Performance Overview

Executive dashboard showing MSSP ACO performance vs benchmarks

Total PMPM Spend ⓘ
$847.32
↓ 2.3% vs Benchmark ($866.50)
Projected Savings ⓘ
$11.2M
↑ $700K vs Target ($10.5M)
Quality Score ⓘ
87.4%
↑ 5.2 pts vs National (82.1%)
Network Leakage ⓘ
23.7%
$4.2M Opportunity

PMPM Trend vs Benchmark

Market Performance Summary - Click to Drill Down

Market Region Lives PMPM vs Benchmark Quality Leakage
Atlanta North 12,456 $823.45 -$43.05 (-5.0%) 89.2% 18.3%
Atlanta South 15,234 $871.22 +$4.72 (+0.5%) 86.1% 27.4%
Columbus 8,923 $834.67 -$31.83 (-3.7%) 88.5% 21.2%
Augusta 6,734 $892.18 +$25.68 (+3.0%) 84.3% 31.8%
Macon 4,476 $851.34 -$15.16 (-1.7%) 85.9% 19.6%

Executive Insights

  • Overall: Tracking 2.3% below benchmark - on track for shared savings
  • Risk Areas: Augusta market elevated spend (+3.0%) and high leakage (31.8%)
  • April Decision: Recommend continuing MSSP participation for 2025
  • Actions: Focus leakage reduction in Augusta and Atlanta South ($2.1M opportunity)

Projections & Forecasts

Actuarial modeling with scenario analysis for April gut-check decision

Scenario Variables - Adjust to Model Different Outcomes

Projected Year-End Performance (Dec 2024)

Projected Total Spend
$486.7M
95% CI: $481.2M - $492.1M
Projected Benchmark
$498.3M
Based on historical data
Projected Shared Savings
$11.6M
70% probability

Confidence Levels

Break Even or Better
85%
Achieve Target ($10.5M+)
70%
Risk of Loss
15%

Monte Carlo Simulation (10,000 iterations)

April Gut-Check Recommendation

CONTINUE MSSP ACO PARTICIPATION

85% probability of break-even or better. Projected $11.6M savings exceeds $10.5M target with 70% confidence.

Key Assumptions: +2% lives growth, -1% utilization trend, no major risk score deterioration, -2% leakage reduction

Limitations: Does not account for CMS policy changes or major market disruptions. Monthly monitoring recommended.

Quality Metrics - MSSP ACO PY2025

Performance on CMS quality measures with drill-down capability

Overall Quality Score

87.4%
⭐⭐⭐⭐ (4-Star Equivalent)
Based on 33 quality measures

Measures Achieved

28/33
84.8% Achievement Rate
5 measures need improvement

Quality Payment Impact

+2.5%
Performance Bonus
Est. +$1.2M in shared savings

ACO Quality Measures by Domain (Click measure to view performance dashboard)

Domain Measure Performance Benchmark Gap Status
Patient/Caregiver Experience (ACO-01 to ACO-34)
Getting Timely Care (ACO-34) 89.2% 82.5% +6.7 pts Achieved
Care Coordination/Patient Safety
Risk-Standardized Acute Admission (ACO-43) 12.4% 14.2% -1.8 pts Achieved
All-Cause Unplanned Admissions (ACO-38) 8.7% 9.3% -0.6 pts Achieved
Preventive Health
Breast Cancer Screening (ACO-17) 82.3% 75.8% +6.5 pts Achieved
Colorectal Cancer Screening (ACO-19) 76.8% 69.2% +7.6 pts Achieved
Annual Wellness Visit (ACO-43) 58.4% 62.1% -3.7 pts Need Improvement
At-Risk Population - Diabetes
Diabetes: HbA1c Poor Control (ACO-16) 18.2% 22.4% -4.2 pts Achieved
Diabetes: Eye Exam (ACO-18) 68.9% 61.3% +7.6 pts Achieved
At-Risk Population - Hypertension
Controlling High Blood Pressure (ACO-08) 72.4% 67.8% +4.6 pts Achieved
At-Risk Population - Heart Failure
Statin Therapy - Cardiovascular Disease (ACO-14) 74.2% 78.5% -4.3 pts Need Improvement
Behavioral Health
Depression Screening and Follow-up (ACO-40) 81.2% 74.6% +6.6 pts Achieved
Screening for Social Drivers of Health (ACO-46) 52.8% 58.3% -5.5 pts Need Improvement

Quality Performance Trends

Quality Improvement Opportunities

  • Annual Wellness Visits: 3.7 pts below benchmark. Close gap with 177 additional AWVs to gain quality points
  • Statin Therapy: 4.3 pts below benchmark. Target 205 patients with CVD not on statins
  • Social Determinants Screening: New measure for PY2025. Need to screen 263 additional patients
  • Estimated Impact: Closing these 3 gaps could increase quality score to 91.2% and add $400K in quality bonus

Total Cost of Care Analysis

Cost driver breakdown with actionable intervention opportunities

Total Annual Spend
$486.7M
47,823 attributed lives
PMPM (Per Member Per Month)
$847.32
$19.18 below benchmark
PMPY (Per Member Per Year)
$10,168
CMS benchmark: $10,398

Cost Distribution by Category

Cost Category Details

Inpatient Facility $187.2M (38.5%)
PMPM: $326.23 | Admits per 1000: 142
Outpatient Services $143.8M (29.5%)
PMPM: $250.72 | Visits per member: 8.4
Professional Services $89.4M (18.4%)
PMPM: $155.87 | Visits per member: 6.2
Pharmacy $48.7M (10.0%)
PMPM: $84.93 | Scripts PMPY: 24.3
Post-Acute Care (SNF/HH) $17.6M (3.6%)
PMPM: $30.57 | Days per 1000: 87

Avoidable ED Visits by Market - High Impact Opportunity

Market Region Total ED Visits Avoidable Visits Avoidable % Cost Impact Opportunity
Atlanta South 4,231 1,523 36.0% $1,868,271 $1,400K savings potential
Augusta 2,187 789 36.1% $967,803 $725K savings potential
Atlanta North 3,456 967 28.0% $1,186,309 $890K savings potential
Columbus 2,534 658 26.0% $807,066 $605K savings potential
Macon 1,245 349 28.0% $428,223 $321K savings potential

Cost Trend Analysis - Last 12 Months

Cost Reduction Opportunities - $3.9M Annual Impact

  • Avoidable ED Visits: 4,286 visits at avg $1,227/visit = $5.3M spend. 75% reduction = $3.9M savings
  • 30-Day Readmissions: 487 readmissions at avg $18,500 = $9.0M. 20% reduction = $1.8M savings
  • SNF Utilization: Days per 1000 at 87 vs benchmark 75. Reduction = $2.1M savings
  • High-Cost Imaging: Outpatient MRI/CT rate 15% above benchmark = $1.4M opportunity
  • Total Opportunity: $9.2M in identified cost reduction initiatives

Network Leakage Analysis

Comprehensive view of out-of-network spend with geographic and referral pattern analysis

Network Distribution (Click to filter)

Key Metrics

In-Network Spend
$371.4M
76.3%
Out-of-Network Spend
$115.3M
23.7%
Target Leakage (20%)
$97.3M
Industry benchmark
Recovery Opportunity
$18.0M
If reduced to 20% target

Top 5 Out-of-Network Providers (Where Leakage Goes)

OON Provider/Facility Specialty/Type Total OON Spend Patient Count Avg Cost/Patient Primary Service
Atlanta Cardiology Associates Cardiology Group $12,347,892 1,234 $10,009 Interventional Cardiology
Peachtree Advanced Imaging Imaging Center $8,923,441 3,421 $2,608 MRI / CT Scans
Southern Orthopedic Specialists Orthopedic Surgery $7,654,223 892 $8,582 Joint Replacement
Georgia Pain Management Center Pain Management $5,234,887 1,567 $3,340 Injections / Procedures
Metro Neurology Group Neurology $4,892,334 1,098 $4,456 Neurology Consults

Top 5 PCP Attributed Providers with Highest Leakage

PCP Name Market Attributed Lives Total Spend OON Spend Leakage %
Dr. Robert Martinez Augusta 1,247 $14,234,887 $5,892,334 41.4%
Dr. Amanda Williams Atlanta South 1,523 $17,892,441 $7,234,556 40.4%
Dr. Michael Chen Atlanta South 1,389 $15,667,223 $6,123,445 39.1%
Dr. David Thompson Augusta 982 $11,234,665 $4,234,887 37.7%
Dr. Sarah Patel Atlanta South 1,298 $14,556,332 $5,334,221 36.6%

Geographic Leakage Pattern - Patient Origin vs Care Location

Low Leakage (<20%)
Moderate Leakage (20-30%)
High Leakage (>30%)

Referral Flow Analysis (Click PCP in table above to view)

Sankey diagram showing flow from attributed PCP → Rendering Provider, filterable by service line and Part A/B

Leakage Reduction Strategy - $18M Opportunity

  • Contract Expansion: Negotiate with Atlanta Cardiology Associates ($12.3M) and Peachtree Imaging ($8.9M) to bring in-network
  • PCP Education: Target Dr. Martinez, Dr. Williams, and Dr. Chen for referral pattern optimization (combined 40% leakage rate)
  • Network Recruitment: Add orthopedic and pain management specialists in Augusta market
  • Geographic Gaps: High leakage in southern Augusta zip codes - consider adding access points
  • Service Line Focus: Cardiology (32%), Imaging (23%), Orthopedics (19%) represent 74% of total leakage

Risk Adjustment & HCC Analytics

RAF score optimization and coding opportunity identification

Average RAF Score

1.247
National Avg: 1.195
+4.4% above benchmark

Revenue Impact

$5.2M
Additional CMS revenue
vs. unadjusted baseline

Suspected HCCs

3,421
Require documentation
$2.8M opportunity

Capture Rate

76.3%
Industry Avg: 72.1%
+4.2 pts above avg

Top HCC Coding Opportunities by Provider

Provider Name Specialty Panel Size Avg RAF Suspect HCCs Revenue Opportunity
Dr. Sarah Johnson Internal Medicine 1,847 1.189 427 $687,450
Dr. Michael Anderson Family Medicine 1,923 1.256 398 $542,340
Dr. Jennifer Brown Internal Medicine 1,654 1.178 312 $498,720

Top Suspected HCC Categories

HCC Category HCC Code Suspect Count RAF Weight Revenue Impact Common ICD-10
Diabetes with Chronic Complications HCC 18 487 0.318 $842,336 E11.65, E11.21, E11.36
Chronic Obstructive Pulmonary Disease HCC 111 392 0.328 $698,944 J44.0, J44.1
Congestive Heart Failure HCC 85 341 0.331 $613,051 I50.9, I50.23, I50.33
Vascular Disease HCC 108 298 0.288 $466,176 I70.0, I73.9

RAF Score Distribution

Risk Adjustment Action Plan - $2.8M Revenue Opportunity

  • Provider Outreach: Focus on Dr. Johnson (427 suspects), Dr. Anderson (398 suspects), Dr. Brown (312 suspects)
  • Diagnosis Categories: Prioritize Diabetes w/complications (HCC 18), COPD (HCC 111), CHF (HCC 85) = 71% of opportunity
  • Documentation Training: Q1 focus on chronic disease specificity and annual recapture
  • Technology Support: Deploy EMR alerts for suspect HCCs during encounters
  • Financial Impact: $2.8M in additional CMS revenue if 100% capture achieved (conservative 70% = $1.96M)

Episodes of Care & Clinical Variation

Episode-based analytics identifying cost variation and standardization opportunities

About Episode Grouping

Episodes are created using virtual bundle logic to group all services related to a clinical condition or procedure within a defined time window. This enables comparison of total cost of care across providers for clinically similar patient cohorts.

Top Episode Types by Volume and Cost Variation

Episode Type Episode Count Avg Cost per Episode Std Deviation Variation % Opportunity
Joint Replacement (Hip/Knee) 342 $28,456 $8,234 28.9% High variation - standardize
Congestive Heart Failure 568 $18,923 $5,122 27.1% Post-acute variation
Percutaneous Coronary Intervention 234 $32,667 $9,445 28.9% Device/implant variation
COPD Exacerbation 487 $12,334 $3,221 26.1% LOS and readmission variation
Pneumonia 623 $9,876 $1,892 19.2% Good standardization
Spinal Fusion 156 $45,223 $14,667 32.4% Highest variation - prioritize

Episode Cost Distribution - Joint Replacement Example

Post-Acute Utilization by Episode Type

Episode Type SNF Rate Avg SNF Days SNF Cost PMPM Home Health Rate Avg HH Visits Total PAC Cost
Joint Replacement 42.1% 18.2 $4,234 68.3% 12.4 $7,892
Congestive Heart Failure 28.4% 14.2 $2,234 71.2% 15.3 $4,556
Spinal Fusion 38.5% 16.7 $3,667 62.8% 11.8 $6,223

Clinical Variation Reduction Opportunities - $4.2M Impact

  • Joint Replacement Standardization: 28.9% cost variation. Reduce to 15% through clinical pathways = $1.8M savings
  • Post-Acute Optimization: SNF rate 42.1% vs benchmark 28%. Increase home health = $1.2M savings
  • Spinal Fusion Protocol: Highest variation at 32.4%. Standardize surgeon selection and implant choices = $900K savings
  • CHF Readmission Reduction: 30-day readmit rate 18.2% vs benchmark 14%. Improve transitions = $600K savings
  • Total Episode Opportunity: $4.5M through clinical standardization and care pathway optimization