Solving the health care risk challenge

Elena WhiteDid you know that one-third of Americans’ health plan coverage will be part of a shared-risk program by 2020? In fact, more than 90 percent of health plans already include value-based reimbursement contract terms with their network providers.

The transitioning market has created the Triple Aim, where quality of care, more affordable care and patient satisfaction are the goals. The Triple Aim, appropriately, takes the consumer perspective.

To operationalize the Triple Aim, many health plans are offering consumers plan benefit designs with lower premiums in exchange for share of cost in their non-preventive medical care expenses (e.g., high-deductible health plans). With such plans, consumers are becoming more conscientious about and demanding more transparency in their cost for care. For health care providers, a “Modified Triple Aim” can help us give patients what they expect under value-based care models.

  • Healthy populations: To successfully manage risk, providers must have processes in place that drive toward predictable improvements in the health of their patient populations.
  • Preferred networks: Consumers will choose low-cost, high-quality providers in their health plan’s covered network. Delivering high quality care will keep providers competitive, while managing medical cost efficiency can help solidify their preferred position.
  • Patient satisfaction: Consumers expect to be satisfied, not just with the care they receive but also with its responsiveness to their needs and preferences.

Unfortunately, many organizations approach value-based care from the wrong direction. They start buying up infrastructure first before they determine their partnership and provider strategy.

Re-creating your organization around value means focusing on your core values and strengths. You are not creating a new organization. Rather, you should be developing a new risk-based focus in your current organization and properly aligning for the transition.

With your core strengths and values in mind, you should then align people, processes and technologies within the organization. Start with payer contracting and financing to focus your business model. Next, move to network development and management, with an eye toward how your provider network will evolve from fee-for-service to fee-for-value. Then, determine how you’ll deliver and manage care under risk. Finally, identify and implement the infrastructure and IT that makes the above three elements work.

To see an infographic view of how to solve the health care risk challenge, check out the Fall 2015 edition of RISKMATTERS.

About the author

Elena White currently serves as Vice President of the Risk Quality & Network Solutions division for Optum. She has over 18 years experience leading network optimization initiatives, network development and expansion, business planning, provider reimbursement development, transformation to risk based arrangements and medical cost management strategies for both health plan and provider organizations.

Elena holds a Bachelor’s Degree from University of California at Riverside and Master’s Degree in Business Administration from Loyola Marymount University.

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