Enablement

VBC programs typically require a combination of the following capabilities: Program Population Management, Cost Efficiency Measurement, Quality Outcome Measurement, Information Sharing, Financial Settlement, and Delegation. Our team has unique offerings for each capability, along with capability-agnostic offerings such as data management, business solution architecture, and custom/vended solution delivery and implementation.

Program population management

VBC programs target a specific set of members, often based on complex algorithms and large data sets that require the application of analytical processing techniques embedded in production class applications. For plans with multiple programs, multiple algorithms to identify populations are almost certainly required. Many health plans face challenges deploying the collections of production class algorithms required to align populations with VBC program.

How we can help:

• Population identification approach definition – we provide business rule input based on program objectives, perform prototype development and execute back testing to support definition of final algorithm business rules. We support definition of different population subsets required by various aspects of a program definition.
• Solution approach definition – we translate algorithm requirements and enterprise technology standards into configurable and customizable solutions that meet business, operational and technical needs, with the ability to support the different VBC models that have been, or are planned to be, deployed to the market place.
• Solution development – we create and support analytical models to determine program attribution, manage all population sets required for program administration, and define and build integrations into all system components that require populations.

Cost efficiency measurement

VBC program alternative payment models often include incentive payments based in part on measurement of cost efficiency. Each different program a health plan runs requires a different cost efficiency model. Model types may include measures of total cost of care against predicted targets, measurement against defined trends, episodic bundle costs or other utilization based measures. Like population management, production class execution of cost efficiency models is required for successful program administration.

How we can help:

• Cost efficiency measurement approach definition – we define business rule input based on program objectives, prototype development and support back testing to enable definition of final algorithm business rules. 
• Solution approach definition – we translate algorithm requirements and enterprise technology standards into configurable and customizable solutions that meet business, operational and technical needs, with the ability to support the different VBC models that have been or are planned to be deployed to the market place.
• Solution development – we create and support analytical models to measure the cost performance for contracted providers, and build integrations into downstream reporting systems to support provider performance insight.

Quality outcome measurement

VBC programs must include quality measurement targets in addition to cost efficiency measurement.  Both certified measure sets and other accepted quality standards are typically deployed to drive desired outcomes and provide input into financial incentives.  Quality measurement solutions typically require specific extensions to support integration to value based care populations and program specific measurement requirements.

How we can help:

• Program measure definitions and measurement approaches – we can support selection of the right measure sets and measures for a given program, develop prototype quality calculations, collaborate on the definition of goals and targets, and finalize program business rules for quality measurement.
• Quality measurement calculation implementation – we can custom build in-house or implement vendor-based quality measurement solutions, integrate program populations into measurement tools to support generation of contract level metrics, and build capabilities to calculate aggregate quality performance against contract targets.
• Support quality audits – we coordinate with certified auditors that provide attestation that quality measures generated specific to VBC program populations comply with quality standards.

Information sharing

Success in VBC programs comes down to the effective sharing of complex data and information between health plans and providers.  Programs typically require bidirectional sharing of clinical and administrative data and reports that cover cost, utilization, quality, financial performance and intervention opportunity domains. 

How we help:

• Design of actionable reports – we support the design of reports that highlight performance trends and improvement opportunities that allow end users to move from summary to drill-downs and build plans for change based on data driven insights.
• Reporting and analytics build – we can support custom and vendor solutions to build actionable and transparent reporting that support progress towards improving quality outcomes, cost efficiencies, provider referral patterns, and more.  We can support integration of public and proprietary insight models and ensure that solutions include an appropriate focus on data access and privacy controls.
• Data sharing implementation – we design and build solutions to exchange data securely between health plans and providers.
• Engagement of operations and providers – we define and establish operational processes to leverage data and reporting insights to support medical cost intervention opportunities in collaboration with contracted providers.

Financial settlement

VBC programs require the capability to value incentives, administer provider payments, integrate incentive results into premium pricing processes, and support self-insured account billing and reporting outside of claims processes.

How we can help:

• Deployment of non-claims transaction processing systems – we can support deployment of custom or vended systems to support non-claims-based transaction processing, integration into payment, billing, ledger and client reporting systems, as well as control design and build.
• Reporting and analytics build – we design and build reporting solutions to provide stakeholder transparency and to support detailed attestation of payment and charge accuracy.

Delegation

VBC programs create the opportunity to shift complex care management and disease management responsibilities directly to providers, moving activities closer to the actual care delivery relationship. This results in the provider having greater oversight of care coordination, as well as the patient’s increased comfort with interacting with their provider.  Capitation programs may also delegate network management, claims processing, customer service, and other health plan functions that further align their responsibilities with the financial risk that they take.  Delegation arrangements and delegation oversight require significant system and process support.  

How we help:

• Delegation program and related capability definition – we can help define the detailed process implications of delegation decisions and required supporting operational capabilities.
• Solution delivery – we can support enhancements to existing systems or deployment of new systems to support changes required by delegation agreements, including areas like care management program suppression for members engaged with a delegated provider, account billing process changes, and secure care management plan and activities sharing, oversight and audit.

VBC programs require deployment of multiple complex systems, utilization of legacy capabilities in new ways, and process and data flows that connect everything end-to-end.

How we can help:

• Overall solution architecture definition – we define the discrete solution components required to solve business problems, illustrating integration across solution components, and alignment of the enabling technology to each component.
• Solution decomposition – we decompose solutions into subcomponents, features, and versions to enable definition of work plans at both the component and “big picture” level.  We strive to align all key project activities to defined solution components to allow all team members to speak the same language and execute work more efficiently as a result.
• Marketplace solution identification – we support build or buy decision making by defining critical and unique functional business and technical requirements, conducting vendor research, executing RFI and RFP activities, including helping to drive scripted demos, and assisting in the selection of vendor products.

Health plans must ensure operational units are trained and prepared for new VBC program technology and processes, and that up front configurations and connectivity are established with participating providers prior to program launch.

How we can help:

• Business process readiness – we identify likely change impacts in operating models, roles and responsibilities, and business processes as current state operations are assessed against future state needs.
• Pre-launch operational readiness plans – we collaborate with our clients to define operational readiness plans and checklists that can be used on an ongoing basis to prepare operational teams for provider onboarding to VBC programs.
• Post-launch operational readiness plans – we collaborate with our clients to define approaches to ongoing business process cadences, quality control procedures, issue resolution paths, ad hoc inquiry support, and other factors to ensure teams are ready for ongoing operations.

VBC programs often involve collaborative design between multiple enterprise functions, including network management, care management and pharmacy.

How we help:

• Pharmacy business unit integration – we help to integrate incentive and quality aspects of program design across both medical and pharmacy domains to drive approaches that cover larger aspects of the overall cost of care.  
• Care management team engagement – we collaborate with care management teams in multiple ways, dependent on program design. At a minimum, the expertise of care management teams should be a key contributor to program design - focused on data and insight sharing requirements and suggestions around provider care management approaches. As programs evolve to include delegation aspects or more collaborative operating entities, care management teams need to be involved in activities such as delegation oversight and joint operating committees.

Effective adoption and scale of VBC programs have a definitive impact on business teams.  Health plans must integrate organizational change activities into project plans to ensure change is realized in impacted areas of the organization. 

How we help:

• Governance definition – we work with our clients to create governance models for program delivery and ongoing operational solution maintenance to enable effective communications, decision making and delivery effectiveness.
• Communication plan development and execution – we develop and distribute communications across a variety of media and audiences, such as status reports and newsletters to executive sponsors and impacted operations teams.
• Business process design and optimization – we assist in the creation of process design at multiple levels of detail, process standardization, and the translation of business processes to custom technology and vendor solutions.
• Value realization management – we define desired program business outcomes, targets and processes to measure performance against program goals.
• Organizational design – we support definition of required roles and responsibilities, RACIs, interaction models, and the organizational structures that support them.  We also support staffing model development and workforce planning.
• Training and support – we define training plans, develop training materials, coordinate the delivery of training across a variety of media and techniques, and assist in the definition and delivery of a long-term post-release support plan. 
• Change impact assessments and management – we support change readiness assessments, change risk analysis, the build or update of job and role definitions and change management plans