Health plan drivers of innovative risk and quality provider reimbursement programs

Over the course of the past few decades, provider reimbursement has taken on different forms with varying degrees of acceptance and success. Many have had their share of challenges and opportunities, but for the most part, all were intended to create an environment that modified behavior, created visibility and perhaps motivated providers to achieve a particular goal(s). These early programs may have achieved a short-term operational objective, but they could be improved to create additional positive impact from the practitioner-patient perspective.

It is important to recognize the history of provider payment programs and their fundamental effects — and reconcile what has been effective and what has been challenging. From these lessons, what do we know to be effective in addressing challenges?

Optum held another of its monthly webinars in The Path to Risk and Quality Success series. Chris Corbin, VP Clinical and Quality Solutions and Rose Bernards, senior director, Risk Adjustment Advisory Services, spoke about how to improve risk and quality through value-based provider contracting.

Health plan perspectives on value-based arrangements
We asked health plan attendees what percentage of their membership that is part of contracted arrangements has some sort of value-based or risk-sharing arrangement. Results were fairly evenly distributed between all the choices with 0 to 25% being the highest at 23.4%.

Reporting transparency is key
One of the activities we discussed was how crucial transparent reporting is. Providers want to know how they are performing. Reporting should be transparent and provide program data so providers can see progress toward goals. Program design should allow for a minimum of monthly reporting.

  • Offer report access and delivery options so providers can monitor progress proactively. For those that aren’t proactive, be sure to communicate their progress.
  • Keep it simple. Program and performance reporting should be reasonably simple to understand. The ability to see high-level progress or drill down to the goal is important. This leads to clear objectives, goals, reporting progress toward those goals, timing and the carrot or stick criteria.
  • Communicate clear information about payment program objectives, how goals are evaluated and transparency of gathering or reporting data for program organization and goal alignment.
  • Deliver timely feedback on performance information so that objectives can be redirected before it’s too late.
  • Provide progress metrics. Health plans are excellent at selecting metrics that are meaningful toward risk, quality and cost goals but may create workflow complexity for providers.

Four things to know when strategizing new reimbursement arrangements
While we always will need to be mindful of the regulatory and political climate, these general design principles will help health plans and providers align toward common objectives:

  1. Design – Simple is better. Have clear objectives and programs to work across the provider continuum.
  2. Align – Align health plan and provider programs through the lens of a common goals like the quadruple aim. Use – Specific, Measurable, Achievable, Relevant and Time-bound (SMART) goals, transparent reporting and ensure the right program for the right provider type.
  3. Implement – Providers will do increasingly better if they can perform work in their primary system. Programs that allow EMR integration — at least for the largest providers — will see greater outcomes.
  4. Refine – Revisit your program each year to look for opportunities to refine and expand (e.g., specialists, episodes, etc.).

Optum can help
You may already have value-based care (VBC) arrangements with your providers but feel ready to move them to the next level of accountability. Or, your health plan may be wondering how to move from fee-for-service to VBC, Optum Advisory Services can help, regardless of where your health plan is and where it wants to go on the VBC spectrum.

On-demand and upcoming webinars
Please visit our Medicare Advantage webinar series page to explore upcoming topics and register for the next monthly webinar.

If you were unable to attend the webinar on improving risk and quality through value-based provider contracting or one of our other past webinars in this series, you may watch on-demand.



Meet the Authors

Chris Corbin headshotChris Corbin, MBA
Vice President, Clinical and Quality Solutions

Chris Corbin is responsible for strategy and solution architecture for Optum Risk and Quality Solutions. He has over 20 years of healthcare experience with broad expertise in risk adjustment, HEDIS® quality, provider engagement, network contracting, health policy, interoperability and population health management. Chris has extensive experience in care delivery operations, provider workflow with an emphasis in Medicare Advantage and Medicaid. He holds a BS in Health Administration from Western Kentucky University and an MBA from The Gatton College of Business at the University of Kentucky.

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).


Optum-july-ma-webinar-blog-FINALRose Bernard
Senior Director, Risk Adjustment for Optum Advisory Services

Rose Bernards has more than 25 years of health care experience spanning health plan and provider organizations. Her specific subject matter expertise is in risk adjustment methodology across Medicare Advantage, Affordable Care Act and Medicaid lines of business.

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