A multi-state health plan focused on serving the Medicare Advantage and Dual-Eligible segments wanted to optimize its performance. In particular, the organization was interested in developing stronger engagement of primary care physicians to achieve appropriate risk adjustment performance and better management of total cost of care.
This effort started with the creation of a cross-functional team including executive leadership from actuarial, network and clinical services to develop the new value-based program. Guided by this team, the organization developed a new value-based program which would meet providers where they were, starting with pay-for-performance and shared savings opportunities and advancing to varying levels of shared risk. To address provider concern around the lapse in the time between providers performing well and receiving financial rewards, the program used an innovative structure where physicians that were performing favorably based on two quarters of data would have a partial pay out of their incentives. This approach helped to drive favorable physician engagement with the program which proved invaluable over time.
The new value-based program successfully achieve both objectives driving substantial revenue improvements from appropriate risk adjustment as well as significant reductions in total cost of care.