As an accountable care organization (ACO) leader, improving your Medicare Shared Savings Program (MSSP) metrics is a major priority, and in these uncertain times, making changes quickly can feel daunting. Lightbeam Health Solutions drives MSSP ACO performance and can help you build a roadmap to achieve your goals, as demonstrated by nearly half a billion in gross MSSP savings generated for ACOs in Performance Year 2023. Begin by prioritizing low-hanging fruit that can deliver an immediate impact by leveraging your current resources.
1. Focus on High-Volume Preventative Measures
Start with preventive care visits and compliance to enhance primary care provider (PCP) relationships and close Hierarchical Condition Category (HCC) coding care gaps. Contact patients about regular health screenings and follow-up care, including colonoscopies, mammograms, and immunizations. Push reminders to schedule preventative care screenings and vaccinations. These patient actions are easy to track and outreach campaigns can improve participation quickly.
The other key is chronic disease management—optimizing diabetes, hypertension, and heart failure care. Regular check-ins and monitoring for medication adherence can significantly reduce emergency department visits and avoidable admissions. Using an AI-powered, data-driven platform, like Lightbeam can help automate reminders for the highest risk patients and streamline administrative tasks to accelerate patient participation and improve outcomes.
2. Improve Care Transitions
Post-discharge can be a precarious time. Contacting patients within 24 hours of discharge is essential to preventing readmissions. These interactions also give care managers opportunities to access medication reconciliation and care plan adherence. A key piece of this puzzle is close coordination with post-acute providers. It is helpful to develop strong partnerships with skilled nursing facilities and home health agencies to ensure smooth transitions. In addition, an integrated admission, discharge, and transfer (ADT) feed can provide critical data and actionable insights to optimize care transitions in real time.
Another powerful tool is a state-of-the-art Remote Patient Monitoring (RPM) system to expand the reach and capacity of your staff. You can track interaction data to prioritize interventions with rising risk patients to prevent condition escalation and avoidable admissions.
3. Strengthen Data Management
Operationalize your data to precisely target patient care. Equally as important is ensuring accurate documentation and HCC coding in electronic health records (EHRs). Be sure to educate physicians and staff on coding requirements to maximize MSSP compliance. Missing, inaccurate, or incomplete data can lead to underperformance and missed reimbursement opportunities. Automate data analysis and run reports to identify gaps in care and target rising risk patients for timely interventions.
Use an AI-powered platform to stratify risk and identify the most urgent patient needs and suggested actions by aggregating external data sources, such as social determinants of health (SDOH) warehouses in real time. Also, centralizing and automating care management through dedicated care coordinators and an advanced technology solution will help you more effectively deliver services to the patients who need you most in value-based care settings organizations.
4. Prevent Avoidable ED Utilization
Maximize practice and physician accessibility to address patient conditions as early as possible to divert ED visits. Conduct systematic post-discharge outreach to check on medication and care plan adherence. Implement same-day or next-day appointments and telehealth services to increase engagement options and reduce perceived barriers to care. In addition, provide and promote 24/7 nurse or provider hotlines to address concerns, particularly after hours, which might avert unnecessary ED visits before conditions escalate.
5. Gather Patient Feedback Often
Survey patients frequently to identify and address concerns or questions about care coordination and their experiences before discontent turns into dissatisfaction—or emergent problems. Identifying issues proactively can help you manage the patient satisfaction scores that can directly impact your performance measurement. Provide and promote patient education campaigns using email or text to inform and remind patients about services needed. When you empower patients with shared decision-making, you will improve patient adherence by simplifying and demystifying complex or overwhelming care decisions.
No matter where you decide to begin, the Lightbeam Population Health Advisory Services team is an effective place to start to help you make measurable impact quickly. Our actively engaged ACOs generated more than $250 million in gross savings in PY 23 and averaged more than $17 million in gross savings per ACO—6% higher than the average across all other industry ACOs. Given the Centers for Medicare & Medicaid Services’ (CMS) recent requirement to move toward downside risk, Lightbeam’s Advisory Services can help you increase savings and improve patient outcomes at every level of care. Additionally, Lightbeam Deviceless RPM® can aid in increased patient satisfaction across multiple Consumer Assessment of Healthcare Providers and Systems (CAHPS) measures, achieving average scores higher than industry benchmarks.
To learn more, read about our industry-leading results or speak to a Lightbeam expert today—and begin improving your MSSP ACO metrics now.
Melissa Tyler, Director, Advisory Services, Lightbeam Health Solutions