Medical professional reviews on operations

Core Operational Capabilities

Value-based care (VBC) programs require new operational capabilities, consisting of both new systems and processes built on top of foundational fee-for-service systems, processes and data sets, as well as extensions of existing systems.

Core Operational Capabilities

Program population management

Value-based 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 value-based programs.

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

Value-based 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.


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 care coordination oversight, 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.

Program monitoring and optimization

Post launch, value-based programs require continuous monitoring and optimization efforts to ensure strategic objectives are met and performance does not atrophy over time.

How we can help

  • Definition of program monitoring approaches – we support the definition of techniques to monitor value-based program performance over time to support governance decisions around program modification, expansion, or retirement.
  • Monitoring capability build – we can develop analytical models to enable the ongoing regular execution of monitoring analysis to support regular insight into program performance.