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PROVIDER ORGANIZATIONS, BUCA PAYERS AND LARGE REGIONAL PAYERS ARE FOCUSING ON THEIR RESPECTIVE TRANSFORMATIVE IMPERATIVES...
Market Dynamics Context for Revenue Model Strategic Repositioning
1Par Networks... Tier 1 and Tier 2 Networks... FFS
and Risk Sharing... Care Setting Appropriateness and Cost... Longer-Term Goal... Full Risk Capitation
Benefit Design... Tiered Benefits W/ +$ Cost
Sharing... Continued Cost Shift to Member In/Out of Network & Network Tier Cost Sharing... Group Market Margins Tight... Major Growth in Individual Markets... Commercial, MA and Medicaid
3
2PMPM Total Cost of Care... Reduce PMPM
Spend... Major Focus on Reducing Out-of-Network and Out-of-State PMPM Spends... Move Towards Maximum Allowance Only for OON Providers... Beginning Site Neutral Payments and Loss of HOPD
Driv
ing
To
wa
rds
Inte
gra
ted
Ca
re
an
d V
alu
e-B
as
ed
Pa
ym
en
t Mo
de
ls
HIX/Narrow Networks... Public HIX ??
Narrow Networks Accelerated... Narrow Networks Favor High Efficiency / Low TCOC Providers... Payer LOBs Shifting to Narrow Networks
4
Alignment of Imperatives? Economic Implications? Your Organization?
Key Strategic Questions Re: Your Revenue Model and Total Cost of Care: Preparing for Changes Under ACOs and Risk Sharing
HOW WILL HEALTH PLANS PAY YOU IN YOUR MARKET? WILL YOU BE
READY FOR VALUE-BASED PAYMENT (“VBP”) MODELS AND ACO DEALS?
Which of the above payment methodologies illustrate the “most likely” trending alternative payment arrangements that will gain traction in your market between Calendar Years 2018 – 2022.
3rd
Part
y
Payer
Medicare
E.G. “Managed Care” Value Based Payment Models
EOC Payments (Prospective and Retrospective)
Shared Savings(Prosp / Retro)
Shared Risk (Upside and Downside)
% of Premium Capitation
Str
ate
gy
Descri
pti
on • Value Based Payments
• BPCI and BPCI Advanced
• MSSP (Tracks 1 – 3)
• Next Gen ACO
• OCM
• New Pilots 2018 –2020
• Global payments for EOC
• Retrospective –Access payer par network, no downside
• Prospective - Your “network” and at risk payment
• Receive portion of savings by reducing TCOC
• Prosp. has a downside risk
• Retro. is upside only
• A mix of FFS and Risk (e.g., PMPM medical and FFS hospital)
• Direct to Employers
• A negotiated medical loss ratio (“MLR”) for at risk / attributed lives
• Payer average contracted rates and utilization
• Often includes a FFS discount w/ a LOB
• Capitation – Attrib. PMPM that covers all HC services
• Global – A Product specific global PMPM, not linked to an attributed pop
Pro
vid
er
Netw
ork PCPs and PAC; Specialist
and Subspecialists for Chronic Care Patients;
System CIN/ACO network
Applicable providers w/ian EoC... Vertical
operative/non-operative model, manage clinical variation across EOC
YOUR TRANSFORMATION / TRANSITION PLAN FROM VOLUME-TO-VALUE?Finance, IT/Analytics, Operations, Care Network, Patient Channels, Population Health and Risk/Reward
Your Strategic
Roadmap?
FFS Transaction-Based Care
Value-Based Care
Population-Based Care
• FFS Specialist Clinical Model...
Reliant on Referral and 2nd Opinion
Volumes
• Revenues Tied to Utilization and
Rates... but Margin Largely Tied to
Commercial Rates
• Focus on Individual Specialist
Providers and for Hospital OP...
Provider Based Reimbursement
• Commercial Rate Optimization
Strategies
• Pursuit of Excellence in Specialty
Medicine with Integrated Primary
Care Access Points
• Streamlining Patient Access to
Hospital Services Across Network
Model
• Coordinating Patient Care Across an
Entire Episode of Care Continuum,
While also Reducing the Total Cost
of Care
• FFS and Gainsharing Payment
Models w/Payers
• Care Model Transformation in
Process
• Integrated Delivery Model
• Promotes and Manages Population-
Based Specialist and Primary Care
Across a Network
• Combined FFS and “Premium-
Based” Rev.
• Effectively Manages Total Costs of
Care
• Member/Patient Centered and Value
Based Care
• Select Alliances w/Payer Partners
Future Revenue Model, Risks and Value-Based Payments and Strategic Roadmap
IMPACT ON FACILITIES, CAPITAL AND LONG-RANGE FINANCIAL PLANS