8 metrics you should be tracking (and why)

By Kelly Kolepp 

Are you engaged in a Medicare Advantage Shared Savings contract? If the answer is yes, data is key to your success when it comes to quality, cost, and care.

While many payers, providers, and provider organizations do successfully track some data, it’s the missing metrics that could be keeping you from getting the most out of your contract.

The specific metrics you track should be driven by your goals, priorities, contract terms, and the needs of the population served. However, there are universal metrics that can be beneficial to managing any shared savings contract. We cover those below.

  1. Total cost of care

    In shared savings contracts, a medical loss ratio is used to establish the threshold for potential shared savings revenue. If the total cost of care for a contract is below the medical loss ratio threshold, the provider group could receive a portion of the shared savings.

    By monitoring the cost of care at the patient level, you’ll gain valuable insight into patients who could be high utilizers and may need additional clinical intervention. Not only that, but there are also long-term benefits of data collection at the patient level that can be used to guide future contract negotiation and establish requirements for reinsurance.

  2. Specialty spend

    Along with patient-level cost tracking, it’s important to monitor spend by specialty. Why? It shows what areas may be a higher spend category for your population. With this information you’ll be able to see if specialty spend is driven from inside or outside of your network, providing insight into areas of opportunity to build out your specialty network.

  3. Healthcare utilization

    High healthcare utilization = high medical spending. So, what can you do? Track areas where improving care and engagement prevents costly, unnecessary healthcare utilization. It’s also a great way to identify facilities with the best care and outcomes. A few key healthcare utilization metrics to track:

    • Hospital admission rates and average length of stay
    • Hospital readmission rates
    • Preventable emergency department visits
    • Skilled nursing facility average length of stay
  1. Quality metrics

    The Centers for Medicare & Medicaid Services publish Star ratings annually, which rates (on a scale of 1 to 5, with 5 being the highest) the quality and performance of Medicare Advantage plans. These ratings are based on several quality categories, including clinical care, member experience, and health outcomes.

    Most Medicare Advantage contracts require providers to participate in some of these measures and achieve an established star level to receive a shared savings or pay-for-performance payment. Keep in mind that each measure carries a different weight.

    Your contracted measures are the most important to track. Carefully monitor higher weighted measures as lower performance in those measures can drastically impact your Star rating. Higher weighted measures include:

    • Medication adherence for diabetes medication
    • Medication adherence for hypertension
    • Medication adherence for cholesterol (statins)
    • Diabetes care blood sugar control
    • Controlling blood pressure 
    • Plan all-cause readmission
Download our white paper on meeting quality measures to improve Star rating to learn more.
  1. Prescription drug costs

    Tracking prescription drug spend is essential to controlling cost. Utilization of high-cost drugs with lower cost alternatives can be monitored at the patient and provider levels.

  2. Social determinants of health

    Research shows that 30-55% of an individual’s health outcomes are based on social determinants of health. And CMS is placing more emphasis on addressing them.

    CMS recently released a measure set for hospitals in the federal payment program and announced that Medicare Advantage Special Needs plans must meet new requirements to include one or more questions on housing stability, food security, and access to transportation in their health risk assessments beginning in contract year 2024.

    There are several free screening tools available, including CMS’s Accountable Health Communities Health-Related Social Needs Screening Tool.

  3. Risk adjustment

    Medicare Advantage organizations are paid based on the risk profile of their members. Risk adjustment takes into consideration the variations in per person cost based on individual health status and demographic factors.

    Health status is captured using diagnosis codes through CMS’s hierarchical condition categories. Accurate capture of these diagnosis codes ensures that a plan is adequately reimbursed to care for its population. In a shared savings contract, that reimbursement is a component of MLR calculation, along with cost.

    So, it’s essential that providers accurately capture and recapture diagnosis codes for this population each year so that the complexity and needs of the population are appropriately documented.

  4. Care coordination

    Gain valuable insight into patient engagement by tracking care coordination and transition of care metrics. Some metrics to consider are:

    • Annual wellness visit rate
    • Follow-up after emergency department visit for people with high-risk multiple chronic conditions
    • Transition of care – patient engagement after inpatient discharge – within 30 days
    • Transition of care – medication reconciliation post-discharge – date of discharge through 30 days

Looking for support with data tracking? We’re here to help.

Set up a demo today.