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Background: Geneia’s client is a regional health plan with approximately 750,000 members, 10 accountable care arrangements, and a number of other provider risk-sharing contracts. Because the plan operates in a very competitive market, there are consistent pressures on premium and provider reimbursement levels. The plan has long sought differentiation from its competitors.

One year after the Affordable Care Act was enacted, the health plan launched the first of 10 accountable care arrangements with the intention of improving the quality and cost of member healthcare as well as provider satisfaction. Specifically, the plan’s goals were to:

Increase patient access to timely care

Reduce hospital admissions and readmissions as well as preventable complications

Promote the use of preventive care and wellness

Improve member, provider, employer and health plan communication and care coordination

Create stronger ties with its physician network

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“[Our health plan] is investing in innovative solutions and delivering powerful analytics tools…. By drawing valuable insights from an abundance of health plan data, we can work together with employers and health professionals to bring about better health outcomes and cost savings throughout the

health care system.”

The chief medical officer of a geneia health plan client

How Health Plans Are Using advanced analytics to Improve Medical Costs and Quality

Under the accountable care model, the health plan partners with primary care physician practices to provide dedicated care management resources and technology to deliver patient-centered, holistic care.

Three years after the inception of the accountable care program, the health plan began to use Geneia’s advanced analytics solution, the Theon® platform, to manage its accountable care arrangements. It also offered the platform to participating physician practices.

The Theon® platform integrates claims and utilization data, as well as clinical data and benefit information, to create one comprehensive, 360-degree view of members that enables physicians, hospitals, and employers to improve the quality and cost of care.

“As a practicing family physician, I know firsthand that the demands on physicians are unending. We’re giving our physicians a tool that easily fits into their existing workflow and easily yields information and insights to help us meet the needs of patient populations while personalizing the time and care offered to higher

need patients.”

Physician leader of Geneia physician organization client with 22 practice sites, more than 500,000 patients, and number of accountable care and risk-sharing arrangements with payers

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results The health plan’s accountable care arrangements are improving the quality and cost of healthcare.

“As healthcare continues to evolve at a rapid pace, it is important for health insurers to remain focused on finding better ways to improve the quality of care, while putting downward pressure on the rising cost trend. We have done just that over the past four years by collaborating with area providers to implement accountable care arrangements throughout the region. Not only has our model been enthusiastically embraced by physicians and their patients, but this holistic approach to medical care is working as

we had hoped.”

The chief medical officer of a geneia health plan client

Utilization and Cost: Data for a recent 12-month period – one in which the plan was using the Theon® platform - show that the accountable care arrangements are outperforming their peers for the following measures:

Acute inpatient admissions are 4.7 percent lower for employer group customers and 7.2 percent lower for Medicare plan customers.

Readmissions are 8 percent lower for employer group customers and 14.8 percent lower for Medicare plan customers.

Emergency department visits are 8.4 percent lower for employer group customers and 8.2 percent lower for Medicare plan customers.

Medical and pharmacy costs for the plan’s accountable care arrangements are growing at a lower rate than the total book of business and compare favorably against similar arrangements implemented by regional plans across the country.

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“We use advanced analytics to integrate claims and utilization data, clinical outcomes, and benefit information to create one holistic view of each member that enables our physician and hospital partners to improve the quality and cost of care. As a result of this all-inclusive approach to population health management, [our health plan] is improving the health of its members while simultaneously increasing member and

provider satisfaction.”

The senior medical director of a geneia health plan client

Quality: Data from physicians who have participated in one of the plan’s accountable care arrangements and used the Theon® platform for at least one full year show that:

Accountable care arrangements are meeting or exceeding agreed-upon quality goals relating to chronic disease management, helping patients who have chronic conditions such as diabetes, coronary artery disease and congestive heart failure experience improved health.

The accountable care arrangements are exceeding the regional average for Healthcare Effectiveness Data and Information Set (HEDIS1) measures for some of the leading chronic diseases. For example, several participating providers have demonstrated performance of greater than the 95th percentile for the Comprehensive Diabetes Care measure and greater than the 90th percentile for the Cholesterol Management for Cardiovascular Conditions measure.

One of the longest standing accountable care arrangements achieved a greater than the 95th percentile in the following Consumer Assessment of Healthcare Providers and Systems, Clinician & Group Surveys (CG-CAHPS2) categories:

• Composite: Getting Timely Appointments, Care, and Information

• Composite: How Well Doctors Communicate With Patients

• Doctor’s Office Followed Up To Give Test Results.

immediate roi: As the result of the plan’s successful implementation of the Theon® platform, the company realized annual savings of $1.7M through sun-setting investments in legacy software and support contracts, while improving satisfaction among the provider community.

In addition, as the result of leveraging the Theon® platform beyond the accountable care arrangements to take a holistic approach to population health management, the plan is realizing approximately a 2 percent reduction in claims expense.

1HEDIS is a comprehensive tool used by most health plans to measure performance on important aspects of care and service.

2The health plan’s accountable care arrangements use CG-CAHPS to ask patients about their recent experiences with clinicians and staff, and to measure and hold individual providers accountable for patient satisfaction.

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disclaimer:This case study is intended to provide an example of how health plans can use Geneia’s advanced analytics and insights platform to improve the cost and quality of member healthcare. Geneia does not claim that the outcome of this particular case study is a typical result, or that it is necessarily representative of those who will use its services. Geneia expressly disclaims any representations or warranties in relation to this case study or the information provided on this website. aBout geneia:At Geneia, we’re focused on one thing: transforming healthcare – for the better. Our physicians, nurses, technologists, analytics experts, and business professionals have created a suite of solutions that enable health plans, hospitals and employers to better understand, evaluate and manage the health of their populations. Using our advanced analytics platform, remote patient monitoring tool, and education and research institute, we work with you to improve outcomes, lower cost and restore the Joy of Medicine. The company has offices in Harrisburg, PA, Manchester, NH, and Nashville, TN.

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