Medicare Advantage Program Optimization
Baker Tilly understands your MA program’s most pressing problems and recognizes that each stakeholder, both inside and outside of your organization, has different needs. In order to form a cohesive strategy across all groups, Baker Tilly’s team of professionals is able to offer an integrated set of solutions that helps build and optimize your MA program’s objectives and related operational capabilities.
Success in the MA space is dependent on an integrated organizational approach that focuses on provider network design and contract strategy, value-based incentive models aligned to patient health outcome and MA program goals (e.g., STARs and Risk Adjustment), risk adjustment program management, a focus on data management and project and program delivery skills that brings all of the pieces together.
To help increase financial efficiency of healthcare expenditures while increasing quality of care, it is paramount to match your program with an appropriate healthcare provider network and incentivize that network appropriately to maximize the quality and value of care. Baker Tilly can help your organization build and optimize an effective provider network strategy, including:
The transparency of premium pricing and the direct influence by providers on premiums within MA offer a unique opportunity in the market to pursue risk-based contracts with providers. Whether your organization pursues capitated arrangements, shared savings programs, or hybrid fee-for-service (FFS) with targeted VBC incentive arrangements, a key to contracting success is to consider both the financial performance and operational performance incentive structures required to maximize contract outcomes. The inclusion of operational incentives allows an MA plan to support alignment of provider behaviors with performance metrics required to maintain attractive products in the MA space (e.g., STAR ratings).
Baker Tilly has vast industry experience integrating VBC payment models alongside FFS reimbursements, and defining pathways for providers to increasingly share the amount of financial risk over time, with the potential to enter capitated contract agreements. We also understand the organizational and technical requirements to successfully initiate contract terms across the risk-sharing spectrum, and can help your organization with:
While the decision to enter capitation arrangements should be determined by provider risk readiness evaluations, the opportunity to engage providers in capitation agreements is higher in an MA setting where there is more transparency into premium costs and more direct influence on premium drivers as compared to other population segments.
While formulating the design of a capitation program, multiple clinical and operational decisions must be made, including defining services covered under the capitation payment, development of incentive models beyond the base capitation payments, and finalizing administrative and clinical delegation decisions. The program definition that results from these decisions will also have definitive implications on core MA operations, including STAR HEDIS, STAR customer service, encounter/diagnosis data capture, network contracting (or sub-contracting) for provider systems with limited specialties, claims processing, and provider directory considerations, among others.
Baker Tilly can assist health plans with the operational implications downstream from capitation arrangements, including:
While capitated agreements are an attractive contracting methodology for MA, not all organizations are prepared to enter capitated arrangements. If provider readiness assessments determine that more traditional FFS agreements with VBC incentives are more appropriate, or the plan is not yet ready to tackle capitation, there are other value-based options to consider in order to support MA success.
To enhance the effectiveness of MA programs, health plans must optimize their contractual relationships with providers and enable payment models that incentivize provider behaviors to increase quality of care while decreasing costs. Baker Tilly can assist with planning, setting up and executing other VBC contracting arrangements, including:
Core operational focus on the MA risk adjustment program is of course also required as a component of MA plan management.
Baker Tilly understands the key insights required to drive proactive care plans appropriate for each MA member and how to develop proactive analytics tools to identify and act upon potentially missing diagnosis information. Within the MA space, these insights are key to driving provider and member outreach to schedule in-home or in-office visits to document all pertinent diagnoses and manage members’ health. Baker Tilly knows the importance of the risk-adjusted MA programs and can support your organization’s MA program risk optimization strategy, including:
Whether your organization pursues capitated agreements or hybrid VBC/FFS agreements with providers, data management is key to controlling risks and costs while also managing MA reimbursement. Baker Tilly understands the importance of having a comprehensive and sophisticated data management strategy, and can assist health plans with establishing an effective VBC data management platform, including:
Every decision made to define your organization’s approach to MA has an operational impact on the organization and its stakeholders, processes and systems. In order to fully integrate all of the different components of an effective MA program, a handful of targeted projects, or a larger transformation, may be required. Health plans need to consider the impact on employees, members, providers and all stakeholders; implications for processes both inside and outside of the organization; as well as an array of technology implications.
Baker Tilly has experience working with both large and small organizations to establish roles and responsibilities to help companies “bring it all together” from end-to-end. We believe in driving transformations through use of a holistic business architecture with a focus on solution components, whether they are people, process or technology based, and by offering expert advice on whether building, buying new or adapting existing solutions is most effective to meet business needs. We use solution architecture to create delivery plans that leave the organization with an integrated set of components to achieve their business objectives. Whether it’s individual projects to deliver partial capability sets, or a complete organizational transformation to drive program evolution, Baker Tilly has the experience and expertise to serve as a partner on the path to MA excellence.