About the customer
5,000+
Physicians in-network
Multiple
Hospitals in system
Multiple
Acute and ambulatory care centers in system
Challenges
Our member is a fast growing integrated delivery network (IDN) that underwent explosive growth due to a merger with another large health care organization. The member needed a way to identify high performing providers to bring into their network as well as find the right providers to include in their referral network for specialty care. Although they had access to several provider performance scores and data from other vendors, they all fell short due either being too simplistic (lacking algorithmic rigor), or black box (lacking transparent methodology). This often resulted in poor or incomplete insights that were unusable in making key business decisions due to lack of trust and buy-in from leadership.
How we helped
Our member relied on CareJourney’s Provider Performance Index scores on cost and quality to evaluate providers on their Medicare performance. These scores are universally accepted and adopted through the organization, including the leadership due to its open methodology, and transparent and reliable metrics. It is used in planning decisions around which providers to add to their PCP network and in establishing a specialist referral network.
Additionally, the organization is working on developing a central scorecard to evaluate all providers in their market, using three core metrics, including — CareJourney Provider Performance Index Scores (based on Medicare claims data), BCBS score (based on commercial data), and PACES episode grouper.
Lessons Learned
1. Simplistic or black-box scoring tools don’t earn leadership buy-in.
Methodology transparency was the deciding factor in adoption, not just data accuracy.
2. Rapid growth through M&A creates urgent network-design needs.
A merger can outpace an organization’s ability to evaluate provider quality using legacy tools.
3. A single performance score isn’t the end state.
The organization is layering multiple sources (Medicare claims, commercial claims, episode groupers) into one scorecard rather than relying on one index alone.
4. Provider performance data has two audiences.
It needs to work for both operational network-planning teams and executive leadership making strategic decisions.
5. Transparent scoring supports network growth and specialty referral design.
The same performance data served two distinct use cases for this customer.
“We have had access to other provider scoring tools, but CareJourney’s is a lot better – more comprehensive, transparent, and accurate. We are already using it in conversations with leadership as they build strategies for network expansion.”
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