ACO Identifies $1.1M Annual Gap in Risk Score Benchmark

About the Customer

A smaller MSSP ACO in the Midwest serving 17,000 Medicare beneficiaries across its state.

Problem

Risk scores understated patient acuity across the ACO population

Outcome

$1.1M gap in MSSP risk score benchmark

This member struggled to understand why their ACO population’s risk score was consistently lower than average. They were confident that their patient population was not significantly healthier than average, and wanted to make sure their financial benchmark appropriately accounted for the acuity of their patients. Ultimately, they sought to improve performance in MSSP by leveraging our risk score benchmarking analytics to understand the inputs driving their population’s risk score.

Challenges

As a smaller ACO, this member didn’t have the resources to audit the risk scores for all of their assigned beneficiaries. Therefore, they leveraged our risk score bench- marking analytics to better understand the variation drivers for their population risk score.

How we helped

Leveraging historical claims data, we compared the ACO’s risk score, HCC prevalence and coding practices to regional and MSSP population benchmarks to identify where their patients looked different from a risk score perspective.

We helped this ACO identify that their population appeared to have a lower prevalence of Heart Failure compared to the rest of the state, which didn’t align to their expectations. Upon further analysis, they identified there were two high volume provider organizations within their ACO with significantly lower recapture rates of heart failure. Their patients with heart failure were not being seen on a regular basis. As a result, these patients were missing out on important care to manage their condition, and their acuity was not accurately being captured. Not only does this negatively impact patient care, but the ACO wasn’t receiving the appropriate budget for their population.

Impact

We concluded that every uncaptured beneficiary with heart failure corresponds to roughly $3,700 in PMPY benchmark to help manage their condition appropriately. If the ACO was similar to the state in terms of heart failure prevalence, it would translate to an increase in their MSSP benchmark by $1.1M.

The ACO also plans to leverage us to inform their internal HCC audit and compliance efforts to understand where they may be at risk for overcoding.

Lessons Learned

1. An unexpectedly low risk score is a signal, not a reassurance.

The ACO correctly suspected its lower-than-average score reflected a data gap rather than a genuinely healthier population.

2. An organization cannot see blind spots on its own.

Benchmarking against regional and program peers surfaces blind spots a single organization can’t see on its own.

3. A population-level anomaly often traces back to a small number of provider organizations.

Two high-volume groups accounted for the bulk of the heart-failure recapture gap.

4. Undercapturing chronic condition acuity has a dual cost.

It understates the patient’s need for ongoing management and understates the budget the ACO receives for that population.

5. Smaller ACOs can benefit disproportionately.

External benchmarking analytics benefit organizations when they lack the internal resources to self-audit risk scores at scale.

“Our organization has invested a lot of resources into understanding the risk scores of our patient population, but we were missing a piece of the puzzle because we didn’t know how our risk scores compared to similar providers in our markets. It helped us identify the conditions and markets where we needed to prioritize coding and documentation initiatives.“

VP, Value-Based Care