LinkedIn: AMGA: Advancing
High Performance Health
is employed to optimize the results of these efforts. For
example, risk stratification analytics tie into engines that
capture characteristics of care navigation and management
staff, both in terms of licensure and areas of expertise—
ensuring patients at greatest risk are matched with the
individuals in the best position to help them.
3. Improve ongoing performance. When CMS designed the OCM,
it did so with a core belief that sustained improvements in
care quality, cost, and experience require a fundamental
change in how practices operate. OCM participants therefore
realized from the beginning that advances in data management and analysis would need to accompany investments
in new skills, capabilities, and workflows. CMS explicitly
prescribes seven focus areas for practice transformation—
from 24/7 availability of a clinician with chart access to
evidence-based care planning. In addition, practices have
established new governance mechanisms for their clinical and
financial leaders to surface findings and agree on coordinated
responses in ways that fit their specific workflows.
4. Optimize reimbursement. To identify missed billing
opportunities while also reducing the risk of duplicated
claims, practice leaders are investing in robust analytics
tools that enable personalized queries at the patient level.
These reports compare eligibility against their practice
management reports to identify gaps, from unpaid and
unbilled to denied.
While initial analytics aimed to provide a near real-time
view of status, as OCM practices evolve, their purview is
expanding to incorporate predictive models that prescribe
interventions for high-risk cohorts before costly events occur.
In short, to optimize performance under the OCM, practices
are leveraging the data to which they already have access—
both clinical and financial—to risk-stratify their patient
populations, identify OCM eligible patients, and gain near
real-time visibility into quality and cost performance. Practices are also investing in data integration and analytics that
enable rules-based identification of eligible patients.
Charles Saunders, M.D., is CEO of Integra Connect.
1. Centers for Medicare & Medicaid Services. 2018. Speech:
Remarks by CMS Administrator Seema Verma at the
American Hospital Association Annual Membership Meeting.
Accessed August 13, 2018 at cms.gov/newsroom/fact-sheets/
2. UnitedHeatlhcare. 2018. Welcome to Value-Based Care. Accessed
August 13, 2018 at uhc.com/valuebasedcare.
3. A.B. Mariotto, K.R. Yabroff, Y. Shao, et al. 2011. Projections of the
Cost of Cancer Care in the United States: 2010-2020. Journal of
the National Cancer Institute, 103( 2): 117–128.