Pop health platform helps one ACO save $1M in treating disability patients

The nation’s most fragile, at-risk patient populations are adults with disabilities. The Alliance for Integrated Care of New York oversees the healthcare needs of individuals with intellectual and developmental disabilities. It is the only Medicare Shared Savings Program-approved ACO of its kind in the United States.


The Alliance for Integrated Care of New York initially was owned by a company that controlled a large number of MSSP ACOs. The company was associated with a large, national health insurer. It used proprietary programs to analyze claims data and only shared global information with member practices in formal meetings.

This high-level information proved useless because it lacked the patient-specific data points to enable the member practices to develop interventions and to inform provider and patient engagement activities.

“Only knowing occasional ‘report card’ scores did not provide information detailed enough to evaluate spending against numerous benchmarks, which is a core element of successful ACO operations,” said Duane Schielke, executive director of the Alliance for Integrated Care of New York.

“Essentially, no data was available to provide member practices with any actionable information to carry out the ACO’s mission and goals,” he said. “No shared savings were received.”


The alliance was purchased by United Cerebral Palsy Associations of New York State at the commencement of the second 3-year performance period. In a partnership with the New York Integrated Network and Centene, vendor HealthEC was engaged to extract CMS Claim and Claim Line Feed files and securely store and manage that data.

The prime service to be provided was analytics, which would enable the development of a cogent strategy to address the healthcare needs of the ACO’s beneficiaries. The beneficiaries are unique being 50 percent typical MSSP beneficiaries served by an IPA in Queens and 50 percent patients with intellectual and developmental disabilities residing across New York State served by health centers operated by 10 non-profit organizations that focus on the needs of individuals with IDD.

“We chose HealthEC’s population health management platform to help integrate the disparate data points and then provide a singular view of our ACO populations,” said Dr. Vincent Siasoco, medical director at Alliance for Integrated Care of New York. “This solution was intentionally implemented to help integrate the disparate systems together and then aid our providers in their care coordination and decision making.”


There are many vendors of population health management technology serving the health IT marketplace, including athenahealth, Allscripts, CareEvolution, Cerner, eClinicalWorks, Epic, Geneia, GSI Health, Health Catalyst, Innovaccer, MAP Health Management, Medicity, NextGen Healthcare, Optum, Privis Health, Vivify Health and ZeOmega.


CCFL files were extracted into the HealthEC population health management program and assigned to the various member practices. HealthEC conducted ongoing population health analysis to include meaningful risk stratifications; provided comparative spending versus benchmarks analysis and reports; provided risk stratifications for the purpose of implementing chronic care management with embedded targeted medical case management; and quantified and reported provider performance on GPRO PQRS standards and the Merit-Based Incentive Payments System.

“Every member practice was provided HealthEC credentials and webinar and individual training to access and utilize the platform,” Schielke said. “Individual practice dashboards were created and reviewed with each practice. Monitoring information indicated that expecting independent member practice was not occurring, so instead the alliance medical director and population health specialist organized, initiated and conducted regular sessions with all IDD member practices.”

Alliance medical care managers initiated similar sessions with each of the 28 QCIPA member practices. The primary purpose of these sessions was to identify the highest use beneficiaries to develop interventions, which would improve service and reduce cost, Schielke said. Chronic care management was chosen as the prime intervention to include more than just the highest user group.

“The HealthEC population health management program utilizes the John Hopkins ACG risk assessment tool to identify beneficiaries who would benefit from chronic care management in addition to beneficiaries that may be identified by the practice’s EHR program,” Schielke explained. “Some EHR programs, in this case, eClinicalWorks, have a chronic care management module.”

Alliance care managers employed by HealthEC were embedded in each practice to implement the chronic care management program, leaving the decision to bill for the service up to each member practice, and, if billing, provide the required backup for each claim.

“A pilot was initiated to integrate the HealthEC population health management program with the eClinicalWorks program used by a member practice that is a Federally Qualified Health Center serving patients primarily with IDD living in New York City,” Schielke said. “The integration would include the cloud-based program, Precision Care, utilized by the residential providers to manage the beneficiaries’ long-term care services.”

Interoperability was achieved between the three platforms with bi-directional channels, Schielke explained. This project is now being replicated with three additional residential providers that are associated with the FQHC that is a member practice of the alliance. The goal is to achieve interoperability for 1,000 patients of the FQHC.

“HealthEC’s solution has significantly helped to streamline the data integration challenges while providing the flexibility to serve the unique needs of our two patient populations,” Siasoco said. “Having access to the data and information at the macro and micro perspectives has helped equip our care coordinators to be especially proactive with our most challenging patients in order to alleviate unnecessary healthcare costs.”

These care coordinators have helped drive notable improvements closing gaps in care while helping the alliance to truly shift to a value-based care model, Siasoco added. As a result, the alliance has experienced greatly improved outcomes, he stated.


The alliance has indeed experienced notable success. The population health data and analytics technology was used to risk-stratify patients that resulted in a $1.5 million cost reduction. 3,400 patients eligible for chronic care management services were identified with a potential total cost impact of $1.88 million for 2018. And since the initial implementation, alliance case managers who manage approximately 25,000 patients reduced at least $3,400 cost per patient for a total impact of $660,000.

“Beneficiaries’ health status has improved and the alliance has enjoyed a shared savings from the 2017 performance year: The total savings was $2,379,558, resulting in a shared savings of $993,935.”

Duane Schielke, Alliance for Integrated Care of New York

“Beneficiaries’ health status has improved and the alliance has enjoyed a shared savings from the 2017 performance year: The total savings was $2,379,558, resulting in a shared savings of $993,935,” Schielke reported. “The alliance accumulated IDD beneficiary data previously non-existent. The information has spawned some new innovative initiatives.”

In addition to the population view of outcomes, the new pop health technology gives caregivers the ability to drill down to the individual patient level to identify which patient, or patients, are the top users of emergency services, or which has a very high cost of care, for example, Siasoco said.

“Interestingly, some of the highest use patients receive treatment for behavioral services,” he added. “We can also see who the physicians are that are involved in the care of that individual. This becomes important and valuable when our care coordinators can proactively reach out to the care team of a high-use patient to provide preventative and proactive care.”

One of the goals of the ACO is to reduce the number of emergency department visits and the overall length of stay for inpatient visits. Another goal is to improve chronic condition care. Having the ability to be proactive with data and communication in either of these scenarios significantly helps the alliance achieve its organizational goals, he said.


“The alliance’s experience with the technology provided by HealthEC was extremely positive and probably very unique in some of the outcomes,” Schielke said. “Utilizing the platform enabled our ACO to learn how to best approach the challenges it faced to accomplish its goals. I don’t know how any ACO can function successfully if it does not utilize some ‘tried and true’ platform to organize and manage beneficiaries CCLF data in a manner to improve service outcomes and reduce cost.”

Having a population health platform is instrumental for an ACO because it is the only way to move the needle toward a system of value-based care, Siasoco explained.

“Other advice would be to find a solution that is accessible and easy to use,” he said. “As physicians and other providers, having a technology solution that can seamlessly integrate into the workflow of care is a necessity because there is so much demanding our attention. When you can find that in a solution, we can start to see value-based care emerge as a real opportunity to improve outcomes for the health of our populations.”

Twitter: @SiwickiHealthIT
Email the writer: [email protected]

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