsible for clinical operations, policy and quality for approximately 3.5 million members in government and commercial lines of business.
Prior, Dr. Shrank served as SVP, Chief Scientific Officer, and CMO of Provider Innovation at CVS Health from 2013 to 2016. From 2011 to 2013, Dr. Shrank served as Director, Research and Rapid[1]Cycle Evaluation Group, for the Center for Medicare and Medicaid Innovation, part of the Centers for Medicaid and Medicare Services.
Dr. Shrank began his career as a practicing physician with Brigham and Women’s Hospital and as an Assistant Professor at Harvard Medical School.
Dr. Shrank completed his medical degree from Cornell University Medical College, his residency in internal medicine at Georgetown University and his fellowship in Health Policy Research at the University of California, Los Angeles. He also earned a Master of Science degree in Health Services from the University of California, Los Angeles and a Bachelor of Arts degree from Brown University.
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Mat Spaan, MPA, has worked with the state of Minnesota since 2008 in implementing and developing health policy and payment reform initiatives, with his most recent work managing care delivery and payment activities within the state’s Medicaid program. Since 2013, one of his primary roles is as lead on Minnesota’s Medicaid ACO demonstration, known as the Integrated Health Partnerships (IHP) program, and the development of value-based purchasing in Medicaid.
Mat’s previous state projects have included the development of the state’s All-Payer Claims Database and planning director overseeing the creation of a hospital and physician clinic cost and quality comparison tool. Prior to joining the state, he’s held several interesting positions in the private and nonprofit sectors, including as a manager with a national health advocacy organization, organizer for a neighborhood arts and economic development nonprofit in New Orleans, and as a boat captain on Lake Michigan. Mat earned his Master of Public Administration degree from the University of New Orleans.
Dr. Mark Friedberg is Senior Vice President of Performance Measurement and Improvement for our company, the largest private health plan in Massachusetts and one of the largest independent, not-for-profit Blue Cross Blue Shield plans in the country. We serve more than 3 million members and more than 20,000 employers and are consistently rated among the nation’s best health plans for overall member satisfaction and quality.
Mark is responsible for all activities related to measuring and improving the performance of our provider network, including quality and equity metrics used in our value-based contracts such as our Alternative Quality Contract. He also oversees data analytics related to our own performance, ensuring we meet or exceed state and federal standards as well as HEDIS, NCQA and CMS quality measures.
Before joining our company in 2019, Mark was a researcher at the RAND Corporation, a leading policy research organization, where he led multiple projects to measure, evaluate and improve health system performance.
He is a general internist who provides primary care at Brigham and Women’s Hospital, where he completed his residency and fellowship. Mark works at the Brigham a half day each week.
Mark has an M.D. from Harvard Medical School, a Master of Public Policy from the Harvard Kennedy School of Government, and a Bachelor of Arts from Swarthmore College. He is also a part-time assistant professor of medicine at Harvard Medical School. Mark enjoys music, food, and beach trips with his family.
Brian W. Powers, MD, MBA is Deputy Chief Medical Officer at Humana. In this role, he works across the organization to support rapid learning and evaluation of Humana’s integrated care delivery strategy; to lead research in payment and delivery innovation; and to drive physician engagement, alignment, advocacy, and education across the company. Prior to Humana, he led population health strategy and analytics for CareMore and Aspire Health, both care delivery subsidiaries of Anthem. In prior roles, he was responsible for initiatives to improve health care quality and value at Mass General Brigham, the National Academy of Medicine, and the Massachusetts Health Policy Commission. An accomplished researcher, Dr. Powers is an Assistant Professor of Medicine at the Tufts University School of Medicine, has published peer-reviewed studies in venues such as JAMA, Science, and the New England Journal of Medicine, and serves as Deputy Editor of Healthcare: The Journal of Delivery Science and Innovation. He holds an MD from Harvard Medical School, an MBA from Harvard Business School, and an AB from Bowdoin College. He completed his clinical training in internal medicine and primary care at Brigham and Women’s Hospital and is a practicing internist.
Marc Harrison, M.D., President and CEO of Intermountain Healthcare, is a pediatric critical care physician with a proven track record as a top operation executive on a global scale. He is a national and international thought leader on transformation and innovation—ranking in Fortune’s Top 50 World’s Greatest Leaders in 2019. He also ranked third on Modern Healthcare’s 100 Most Influential People in Healthcare in 2020.
Dr. Harrison is leading Intermountain’s 41,000 employees—who are all called caregivers—to embrace bold new approaches to improve health, re-define value-based care, and serve people in new ways. For example, Intermountain launched Civica Rx, a not-for-profit generic drug manufacturer and distributor, to make generic medications more available and affordable in hospitals across the nation. Intermountain is also a founding member of the Utah Alliance for the Determinants of Health, which is a collaboration of community partners designed to proactively address forces that affect people’s health well before they come to a clinic or a hospital.
Dr. Harrison also served as CEO of Cleveland Clinic Abu Dhabi, Chief of International Business Development at Cleveland Clinic, and Chief Medical Operations Officer at Cleveland Clinic.
He received his undergraduate degree from Haverford College and his medical degree from Dartmouth Medical School, completed a pediatric residency and pediatric care fellowship at Intermountain’s Primary Children’s Hospital, and completed a Master of Medical Management at Carnegie Mellon University.
Dr. Harrison is an all-American triathlete and represented the U.S. at the 2014 World Championships. He is also a two-time cancer survivor with his sights currently on completing an Ironman.
Marshall H. Chin, M.D., M.P.H., the Richard Parrillo Family Professor of Healthcare Ethics in the Department of Medicine at the University of Chicago, is a practicing general internist and health services researcher who has dedicated his career to reducing health disparities through interventions at individual, organizational, community, and policy levels.
Dr. Chin co-chairs the CMS HCP-LAN Health Equity Advisory Team. He also co-directs the Robert Wood Johnson Foundation Advancing Health Equity: Leading Care, Payment, and Systems Transformation program and collaborates with teams of state Medicaid agencies, Medicaid managed care organizations, and frontline healthcare organizations to implement payment reforms to support and incentivize care transformations that advance health equity. He also partners with eight urban and rural communities to integrate medical and social care to reduce diabetes disparities through the Merck Foundation Bridging the Gap program.
Dr. Chin is a graduate of Harvard College and the University of California at San Francisco School of Medicine, and he completed residency and fellowship training in general internal medicine at Brigham and Women’s Hospital, Harvard Medical School. He is a former President of the Society of General Internal Medicine, and he was elected to the National Academy of Medicine in 2017.
Christina Severin is a leading health care executive with more than 20 years of experience and numerous accomplishments in managed care, delivery systems, health insurance, Accountable Care Organizations, quality, public policy, and public health. She has led Community Care Cooperative (C3) since the organization’s launch in 2016, leveraging the proven best practices of ACOs throughout the country, building the organization on the collective strengths of its health centers, and growing the organization to better serve MassHealth members throughout the commonwealth. Christina’s prior leadership experience includes serving as President and Chief Executive Officer of Beth Israel Deaconess Care Organization and as President of Network Health, a nonprofit Massachusetts health plan.
Elizabeth Kasper is the Special Policy Advisor for Alternative Payment Models at North Carolina Medicaid. In this role, she works with external and internal stakeholders to support the design and implementation of value-based payment models and policies that advance NC Medicaid’s priorities. Liz’s 20-year career in health policy and health services research has also included work on health quality and public health measures, federally qualified health centers, Medicaid clinical policy, and pharmaceutical regulation and reimbursement. Liz holds a Master of Science in Public Health from the University of North Carolina at Chapel Hill and a BA from Oberlin College.
Dr. Palav Babaria was appointed Chief Quality Officer and Deputy Director of Quality and Population Health Management of the California Department of Health Care Services beginning in March 2021. Prior to joining DHCS, she served as Chief Administrative Officer for Ambulatory Services at the Alameda Health System (AHS) where she was responsible for all outpatient clinical operations, quality of care, and strategy for primary care, specialty care, dental services, and integrated and specialty behavioral health, as well as executive sponsor for value-based programs including the Medi-Cal 1115 Waiver. She also previously served as Medical Director of K6 Adult Medicine Clinic, where she managed a large urban hospital-based clinic, overseeing all practitioners, improving quality of care, and patient safety programs. In addition, she served on the Clinical Advisory Committee with the California Association of Public Hospitals/Safety Net Institute. She also has over a decade of global health experience and her work has been published in the New England Journal of Medicine, Academic Medicine, Social Science & Medicine, L.A. Times, and New York Times. Dr. Babaria received her bachelor’s degree from Harvard College, as well as her MD and Master’s in health science from Yale University. She completed her residency training in internal medicine and global health fellowship at the University of California, San Francisco.
