Healthcare Contract Analytics Software for ACOs to Execute At-Risk Contracts

Healthcare Contract Analytics Software are in demand by Accountable Care Organizations (ACOs) and other large healthcare delivery systems that provide care for millions of patients every year and manage multiple hospital campuses, same-day/urgent care centers, and primary clinics. These tools assist organizations in adhering to healthcare local regulations designed to enhance the affordability of care, broaden coverage, and promote better health outcomes for the population. ACOs and healthcare systems report improvements like success in Integrated Health Partnership (IHP) contracts, and identifying multiple areas of activity at once that present the greatest opportunity and the specific activities needed to successfully deliver on at-risk contracts. What steps do these organizations take to target sustainable results?

To succeed in their IHP agreements and avoid financial losses, the organizations need to lower healthcare costs while enhancing patient experience and outcomes.

Healthcare Contract Analytics Software enables ACOs and other large healthcare delivery systems to gain new insights into their IHP patient populations, facilitating the creation of interventions to lower total care costs and enhance patient outcomes.

When large health systems and ACOs rely on modern solutions and implement improvements in opportunity analysis, they are rewarded with a robust infrastructure important for effectively using claims data, conducting additional opportunity analysis in the future, and ultimately attaining success in IHP contracts.

The increase in joint ventures, co-branding efforts (aka at-risk contracts), and partnerships between providers and payers has resulted from increased spending for the commercial population and a growing number of government payers. IHP contracts can cover tens of thousands of participants and require healthcare providers to take on greater financial accountability for patient care costs. One Accountable Care Organizations (ACO) can have several IHP contracts at once.

Organizations often lack the appropriate tools, for example, the claims-based analytics apps, to conduct IHP program opportunity analysis and understand how they are progressing in the total care cost reduction.

Healthtech product providers step in at this point. They supply healthcare organizations with advanced predictive analytics software with a range of machine learning-powered solutions for population health and value-oriented healthcare. The Belitsoft healthcare software development company creates, customizes, and modernizes analytics solutions, such as Healthcare Contract Analytics Software to meet the needs of healthtech providers such as cloud migration services, database migration, etc.

Challenges that ACOs Face in Executing of At-Risk Contracts

ACOs need to resolve data integrity issues, lower healthcare expenses, and simultaneously enhance patient experiences and outcomes. Healthcare systems must address the following challenges to meet their demands:

1. Financial and Payer-Related Issues

• An increased mix of government payers, boosted cost burden on the commercial population, reduction in the private payers’ population, and significant financial losses
• Certain accountable care models cover tens of thousands of members nearly half of whom are language, ethnic, or racial minorities or are minors. These models incentivize healthcare providers to assume greater financial accountability for Medicaid patients’ care costs
• Healthcare delivery systems that are IHP participants must show how they manage the balance between costs and quality of care. Providers who demonstrate overall savings compared to their target costs receive a share of the savings. Providers who surpass the cost targets may be obligated to reimburse a portion of the incurred losses.

2. Operational and Program Implementation Weaknesses

• Adapting to programs for instance the Medicare Shared Savings Program
• Lack of value-based programs for business transformation
  Absence of a proper internal system to facilitate the shift to at-risk contracts.

3. Analytical and Expertise Gaps

• Lack of subject matter experts, comprehensive data, and analytics to conduct effective IHP programs’ opportunity analysis
• Analyses of opportunities within the IHP patient population can be tailored to address only a specific issue, carried out by a single analyst, and concentrated on one particular IHP challenge instead of all covered lives
• Lack of understanding where the opportunity to improve costs and outcomes resides and, as a consequence, whether there is progress in reducing the overall cost of health care.

Features of the Healthcare Contract Analytics Tools

To deeper understand the IHP patient population and implement strategies to reduce overall healthcare costs while improving outcomes, healthcare organizations enforce solutions for opportunity analysis. These solutions offer organizations the following capabilities:

Merging and In-Depth Analyzing of Data 

• Integrating external and internal sources to provide insight into clinical outcomes and cost drivers throughout the entire care process
• Combining several data sources that are necessary to complete the opportunity analysis. This analysis includes information from claims that different specialized government entities, for example, social services agencies make
• Identifying an in- and out-of-network view of payment trends
  Leveraging data from electronic health records and analytic apps to generate monthly summaries on leading indicators and analytics for documentation that concentrates on lagging indicators and is prepared quarterly
• Analyzing homogenous patient populations by their categorization based on severity, diagnoses, procedures, or other characteristics related to the patient, encounter, or payer

Determining Performance Drivers and Improvement Areas

• Identifying how Accountable Care Organizations (ACO) procedures, healthcare providers, enrolled members, and specialty areas influence the performance of PMPM (Per Member Per Month) payments
  Pinpointing and analyzing clinical areas with variation and significant cost, beginning with clinical service lines or cross-departmental services such as labs, drugs, hospital readmissions, or out-of-network care leakage
• Mapping the relationship between the project’s total goal, the key factors or areas of opportunity that contribute to that goal
• Finding opportunities for improvement in the IHP patient population.

Measuring and Monitoring

• Tracking interventions and the related cost drivers via various tools that include a performance management tool
  Examining risk-adjusted differences among providers and facilities
• Conducting analyses based on measurements that analysts prepare. These analyses are tailored to the specifics of each intervention.

Planning and Program Development

• Supporting planning and enhancement of programs by financial and logic models
• Implementing measurement planning including an evaluation plan. 

Organizational Measures to Implement Healthcare Contract Analytics Solutions

To achieve optimal outcomes with the new software, certain organizational strategies must be considered. Organization leaders need to make a detailed analysis of potential opportunities, ensure insights related to the targeted patient population and support the creation of a strategic and actionable plan. Healthcare systems should focus on the following important actions:

Foundation for Transition and Strategy Creation

• It is recommended for ACOs and large healthcare systems to establish an appropriate internal structure to facilitate an effective transition to at-risk contracts
• Organizations might determine what they need to know, define the key questions to address, and methods to obtain the answers, before introducing new interventions.

Analytical Tools and Data Utilization

• It would be beneficial for organizations to implement necessary analytical tools that help them to understand their progress in reducing the overall cost of care
  Organizations might also carry out a new structure to oversee, manage, and continuously refine their IHP contracts and associated patient populations: strategy committee, operations committee, and analytics committee.

Role of the Strategy Committee

• It would be beneficial for the strategy committee to take charge of aligning the organization’s value-based care strategy with actionable targeted interventions and operational plans
• Strategy committee members need to focus on identifying, prioritizing, supporting, and supervising programs and service evaluations. They should also ensure consistent and structured reporting of interventions and their associated results.

Role of the Operations Committee

• The operations committee might connect responsibilities related to contract and performance objectives with operational strategies and targeted interventions for the several IHP contracts at once
• It is recommended for the operations committee members to support interventions by establishing structures for the development, assessment, financial planning, and analytical support. Additionally, they should identify and involve key operational stakeholders to guarantee coordination and alignment of efforts across the organization
• The operations committee members could make certain that opportunities are detected, and the analysis is refined to the point of being meaningful. Then they should implement measures aimed at improving or maintaining results for the targeted patient population while positively addressing the specified cost drivers.

Role of the Analytics Committee

• The analytics committee, with the subject matter experts, should establish a structure and offer support for the data-related requirements of the IHP contracts. It includes defining and developing process and outcome measures, guiding data usage, analytical tools, and methods, as well as setting definitions, standards, and decisions
• The analytics committee members could quantify accessible opportunity and effect, split their insights to executives, and oversee all data-related inquiries, including determining the scope, setting priorities, and allocating resources effectively.

Collaboration and Expert Involvement

• ACOs and other large healthcare systems need to involve subject matter experts and clinical operations leaders to exchange opportunities and enhance the analyses
  Operations heads, data analysts, and key stakeholders can cooperate to develop a driver diagram. This diagram shows the relationship between the total project purpose, the main factors or areas of opportunity that influence that purpose, and the specific strategies and interventions needed to aim it
  It would be useful for analysts to contribute to identifying the most effective methods of collecting data and determining its source
• Analysts should take an active part in the measurement plan design and implementation.

What Benefits Practices Get from Using Healthcare Contract Analytics Software?

Organizations utilize the Contract Analytics tool and can achieve the following outcomes:

• Comprehending better the IHP patient population
• Pinpointing several focus areas that offer the most significant opportunity
• Identifying the exact steps that are necessary to achieve success in at-risk contracts
  Developing interventions to reduce the overall cost of care and enhance results
• Creating the infrastructure needed to conduct further opportunity analysis and leverage claims data efficiently
• Applying a step-by-step approach to understand the different nuances of claims data
• Bringing in a range of claims datasets and information stored in the electronic health records
• Creating consistent definitions and implementing processes for matching patients across datasets to enable efficient utilization of claims data and address data integrity issues.

How a Healthcare Software Development Company Can Help?

Outsourcing companies like Belitsoft specialize in healthcare software development and assist top healthcare data analytics companies in building robust data operating systems.

The healthcare software development companies work with integrated data platforms. These platforms are developed to collect, store, process, and analyze large volumes of data from various sources (Electronic Medical Records, clinic management systems, laboratory systems, financial systems, etc.). A top-notch healthcare software development company:

• Automate data processing workflows (cleansing, standardization, and normalization).
• Configure scalable data storage systems.
• Set up and deploy analytical tools for creating dashboards, reports, and data visualizations.
• Keep a strong focus on data security and compliance with HIPAA and other healthcare regulations.
• Utilize machine learning (ML) and artificial intelligence (AI) in analytics.

They also help build specialized analytical apps like Healthcare Contract Analytics Software for:

• Conducting a thorough assessment of the factors influencing the per member per month payment performance
• Rapid pinpointing of the key contributors to per member per month performance, such as PMPM per one thousand utilization rates and network leakage
• Performing per member per month performance analysis to pinpoint areas for enhancement
  Showing trends over time with the help of summary-level statistics
• Investigating the factors that drive trends based on attributes from members, providers, and/or claims
  Filtering the data by payer, contracts, claims, and period of interest
• Examining areas with high costs, frequent usage, and significant variation
  Visualizing total cost of care outcomes improvement strategy via driver diagrams. These diagrams show the relationship between overall goal, key outcome measures, opportunity areas, specific tactics, and interventions
• Analyzing data related to system-wide claims to pinpoint areas with the most expensive areas
• Conducting more tailored additional analysis to offer more detailed insights into the specific areas of opportunity
• Creating regular digests that feature performance reports, care coordination data, and an executive summary.

If you are looking for expertise in data analytics, data infrastructure, data platforms, HL7 interfaces, workflow engineering, and development within cloud (AWS, Azure, Google Cloud), hybrid, or on-premises environments, a healthcare software development company like Belitsoft also can serve these needs.