Overview

This article summarizes the content on the Analyze page for a selected ACO.

Use Cases - A short list of what to look for
Opening an ACO Analyze page - Two ways to open a specific ACO in the Analyze page
ACO Analyze page Overview - the basic features of the ACO Analyze page
Insights tab - the tiles include the most critical metrics to evaluate the selected ACO
Destinations tab - this tab includes four tables that provide summary metrics for organizations participating in the ACO.
Patient Population tab - this shows the location of residence, by county and state, for beneficiaries of the selected ACO
Participating Providers tab - includes a table of physicians associated with the ACO
PMPM Details - (Under Insights) - summary of the content on the PMPM details page

Use Cases

Use the ACO Analyze page to dive more deeply into beneficiaries’ destinations and utilization, member costs, and to identify participating providers.

Use the Destinations tab to

see what hospitals, SNFs, home health, and hospice agencies beneficiaries go to
assess relationships between agencies and the ACO via outcomes and reimbursement

Look to the Patient Population tab to

understand what counties have the most beneficiaries for the selected ACO
see utilization for inpatient and post-acute settings to understand where there may be greater opportunity to lower readmissions, improve hospice utilization, and other favorable outcomes

Check out the Participating Providers tab for

the roster of physicians affiliated with the ACO
the physicians’ patient counts
their patients’ post-acute utilization

Opening an ACO Analyze page

There are two ways to open the Analyze page for a specific ACO.

Option 1 - Global Search

At the top of every page there is a field labeled, "Search by ACO/Provider Name, Location, or ID." Type in the name of the ACO of interest.

Example

To find Community Care of Brooklyn, we start by typing, "brook."

The first results include lots of physicians with "brook" in their names.

If you scroll down a long way, the ACO we want to find is there. Using the filter will save us time.

Click on the "All" dropdown and select, "ACO-MSSP."

Our desired ACO is the second option. Click on the result in the list to open the Analyze page for Community Care of Brooklyn.

The filter on the Global Search allows you to narrow the results of your search to all of the listed provider of facility types along with ACOs.

If you know the ID for the ACO, you can type it in to the Global Search field to find the ACO in a single step.

Option 2 - Explore table - browse or search

The ACO Explore page has a table that includes every ACO. You can scroll through the table to find Community Care of Brooklyn or use the table search.

Use the image below to familiarize yourself with the table search.

Click on the "Explore" button in the left navigation to open the Explore page.

Click on "ACOs" In the tabs at the top of the page to open the ACO tab.

Type in the name of the ACO, or, as in the example, the ACO ID.

The name of the ACO in the table is a link that opens the Analyze page for the selected ACO.

Click on the name of the ACO you want to investigate.

ACO Analyze Page Overview

The following image highlights the basic navigation tools for the page.

Analyze button - The "Analyze" button is highlighted in the left navigation to confirm that the Analyze page is being viewed.

Provider/ACO information - The top section of every Analyze page includes information on the selected provider/ACO. Click on the chevron at the right to open the information panel.

The following image shows the type of information available when opening the panel.

Chart View - Some of the tables on the Analyze page can be viewed as charts. Use the Chart View toggle to turn the charts on or off.

Analyze page tabs - The ACO Analyze page is divided into four sections of content. Clicking on a tab will open the content contained under the selected tab.

Calendar Year dropdown - In order to track trends for the selected ACO, you can use the calendar dropdown to select different data reporting periods. The options will change depending on the latest data released.

Insights tab - The Insights tab is the default tab and displays tiles with the most important metrics for the selected ACO.

The content included under each tab is described below. The follow links will take you to the content for a selected tab.

Insights tab
Destinations tab
Patient Population tab
Participating Providers tab

Insights tab

The following image shows the spread of metrics displayed on and ACO Analyze page. A summary of each tile is included in the table below.

The metrics displayed on these tiles are calculated for all beneficiaries of the selected ACO.

Destinations

When you click on the "Destinations" tab, or on the "Destinations" button on the Patient Population Beneficiaries tile, either route will open the Destinations tab.

There are four tables on the Destinations tab.

Click on the name of each table to navigate to the details for the table.

Hospital Destinations
SNF Destinations
Home Health Destinations
Hospice Destinations

Hospital Destinations

Claim Type Dropdown

The following table includes a brief description of the metrics in the Hospital Destinations table.

	Column/Metric Name	Description
Provider Identification	Name	Hospital name where the inpatient/outpatient claim was filed
	NPI	NPI for listed provider
	State	State of the hospital where the listed facility claim was filed
	County	County of the hospital where the listed facility claim was filed
	City	City of the hospital where the listed facility claim was filed
	Hospital Admit/Visit Count	The count of inpatient admissions or outpatient claims for this ACO's assigned lives at the listed facility beginning during the selected time period
	Hospital Beneficiary Count	The count of the selected ACO's distinct assigned lives with inpatient admissions or outpatient claims at the listed facility during the selected time period
30-Day All Cause Readmissions	Non-Risk Adjusted - This ACO	The percentage of the selected ACO's assigned lives who were discharged from the listed facility during the selected time period and readmitted to any hospital within 30 days of discharge
30-Day All Cause Readmissions	Non-Risk Adjusted - All FFS	The percentage of patients who were readmitted to any hospital within 30 days of discharge from the listed facility
Average Patient Risk	This ACO	Average Hierarchical Condition Category (HCC) Patient Risk Score for the selected ACO's assigned lives admitted to the listed facility during the selected time period
Average Patient Risk	All FFS	Average Hierarchical Condition Category (HCC) Patient Risk Score for patients admitted to the listed facility during the selected time period
Length of Stay	This ACO	The average length of inpatient stay (in days) for the selected ACO's assigned lives who were admitted to and discharged from the listed hospital during the selected time period
Length of Stay	All FFS	The average length of inpatient stay (in days) for all patients admitted to and discharged from the listed hospital during the selected time period
Average Reimbursement	Non-Risk Adjusted - This ACO	Average Medicare spend per inpatient admission/outpatient claim for the selected ACO's assigned lives with visits or admissions to the listed facility beginning during the selected time period
	Non-Risk Adjusted - All FFS	Average Medicare spend per inpatient admission/outpatient claim for all patients with visits/admissions to the listed facility beginning during the selected time period
	Risk Adjusted - This ACO	Average risk-adjusted Medicare spend per inpatient admission/outpatient claim for the selected ACO's assigned lives with visits or admissions to the listed facility beginning during the selected time period
	Risk Adjusted - All FFS	Average risk-adjusted Medicare spend per inpatient admission/outpatient claim for all patients with visits/admissions to the listed facility beginning during the selected time period

SNF Destinations

Claim Type Dropdown

	Column/Metric Name	Description
Provider Identification	Name	Organization name where the SNF claim was filed
	NPI	NPI for listed provider
	State	State of the SNF where the listed facility claim was filed
	County	County of the SNF where the listed facility claim was filed
	City	City of the SNF where the listed facility claim was filed
	SNF Admit Count	Count of skilled nursing admissions for this ACO's assigned lives at the listed SNF during the selected time period
	SNF Beneficiary Count	Count of this ACO's distinct assigned lives admitted to the listed facility during the selected time period
30-Day All Cause Readmissions	Non-Risk Adjusted - This ACO	Percentage of the selected ACO's assigned lives who were discharged from an inpatient setting into the listed SNF during the selected time period and readmitted to any inpatient setting within 30 days of the first inpatient discharge
30-Day All Cause Readmissions	Non-Risk Adjusted - All FFS	Percentage of patients who came from an inpatient setting into the listed SNF and were subsequently readmitted to any inpatient setting within 30 days of the first inpatient discharge
Average Patient Risk	This ACO	Average Hierarchical Condition Category (HCC) Patient Risk Score for the selected ACO's assigned lives admitted to the listed SNF during the selected time period
Average Patient Risk	All FFS	Average Hierarchical Condition Category (HCC) Patient Risk Score for patients admitted to the listed SNF during the selected time period
Length of Stay	This ACO	Average length of skilled nursing stay (in days) for the selected ACO's assigned lives who were admitted to and discharged from the listed SNF during the selected time period
Length of Stay	All FFS	Average length of skilled nursing stay (in days) for all patients admitted to and discharged from the listed SNF during the selected time period
Average Reimbursement	Non-Risk Adjusted - This ACO	Average Medicare spend per admission for the selected ACO's assigned lives admitted to the listed SNF during the selected time period
	Non-Risk Adjusted - All FFS	Average Medicare spend per admission for all patients admitted to the listed SNF during the selected time period
	Risk Adjusted - This ACO	Average risk-adjusted Medicare spend per admission for the selected ACO's assigned lives admitted to the listed SNF during the selected time period
	Risk Adjusted - All FFS	Average risk-adjusted Medicare spend per admission for all patients admitted to the listed SNF during the selected time period

HHA Destinations

Claim Type Dropdown

	Column/Metric Name	Description
Provider Identification	Name	Organization name where the home health claim was filed
	NPI	NPI for listed provider
	State	State of the home health agency where the listed facility claim was filed
	County	County of the home health agency where the listed facility claim was filed
	City	City of the home health agency where the listed facility claim was filed
	Home health Admit Count	Count of home health admissions for the selected ACO's assigned lives to the listed home health agency during the selected time period
	Home health Beneficiary Count	Count of the selected ACO's distinct assigned lives admitted to the listed home health agency during the selected time period
30-Day All Cause Readmissions	Non-Risk Adjusted - This ACO	Percentage of the selected ACO's assigned lives who were discharged from an inpatient setting into the listed home health agency during the selected time period and readmitted to any inpatient setting within 30 days of the first inpatient discharge
30-Day All Cause Readmissions	Non-Risk Adjusted - All FFS	Percentage of patients discharged from any inpatient setting into the listed home health agency and subsequently readmitted to any inpatient setting within 30 days of the first inpatient discharge
Average Patient Risk	This ACO	Average Hierarchical Condition Category (HCC) Patient Risk Score for the selected ACO's assigned lives admitted to the listed home health agency during the selected time period
Average Patient Risk	All FFS	Average Hierarchical Condition Category (HCC) Patient Risk Score for patients admitted to the listed home health agency during the selected time period
Length of Stay	This ACO	Average length of home health stay (in days) for the selected ACO's assigned lives who were admitted to and discharged from the listed home health agency during the selected time period
Length of Stay	All FFS	Average length of home health stay (in days) for all patients admitted to and discharged from the listed home health agency during the selected time period
Average Reimbursement	Non-Risk Adjusted - This ACO	Average Medicare spend per admission for the selected ACO's assigned lives admitted to the listed home health agency during the selected time period
	Non-Risk Adjusted - All FFS	Average Medicare spend per admission for all patients admitted to the listed home health agency during the selected time period
	Risk Adjusted - This ACO	Average risk-adjusted Medicare spend per admission for the selected ACO's assigned lives admitted to the listed home health agency during the selected time period
	Risk Adjusted - All FFS	Average risk-adjusted Medicare spend per admission for all patients admitted to the listed home health agency during the selected time period

Hospice Destinations

Claim Type Dropdown

	Column/Metric Name	Description
Provider Identification	Name	Organization name where the hospice claim was filed
	NPI	NPI for listed provider
	State	State of the hospice where the listed facility claim was filed
	County	County of the hospice where the listed facility claim was filed
	City	City of the hospice where the listed facility claim was filed
	Hospice Admit Count	Count of hospice admissions for the selected ACO's assigned lives at the listed hospice during the selected time period
	Hospice Beneficiary Count	Count of this ACO's distinct assigned lives admitted to the listed hospice during the selected time period
30-Day All Cause Readmissions	Non-Risk Adjusted - This ACO	Percentage of the selected ACO's assigned lives who were discharged from an inpatient setting into the listed hospice during the selected time period and readmitted to any inpatient setting within 30 days of the first inpatient discharge
30-Day All Cause Readmissions	Non-Risk Adjusted - All FFS	Percentage of patients discharged from any inpatient setting into the listed hospice and subsequently readmitted to any inpatient setting within 30 days of the first inpatient discharge
Average Patient Risk	This ACO	Average Hierarchical Condition Category (HCC) Patient Risk Score for the selected ACO's assigned lives admitted to the listed hospice during the selected time period
Average Patient Risk	All FFS	Average Hierarchical Condition Category (HCC) Patient Risk Score for patients admitted to the listed hospice during the selected time period
Length of Stay	This ACO	Average length of home health stay (in days) for the selected ACO's assigned lives who were admitted to and discharged from the listed hospice during the selected time period
Length of Stay	All FFS	Average length of home health stay (in days) for all patients admitted to and discharged from the listed hospice during the selected time period
Average Reimbursement	Non-Risk Adjusted - This ACO	Average Medicare spend per admission for the selected ACO's assigned lives admitted to the listed hospice during the selected time period
	Non-Risk Adjusted - All FFS	Average Medicare spend per admission for all patients admitted to the listed hospice during the selected time period
	Risk Adjusted - This ACO	Average risk-adjusted Medicare spend per admission for the selected ACO's assigned lives admitted to the listed hospice during the selected time period
	Risk Adjusted - All FFS	Average risk-adjusted Medicare spend per admission for all patients admitted to the listed hospice during the selected time period

Patient Population tab

The Patient Population tab has a single table that shows the counties of residence for ACO beneficiaries for the selected ACO.

Metric Type Dropdown

Metric Name	Description
County	The county of ACO beneficiary residence during the year the claim was filed
State	The state of ACO beneficiary residence during the year the claim was filed
Patient Count	The count of unique beneficiaries who were assigned to the selected ACO and who reside in the listed county
Average Risk Score	Average risk score for beneficiaries who are assigned to the selected ACO and resided in the listed county
Mortality Count	The count of mortalities who were assigned to the selected ACO and resided in the listed county
Inpatient Episode Count	The count of unique inpatient episodes admitted during the selected year for beneficiaries who are assigned to the selected ACO and who reside in the listed county
ER/OBS Visit Count	The count of unique ER or observation visits during the year for beneficiaries who are assigned to the selected ACO and reside in the listed county
Readmission Count	The count of distinct All-Cause readmissions during the performance year for beneficiaries who are assigned to the selected ACO and who reside in the listed county, who were discharged from an Inpatient non-IRF facility within 30 days prior to readmission.
Home Health Episode (Count)	The count of distinct home health episodes admitted during the year for beneficiaries who are assigned to the selected ACO and who reside in the listed county
Hospice Episode Count	The count of distinct hospice episodes admitted during the year for beneficiaries who are assigned to the selected ACO and who reside in the listed county
Hospice ALOS	The average length of stay (in days) for hospice episodes of beneficiaries who are assigned to the selected ACO and who reside in the listed county. This calculation is limited to episodes discharged during the performance year.
SNF Episode Count	The count of distinct SNF episodes admitted during the year for beneficiaries who are assigned to the selected ACO and who reside in the listed county

Participating Providers tab

The Participating Providers tab has a single table that contains a list of providers associated with the selected ACO.

Metric Name	Description
Name	The physician name, as listed in CMS Provider Data (NPI) file
NPI	The NPI for the listed physician
State	The primary state in which the listed physician practices (as listed in the NPI file)
City	The primary city in which the listed physician practices (as listed in the NPI file)
County/ZIP	The primary county and ZIP code in which the listed physician practices (as listed in the NPI file)
Specialty	The listed physician's self-reported primary specialty (as listed in the NPI file)
Subspecialty	The listed physician's self-reported primary subspecialty (as listed in the NPI file)
SNF Patient Count	The count of the listed physician’s patients who were admitted to skilled nursing care during the one-year reporting period
Patient SNF Utilization %	The percentage of the listed physician's patients who were admitted to skilled nursing care during the one-year reporting period
Home Health Patient Count	The count of the listed physician’s patients who were admitted to home health care during the one-year reporting period
Patient Home Health Utilization %	The percentage of the listed physician's patients who were admitted to home health care during the one-year reporting period
Hospice Patient Count	The count of the listed physician’s patients who were admitted to hospice care during the one-year reporting period
Patient Hospice Utilization %	The percentage of the listed physician's patients who were admitted to hospice care during the one-year reporting period

PMPM Details

When you click on the PMPM "Details" button, a sub page appears:

This subpage has two sections. The top section pertains to the ACOs PMPM spend. The lower section is a table of all ACO physicians.

ACO Spend

This page of details is focused on ACO spend, annual totals and monthly trends.

The Calendar Year dropdown will allow you to choose which calendar year is displayed on the page. This will allow you to make far reaching historical analysis of the selected ACO.

The PMPM Tile is the same as what was displayed under the insights tab.

The chart shows the trend of monthly PMPM spend for the selected calendar year and for the previous six years.

If you click on one of the circles in the chart, a pop-up will show the actual numbers for the selected month.

Since the chart shows the calendar year rather than a rolling four quarters, any unreported quarters will be shown as zeros in the chart.

To the right of the chart you will find the ACOs total patient spend for each year shown in the chart.

Physician Table

The table includes summary metrics for all physicians in the ACO.

Metric name	Description
Name	The physician's name
NPI	The physician's NPI
State	The state listed in the physician's primary practice address from the NPI registry
City	The City listed in the physician's primary practice address from the NPI registry
County/ZIP	The county/ZIP code listed in the physician's primary practice address from the NPI registry
Specialty	The physician's self-reported primary specialty from the NPI Registry
PMPM-All	This column contains the total per member, per month spend for all patients for whom the physician is listed as the attending or performing physician on a FFS claim during the performance year (PMPM)
Beneficiary Patient Count - All	This metric is the count of patients for whom the physician is listed as the attending or performing physician on a FFS claim in the performance year
Risk Score - All	The average HCC Risk Score of patients for whom the physician is listed as the attending or performing physician on a FFS claim in the performance year

Metric Tile	Details
	PMPM/PMPY PMPM represents the Per Member Per Month/Per Member Per Year cost for all MSSP ACO assigned beneficiaries for the selected Date of Service/Calendar Year. Uses beneficiary assignment data in the VRDC. All costs incurred during the selected Date of Service/Calendar Year for these beneficiaries, divided by 12 for the "per month" metric. Use the "Risk Adjusted" toggle to normalize costs for comparison with other ACOs. For more information, see How do we calculate PMPM? The content of the "Details" button is included below.
	Patient Risk Score (HCC) Represents the Hierarchical Condition Category Risk score based on CMS’ methodology for all MSSP ACO assigned beneficiaries. Percentile represents comparison of the MSSP ACO’s HCC to the HCC of all other MSSP ACOs. MSSP ACOs with null or insufficient beneficiaries to calculate HCC are excluded in the comparison. For more information, see Patient Risk Score Help Article
	All Causes Readmissions Represents MSSP ACO assigned beneficiaries with an Inpatient Admission within 30 days of a Discharge from a previous Inpatient Admission. Readmission could be to the same or different Inpatient facility. Readmissions into Inpatient Rehabilitation Facilities (IRFs) are not included. Planned/elective readmissions are not included. Physicians with <11 beneficiaries are excluded from the denominator. Lookback period is Dec 1st two years ago through Dec 01 one year ago, depending on the time period selected. Percentile represents comparison of the All Causes Readmissions to the All Causes Readmissions of all other MSSP ACOs. MSSP ACOs with null or insufficient beneficiaries to calculate All Causes Readmissions are excluded in the comparison.
	Patient Population Beneficiaries Represents a count of MSSP ACO assigned beneficiaries for the selected Network and Performance Year. Clicking on the "Destinations" button will open the Destinations tab.
	Network Leakage Based on MSSP ACO assigned beneficiaries. Leakage represents claims for the selected MSSP ACO;s assigned beneficiaries who were admitted to a SNF, Home Health Agency or Hospital that is not participating in the ACO. Outpatient or Physician Professional claims are not included. Network Leakage calculation identifies the percentage of events occurring at a provider not participating in the MSSP ACO. Percentile represents comparison of the MSSP ACO’s Network Leakage to the Network Leakage of all other MSSP ACOs. MSSP ACOs with null or insufficient beneficiaries to calculate Network Leakage are excluded in the comparison. Missing Network Leakage numbers could be due to an MSSP ACO having Physician Groups only (no facilities) or with a facility legal business name that does not match the organization name given in the NPI registry.
	SNF Admissions Represents MSSP ACO assigned beneficiaries with SNF admissions from any SNF claim. SNF admissions are counted distinctly per beneficiary, i.e. if one person is admitted more than once any time in the Date of Service/Calendar Year, they are only counted as one SNF admission. Admissions into Inpatient Rehabilitation Facilities (IRF) are not included. Percentile represents comparison of the SNF Admissions for the selected ACO to the SNF admissions of all other MSSP ACOs. MSSP ACOs with null or insufficient beneficiaries to calculate SNF admissions are excluded in the comparison.
	ED/OBS Visits Represents MSSP ACO assigned beneficiaries with Outpatient claims with an Emergency Department or Observation code. ED Visits leading to an Inpatient Admission are excluded. ED/OBS visits are counted distinctly per beneficiary, i.e. if one person visits the ED more than once any time in the Date of Service/Calendar Year, they are only counted as one visit. Percentile represents comparison of the ED/OBS visits for the selected ACO to the ED/OBS visits of all other MSSP ACOs. MSSP ACOs will null or insufficient beneficiaries to calculate ED/OBS visits are excluded in the comparison.
	Inpatient Admissions Represents MSSP ACO assigned beneficiaries with inpatient admissions from any inpatient claim. Inpatient admissions are counted distinctly per beneficiary, i.e. if one person is admitted more than once any time in the Date of Service/Calendar Year, they are only counted as one Inpatient Admission. Inpatient admissions can be at the same or a different inpatient facility. Admissions into Inpatient Rehabilitation Facilities (IRF) are not included. Percentile represents comparison of the inpatient admissions for the selected ACO to the inpatient admissions of all other MSSP ACOs. MSSP ACOs with null or insufficient beneficiaries to calculate inpatient admissions are excluded in the comparison.
	Home Health Admissions Represents MSSP ACO assigned beneficiaries with home health admissions from any home health claim. Home health admissions are counted distinctly per beneficiary, i.e. if one person is admitted more than once any time in the Date of Service/Calendar Year, they are only counted as one home health admission. The percentile represents comparison of the home health admissions for the selected ACO to the home health admissions of all other MSSP ACOs. MSSP ACOs with null or insufficient beneficiaries to calculate home health admissions are excluded in the comparison.
	Hospice Admissions Represents MSSP ACO assigned beneficiaries with hospice admissions from any hospice claim. Hospice admissions are counted distinctly per beneficiary, i.e. if one person is admitted more than once any time in the Date of Service/Calendar Year, they are only counted as one hospice admission. The percentile represents comparison of the hospice admissions for the selected ACO to the hospice admissions of all other MSSP ACOs. MSSP ACOs with null or insufficient beneficiaries to calculate hospice admissions are excluded in the comparison.

Where do I find my ACO content?

Overview

In this article

Use Cases

Opening an ACO Analyze page