In addition, they had little ability to
understand the health risks of their
patient populations because they
lacked the timely, comprehensive
data needed to do risk stratification. As a result, population health
management was hit or miss, and it
was difficult for us to consistently
achieve our cost and quality goals.
Our ACO’s efforts to garner
bonuses under Medicare Advantage contracts were also
hampered by the difficulty of ensuring that all patient diagnoses in those plans were correctly coded. The Hierarchical
Condition Categories (HCC) risk adjustment codes used by
Medicare Advantage plans can have a major impact on their
premium funding and, therefore, on provider reimbursement.
Analytics Drove Improvement
Our ability to deliver value-based care took a quantum leap
forward when we acquired an advanced enterprise data
warehouse (EDW) in 2017. This system has enabled us to analyze and stratify our patient population, detect improvement
opportunities, and provide actionable, timely patient data to
our providers at the point of service.
The EDW stores not only adjudicated claims data, but also
clinical data drawn from the group’s electronic health record
(EHR) and other sources. The software maps and normalizes
this data so that it can be used to identify, and intervene with,
high-risk and rising-risk patients. Furthermore, it creates
a highly accurate enterprise master patient index, which is
fundamental to population health management.
The EDW allows South Bend ACO to report to our physicians based on the aggregated
claims and clinical information.
The clinical data drawn from our
EHR are updated every day. As a
result, our physicians know that
they have the most recent data on
The EDW makes it possible to
provide actionable data to phy-
sicians in specially designed
“face sheets.” These one-page
documents include data on each
patient’s care gaps and key clinical
information, such as diagnoses,
medications, tests, and vaccina-
tions. The software integrates each
doctor’s schedule and automati-
cally prints the face sheets for the
patients a provider is going to see
on a particular day. The physician
can then look at the face sheets in order as they proceed
through that day’s visits.
While this seems very simple, it has spurred physicians to
proactively fill their patients’ care gaps. The face sheets also
help our providers achieve quality goals because they are
calibrated to the quality measures of the insurance contract
for each covered patient (see “Face Sheets by the Numbers”).
Data analytics built into the EDW have helped our ACO drive
up our Medicare Advantage Quality Star ratings and improve
HCC coding for Medicare Advantage plans. The ACO’s ana-
lytics help identify diagnoses that may not have been coded,
using medication lists and comorbidities as a guide.
The analytics also generate actionable performance reports
that allow physicians to drill down to individual patients. Our
population health managers can discuss these reports in
detail with the doctors to explain why performance may be
poorer than expected.
High Quality, Low Costs
Our ACO has beaten its cost and quality benchmarks every
year since 2014. We now feel confident enough in our provid-
ers’ ability to control costs that, in 2018, we chose to enter
With MSSP making it harder to
meet its benchmarks every year,
our ACO continues to work hard to
squeeze out waste and improve
quality. As an organization long
known for our low cost and high
quality of care, SBC ACO looks for-
ward to pioneering innovative ways
to succeed in value-based arrange-
ments while offering excellent
Andrea Cichra is director of population
health for The South Bend Clinic.
Face Sheets by the Numbers
Since we launched our face sheets in August 2017, they have helped raise SBC’s overall
MSSP ACO Quality score from 88.48% in 2016 to 91.7% in 2017. We also increased our Medicare Advantage Quality Stars from an average of 4. 1 Stars to 4. 6 Stars out of 5 maximum
over the same time frame. Year-to-date Healthcare Effectiveness Data and Information
Set (HEDIS) Quality Measure Compliance in May 2018 trended 23% higher than for the same
month in 2017. As a measure of HCC coding impact, our ACO’s year-to-date Percent Coding
Validation (PCV) rating in May 2018 trended 12% higher than in the same month in 2017.
1. Health Affairs. 2010. Accountable Care
Organizations: What’s the Issue? Health Affairs
Health Policy Brief, July 27, 2010. Accessed
November 29, 2018 at healthaffairs.org/do/10.1377/
2. D. Muhlestein, R. Saunders, R. Richards and M.
McClellan. 2018. Recent Progress in the Value
Journey, Growth of ACOs and Value-Based Payment
Models in 2018. Health Affairs Blog, August 14, 2018.
3. National Association of ACOs. 2018. More Medicare
Accountable Care Organizations (ACOs) Achieve
Quality and Cost Goals in 2017. Press release,
August 30, 2018. Accessed November 29, 2018 at
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2018. Medicare Shared Savings Program: Fast
Facts. Accessed November 29, 2018 at cms.gov/