Designing an effective integrated clinical model

As the shift to risk-sharing and value-based models of care continues, physicians, hospitals and hospital based physician group must put greater focus on better coordination of care and outcomes. They must also be capable of taking on some level of clinical and financial risk.

But how do we integrate these different aspects into a single format?

Increasingly, integrated clinical models are becoming the answer to managing risk among stakeholders. They provide insight into understanding which interventions are yielding the best results — at both the provider and member level. Clinical models also help health plans drive transparency across cost, quality and care utilization metrics.

Laying the foundation for clinical improvement

An effective integrated clinical model should be member-centric, focused on value, targeted across all dimensions, and well orchestrated to manage and prioritize closing gaps. Once a model is established, plans find it easier to continually drive quality improvements, improve their risk premium focus, reduce utilization, improve satisfaction and provider abrasion, and importantly, drive return on investment.

Ultimately, the clinical model must be able to provide the right information at the right time with the right intervention to the right stakeholder. That stakeholder should be someone who can help drive the change, or influence that change from a behavioral management perspective.

Creating an effective integrated clinical model

An integrated clinical model can lay the groundwork for clinical improvement, but it requires a solid foundation of its own. This foundation should include:

  • Provider network management
  • Cost and utilization management
  • Integrated quality management
  • Capacity and campaign management
  • Holistic risk-adjustment solutions
  • Value-based enablement

Ideally, the most effective clinical model will coordinate workflow, resulting in a patient-driven approach to provider engagement that cycles from risk-adjusted conditions to clinical quality to care excellence, closing gaps in care along the way and evaluating effectiveness for ongoing model refinement.

Learn more about integrated clinical model best practices by downloading our article, “Integrated clinical model helps plans measure impact of interventions.”

About the authors

Mark AndersonMark Anderson, Senior Vice President Technology and Innovation Risk Solutions Group, Optum

Anderson 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 and A, budgeting, product commercialization, and advanced analytics within health and human capital services. Previously, he’s been on the advisory boards for many national organizations and the strategic benefits board for leading Fortune 500 corporations. He was also the recipient of the renowned “Medistar Award” in 2008.


Scott HowellDr. Scott Howell, Senior National Medical Director, Optum

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.

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