When you’re used to being paid based on a tally of procedures, it can be daunting to consider taking on the financial responsibility for outcomes.
Where do you start? Or if you are already bearing some risk, how do you prepare to accept more?
Organizations pursuing a risk-based strategy need to address five key areas of their business. The knowledge they gain can help them achieve value-based care success.
1. Understand market dynamics
Topping the list, providers need to evaluate their market and competitive position. They also need to gain an understanding of commercial, employer, and government payer-partnership opportunities.
2. Align physicians and staff
Provider network optimization should be a priority. By evaluating historical claim and clinical data, organizations can compare provider performance and select those that have the greatest potential to improve care quality, reduce medical costs, and increase patient satisfaction.
3. Determine patient needs
No organization will succeed without a deep understanding of its patient population. Providers require the ability to stratify and segment their patients in order to gain an understanding of how certain groups will impact medical cost performance.
4. Engage consumers
Health outcomes are determined by whether or not patients adhere to therapies, participate in follow-up appointments, and engage in healthy behaviors. Patients who are able to improve their own health will assist providers in achieving their operational goals.
5. Acquire knowledge of payer contract terms
Health systems need to clearly understand the historical cost associated with medical services they will be providing under risk-based contracts. It will give them critical information in determining the capitation or reimbursement payment they need to provide those services.
For insights on using data to evaluate risk, take five minutes to read the latest #5in5 interview: Can you answer when asked, ‘how much risk can you bear?’
You’ll learn about the benefits of diverse data — including data from newer technologies — and get insights into risk-based contracts.
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.