As we sit post-ACA, it has become apparent that we have entered one of the most dynamic times in all of health care. Risk for all stakeholders has been on an accelerated course since 2010, but managing risk looks different depending where you are in the health care space. Providers — whether hospitals or physician groups like ACOs — are driven to reduce costs, better measure performance and improve quality outcomes. Consumers are also undertaking greater decision-making responsibility through enrollment in exchanges.
Whether it’s to reduce medical loss ratios or improve competitive positioning with more affordable products, health plans are under increasing pressure to reduce medical expenses through population health management. Where do you start when it’s difficult to identify and prioritize areas of opportunity that will have the greatest impact?
It is not necessarily membership itself that’s representing the larger cost of care, but where chronic conditions sit within your membership. For providers and plans, taking that risk means managing both acute and chronic conditions, even though high costs are involved. For now, the vast majority of providers continue to take a “wait and see” approach to developing value-based capabilities because of administrative cost, and a concern that investing capital will not merit rewards.
Add to that, programs in today’s market are very disconnected, fragmented and focused on paying for value as opposed to being orchestrated to prioritize gaps in care and targeted for prevention.
It’s critical that health plans upgrade their clinical management focus to support a care delivery performance approach that includes:
- Proactive engagement with the right members and providers — with the right intervention programs.
- Coordinated processes across departments, including the underlying technology infrastructure to support integration.
- Optimized performance-based results for quality, cost reduction and risk-based revenue.
With a renewed clinical management focus, health plans will find it easier to meet the demands of this dynamic market:
- Simplification, lower cost
- Connected, integrated service solutions.
- Improved risk stratification and workflow alignment
- Ability to control and manage cost, quality, revenue
- Assistance in executing across the care continuum
For a more in-depth discussion on setting a path to an integrated clinical model, view our presentation, “Accelerating the progression toward an integrated clinical model.”
About the authors
Dr. Scott Howell, Senior National Medical Director, Optum
Dr. Howell is responsible for risk adjustment, quality performance and predictive modeling. Prior to Optum™, he was the regional chief medical officer (RCMO) for the Northeast Region of Americhoice, Inc., focusing on the Medicaid and Dual SNPs populations. He also served as the medical director for managed care at the AIDS Healthcare Foundation along with having responsibility for international consulting in Russia, Ukraine, Guatemala, Honduras and Haiti.
Mark Anderson, SVP Technology and Innovation Risk Solutions Group, Optum
Mark leads the innovation effort around risk solutions group, value-based reimbursement administration and advanced analytics. He holds more than 20 years of experience in executive leadership, strategy, M&A, budgeting, product commercialization, and advanced analytics within health and human capital services. Previously, Mark’s been on the advisory boards for many national organizations and the strategic benefits board for leading Fortune 500 corporations. Mark was also the recipient of the renowned “Medistar Award” in 2008.