Outcomes management helps ensure optimal care to members

To improve member outcomes and enhance the quality of care, provider groups and practices need useful feedback. A flexible model backed by real-time and actionable reporting provides such feedback. Understanding the program objectives and managing to specific outcomes is vital to improving quality and risk adjustment performance. Payers set outcomes goals, and an outcomes manager aligns the model’s resources to help achieve those goals. This heightened accountability strengthens the efforts of the experienced provider engagement experts. It also makes the enabling technology more effective, as discussed in the previous blog posts of the series.

Goal setting. Goal setting is fundamental to engaging providers to improve quality and risk and performance. Oversight resources work on behalf of plan sponsors to create and then manage a roadmap to goals and milestones. Outcome managers and oversight resources use key performance indicators (KPIs) to ensure that engagement efforts with providers are on track to meet overall performance goals.

Performance goals might include the percentage of:

  • Providers participating in program
  • Members who have annual office visit
  • Screenings for quality measures
  • Assessments that are complete and accurate

Monitor and adjust. Outcomes managers use analytics and business intelligence reporting to identify provider groups within the network that need support to hit health plan goals and milestones. Health plans often tie these goals to provider incentives. Using KPIs, outcomes managers are able to identify providers who are lagging behind performance goals. They insert specialist resources and intervention programs to help remediate performance issues. For example, a group that is lagging in members with annual office visits may benefit from assistance to proactively schedule appointments with members. Some provider groups could benefit from quality specific coding education. Or some groups may not be comprehensively assessing members and need coaching to ensure they execute complete member assessments. These examples provide insight into how outcomes management can pinpoint issues and remediate them to optimize performance.

Forecast and report. The outcomes manager forecasts and reports quality and risk adjustment performance towards KPIs to the different health plan stakeholders. Providers and health plan stakeholders can avoid performance surprises through constant and consistent communication.

The outcomes manager is also responsible for:

  • Daily tracking of program-specific KPIs such as data returns, completeness of assessments and documentation accuracy
  • Prioritizing providers, members and suspects for provider engagement team
  • Creating and managing a glide path for the overall program and each provider group
  • Reviewing progress of provider engagement team daily
  • Prioritizing workload for provider engagement team
  • Adjusting field resource plan to help ensure each group stays on track

A formula for exponential success: Human engagement + technology + diligent oversight

Payers have traditionally employed aspects of this three-part model. However, it takes all three to form a highly effective model. This model serves provider groups in a way that helps them participate, engage and improve outcomes and results.

To learn more, watch the webinar about the quality and risk adjustment provider operating model 


About the Author:

Sam pic_Provider_blog

Sam Diederich

Vice President of Strategy and Business Integration, Optum

Sam Diederich has spent nearly 10 years in the health care industry. He develops innovative strategies for payers in the areas of risk adjustment, utilization management and government-sponsored quality of care programs. He leads the growth, partnerships and integration strategy for the Optum quality and risk adjustment business. Sam is a graduate of the University of St. Thomas’ Opus College of Business, where he studied financial management and economics.

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