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Elena White, vice president of risk, quality and network solutions, Optum. offers insight into approaching decisions around risk.


1. Risk contracts are testing the limits of providers’ comfort zones. What are their greatest trepidations and how do they begin to address them?

Risk-based contracts represent a significant cultural shift for providers. Hospital systems, whose focus traditionally has been around volume, must now be thinking more about population management, which will have a significant impact on their fee-for-service business.

They have also expressed concern over their ability to manage many different risk-based contracts, each with their own set of metrics and rules governing standards for performance and cost efficiency.

Providers are evaluating their internal infrastructures and capabilities to determine if they are sufficient to manage to the quality and cost-efficiency goals for each of their payer agreements.

Without a comprehensive analytics solution and diverse data, they will find it very difficult, if not impossible, to deliver measurable improved outcomes throughout their networks for their risk-based populations as well as their remaining fee-for-service patients.


2. How has technology evolved to impact care quality while maintaining a healthy balance sheet?

Whether talking about quality reporting systems, electronic medical records, or other enabling technologies, providers are utilizing technology to improve population management and clinical outcomes.

Yet to achieve optimal success, they need to gain a true understanding of the value of having clinical and claims data available at their fingertips.

Aggregated and harmonized, this information becomes a significant resource that provides unique insights on population cohort analysis, risk stratification, predictive analytics, and longitudinal outcomes tracking.


3. Is data-infused analytics the answer for ensuring providers will succeed under a risk-based payment model?

In reality, it’s only one part. There is often a disconnect between the wealth of data providers now have at their fingertips and a deep understanding of how to turn that information into the results they expect to achieve from their investments.

A leader from a very large health system I recently spoke with summed up providers’ need for a coordinated approach to addressing the complex reimbursement issues.

His message was that technology has matured into an effective tool that can help providers better manage their populations, identify and control costs, and consistently maintain high levels of quality.

However, providers still need a solutions partner that can marry a deep knowledge of the processes important to internal clinical and administrative teams with infrastructure and advanced analytics if they are to succeed with shared-risk arrangements.


4. If you were to develop a to-do list for organizations pursuing a risk-based strategy, what would their priorities be?

Topping the list would be the need to evaluate their market and competitive position within the space, as well as gaining an understanding of their competition and commercial, employer, and government payer partnership opportunities

Provider network optimization is also a priority. By evaluating 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.

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.

Engage the consumer! Health outcomes are determined by whether or not patients adhere to therapies, participate in follow-up appointments, and engage in healthy behaviors.

Acquire in-depth knowledge of your payer contract terms. Deploy experts, like actuaries, who can help leaders gain an understanding and accelerate performance under risk agreements.


5. What should providers expect as they travel down the risk-sharing path?

Near term, providers shouldn’t expect to perform flawlessly in a risk-based delivery system. There are still many technology and process kinks that must be worked out before providers can claim they are achieving all the benefits that this model offers.

With thoroughly conceived goals and a well-planned yet flexible road map of how to achieve those goals, I believe there is a bright future in the long term for providers to achieve great success in the new value-based payment era.

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Download the current issue of “RISKMATTERS”: A publication for health care executives taking on risk and improving quality.

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