Provider Network Analytics: Achieving Shared Savings in an MSSP ACO by Mapping Network Referral Patterns, Closing Gaps in Service, and Reducing Out of Network Patient Leakage The Client One of Fibroblast s clients is a $5.5 B integrated delivery network comprised of five hospitals, a 700-physician medical group, and 50 outpatient clinics. The client is in transition from fee-for-service to fee-for-value. Among other value-based contracts, the client s employed medical group and facilities participated in a Medicare Shared Savings Program (MSSP) ACO with approximately 15,000 patients. The client operates in a highly competitive, consolidating service area. It competes with three large, academic health systems and two community integrated delivery networks. Two of the academic health systems have grown through aggressive acquisition of area medical groups and community hospitals, a trend that is becoming more common with recent medicare payment reforms. The Client 50 Clinics 5 Hospitals 700 Physicians $5.5BRevenue The Client's Challenges The client failed to achieve any ACO shared savings through three full years of operation. Worse still, the ACO s actual total patient spend in 2015 was $8.7M more than its benchmarked or projected expenditures. Nevertheless, the client was committed to transforming itself into a value-based care organization, including participating in the the Next Generation ACO program (upside/downside risk), expanding its Medicare Advantage contracting, contracting with payors in commercial ACOs, and working with local employers to provide narrow network products. The client realized that taking on risk for the cost of patient care would be potentially disastrous if the client didn t first understand why it failed to achieve any ACO shared savings. It engaged Fibroblast to help. 1
Fibroblast's Solution Fibroblast s analytics solution combines technology and professional services to help clients uncover hidden, actionable insights. It has four components: 1. Goal Setting. The first component of Fibroblast s analytics solution is Goal Setting. Fibroblast and the ACO s leadership team determined the ACO s strategic, financial, and clinical quality goals for the upcoming performance year, and the most relevant questions to answer in order to meet the goals. Not surprisingly, the ACO s primary financial goal was to achieve shared savings. In order to do that, Fibroblast helped develop the following inquires to run on the client s claims data: How much care are ACO patients receiving within the ACO? How many patients are leaking out of the ACO network to area competitors? What are the root causes of the out-of-network (OON) expenditures? Which ACO providers are referring patients to OON providers? What is the cost of in-network care? What is the cost of OON care? What opportunities exist to improve in-network cost efficiencies? How would impacting ACO provider referral patterns affect down-stream patient spend lost to OON competitors? What are the current gaps in care by geographical service area? Which OON providers are the best to partner with, align, or employ? 2
Fibroblast's Solution 2: Data Scrubbing. The second component of Fibroblast s analytics offering is Data Scrubbing. Fibroblast took the client s raw, incomplete, inconsistent, and disorganized claims data and ran it through Fibroblast s proprietary data normalization application to standardize and organize it. This scrubbed data lays the foundation for Fibroblast s deep network analysis and provided the client with a complete, structured data set of its entire provider network. 3: Data Mapping. The third component of Fibroblast s analytics offering is Data Mapping. During this step, Fibroblast ran the client s scrubbed ACO claims through Fibroblast s proprietary data mapping tools and machinelearning algorithms. Fibroblast s technology mapped provider referral patterns and patient flows, identified the sources and recipients of referral leakage and OON spend, and calculated certain revenue and cost of care metrics for the ACO. Fibroblast identified and ranked each ACO and OON provider according to each provider s contribution margin and affiliation with the client. Fibroblast s technology also produced various heat maps, indicating where the client had gaps in specialty or geographic coverage, and, in areas where it did have coverage, where the client was losing out to competitors head-to-head. 4: Opportunity Targeting. The final component is Opportunity Targeting. Fibroblast presented the client with Fibroblast s analysis and suggested opportunities to improve the ACO s financial performance. Fibroblast also gave the ACO s leadership team an interactive, webbased dashboard for the ACO leaders to explore additional data elements on its own. 3
Actionable Insights Fibroblast s analytics solution helped the ACO identify the following opportunities to achieve shared savings in the upcoming performance year: Leakage Root Cause Identified. Fibroblast was able to identify the ACO providers responsible for the most OON leakage and map the providers referral patterns. Armed with this new information, the client was able to engage the providers in discussions to identify the root cause of their OON referrals. It turns out that 80% of them were referring to OON providers because they had a fundamental lack of understanding of the ACO network. It was not clear to them which ACO providers were part of the network and which weren t; their default was to refer patients based on personal relationships and affinity, not based on objective measure of quality, cost, or network alignment. Providers agreed that having ACO network data at the point of care would help them make more informed referral decisions, specifically including referring within the ACO. To solve this problem, the client resolved to implement a referral management solution to automatically and comprehensively manage network referrals, including deploying a referral decision support tool to algorithmically guide referrals to the highest quality, lowest cost, most aligned ACO providers. 4
Actionable Insights Gaps in Services Closed. Fibroblast helped the client identify geographic and strategic gaps in its services. Prior to Fibroblast, the client made decisions about where to locate or expand its services in the market based on generic market research data and its own intuition. But, using Fibroblast s data visualization tools and heat maps, Fibroblast identified for the client exactly where the client had gaps in service, and how much OON spend the client lost because of each gap. Fibroblast recommended the precise locations where the client should offer new services or extend existing service to capture the most economic value from its expansion. Strategic Growth Opportunities Identified. Fibroblast s data mapping and visualization tools identified the OON providers that received the $27M in leaked referrals, including their specialties, referral volumes and percentages of the leaked spend, alignments with other networks, and geographic locations. With this information, the client engaged the OON providers in discussions about forming strategic partnerships, including joining the client s ACO and other value-based care contracts, and potential acquisition or merger of their practices. The client s goal here was to reduce some competition, while adding to the client s bottom line, and gaining more control over the quality of care that the client s ACO patients were receiving. Fibroblast is a referral management platform that drives in-network referrals and eliminates network leakage. Our solutions include provider network referral analytics, referral decision support, and referral workflow management, which can be deployed fully integrated with any major EMR system or as a stand alone web application. For more information or a demo of our platform, contact info@fibroblast.com 5