Full Risk Capability. Pathway to Future Success

Transcription

1 Full Risk Capability Pathway to Future Success 1

2 DHG Healthcare s Transformational Perspective 2

3 Polling Question #1 Healthcare reform is moving the industry from receiving payment for volume to receiving payment for a) Value b) Each Service Performed c) Clinical Results 3

4 The Journey To Risk Capability Risk Capable

5 Key Element: Understanding the Data Using Business Intelligence (including actuarial tools) to understand population characteristics and build the right risk capability based on relevant critical success factors

6 Business Intelligence 1. Define Population Understand the underlying population: demographics, utilization trends, health, costs, etc. 2. Understand Capitation Rates Stress-test the assumptions & methodologies used to develop capitation rates 3. Analyze Utilization & Cost Assess current utilization and unit cost by service categories across the network 4. Build the Budget Represents utilization and cost of providers; adjusted as necessary for defined payments 5. Sensitivity Test the Budget Stress-test the limits of the budget by adjusting utilization or costs to scenario plan 6. Ongoing Monitoring Monitor expected vs. actual patterns and adjust to maintain profitability

7 Polling Question #2 Business Intelligence is another name for a) Data and Analytics b) Quality c) Market Competition 7

8 Key Element: Integrated Clinical Enterprise An integrated Clinical Enterprise structurally aligns providers around improved health outcomes, management of costs and risk, acceptance of risk contracts, and value delivery to healthcare marketplaces.

9 Clinical Enterprise Maturity Contracting Multiple contract options secure rewards for better quality and demonstrated value Structure & Governance Limited Liability Corporation, Non Profit Corporation, Health Care Authority Infrastructure & Funding Sustainable revenue and provider agreements. Distribution of Funds Flow of funds distributes rewards based on measurable performance. CLINICAL ENTERPRISE MATURITY Participation Criteria Provider agreements outlining expectations/requirements for participation. Information Technology Architecture to monitor and track utilization, control costs, ensure quality and demonstrate value.. Physician Leadership Physicians empowered to have an influence on future direction of the network. Performance Objectives Metrics and targets that impact the clinical practice of all providers to improve care and demonstrate value.

10 Polling Question #3 Clinical Enterprise Maturity is a key element of improving the value of healthcare because CEM a) Aligns providers around outcomes and costs b) Eliminates risk contracts c) Decreases focus on population health 10

11 Key Element: Revenue Transformation Managed Revenue Transformation emphasizes the need for a next-gen revenue management platform focused on a portfolio perspective, reimbursement across multiple revenue models, and aligned model funds distribution.

12 Revenue Transformation 1. Assess Current Risk-Based Environment Understand the revenue portfolio both currently and prospectively 2. Measure and Monitor Impact Develop the portfolio view assumptions to enable key revenue management objectives 3. Assess Gaps in Infrastructure Assess important people, process, and technology considerations 4. Develop Patient- Centered Revenue Models Consider non-ffs payment models and their market application 5. Manage Funds Flow & Contracting Be prepared to revitalize traditional contracting frameworks 6. Acquire Tools to Model Financial Impacts Assess ability to support next-gen/3d financial model builds

13 Polling Question #4 Revenue Transformation will require healthcare financial executives to: a) Build new payment and collection processes b) Hire and develop insurance capabilities c) Take more vacation because it is going to be so easy 13

14 The Risk Capable Healthcare Organization Populations, Utilization, Costs, Budgets, Monitoring Risk Capable Overmanaged, Portfolio, Multiple Models, Funds Distribution Structure, Governance, Alignment, Value 14

15 Risk Capable Overmanaged, Portfolio, Multiple Models, Funds Distribution 15