Case Studies / Best Practices

Case Study - Commercial Quality Measures

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Summary: A major metro-Atlanta physician hospital organization with more than 500 employed and independent physicians partnered with SPH Analytics to develop a solution to burdensome quality measure tracking for commercial value-based contracts. A quality measure dashboard was developed and deployed, empowering physician practices with valuable insights into clinical care gaps to improve population health and maximize revenue opportunities. Background: DeKalb Physician Hospital Organization (DPHO) is a clinically integrated network in metro Atlanta formed between DeKalb Medical Center and its medical staff to provide the full continuum of high quality care within its network and to consolidate group buying power for contracting, which provides a framework for group contracting with managed care plans. The clinically integrated PHO includes 3 hospitals, 500 physicians, 124 TINs, 165 practices, and 32 specialties. The PHO is owned funded and governed 50% by DeKalb Medical and 50% by the PHO physician network. The PHO is managed by a staff of eight and has a reputation for high quality and high efficiency. Challenge: DPHO was facing an enormous challenge to track and improve quality measures for ten commercial payer plans, each with a unique contractual arrangement based on quality and efficiency measures, including commercial Accountable Care Organization (ACO) and Medicare Advantage (MA) plans. These agreements specified pay for performance incentives for closing care gaps. Each payer plan issued care gap, last visit, and member roster reports every month or quarter, amounting to the management of more than 26 spreadsheets in different formats. The DPHO staff spent countless hours each month on manual processes to standardize file formats, determine the care gaps, and push quality gap information out to the physicians. DPHO case managers were then tasked to manage the closing of care gaps and provide documentation to the payers. To further compound the problem, the DPHO physician network used more than 20 different EHRs with no integration of data and several physicians were still using paper records. DPHO spent significant resources on cumbersome chart review to understand the data. This left DPHO with limited visibility into the entire population, as well as minimal drill-down capabilities to individual physicians and patients, and no way to manage network leakage. Quality Measure Management for Commercial Risk Agreements Case Study TM SPH Population Care

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