Our Singular Focus: Financial Optimization for Your ACO.
Due diligence backed by actuarial best practices. Confidence for your board, investors and provider stakeholders.
Financial Optimization For ACOs
Validate Health provides ongoing actuarial and financial optimization services exclusively for ACOs.
By fully recreating CMS’s methodology using computer models for MSSP, Pathways, REACH / Direct Contracting (GPDC), Medicare Advantage, and other accountable care programs, Validate Health enables both strategic and iterative operational decisions throughout the year.
These decisions include regulatory program and track selection, participant selection and network design, performance forecasting, allocation of shared savings contribution by participant provider, HCC risk adjustment optimization, multi-year risk hedging, beneficiary attribution and churn management, and growing your geographic market share.
SUPPORT & DUE DILIGENCE
Validate Health simulates the impact of multiple decision scenarios for your ACO, provides due diligence and supporting documentation for the decisions made, and identifies methods to de-risk the expected outcomes.
BEST PRACTICES & CUSTOMIZATION
You get access to the same program evaluation and regulatory financial impact analysis capabilities that Validate Health has been providing for NAACOS and CMS, but customized to your ACO.
WHAT ARE YOUR ACO’s BUSINESS GOALS?
Validate Health developed the PRISM (Programs, Risk, Size, Margins, Funding) framework to help your ACO realize its business goals. Whether your goals are around growing market size, increasing margins, optimizing program portfolio, managing risk, or securing funding, PRISM identifies the analysis needed to enable your most impactful financial decisions.
GROW MARKET SIZE
For ACOs wanting to grow their geographic footprint, add participant providers, or optimize beneficiary attribution.
For ACOs wanting to maximize their shared savings given their current program selections, provider network and competitive advantage.
Understanding Past Results is Not Enough
Validate Health forecasts shared savings and impacts of decisions months in advance.
…So you can be proactive and make adjustments to future improve performance throughout the year.
HOW WE ENABLE YOUR MOST IMPORTANT DECISIONS
Validate Health provides ongoing actuarial and financial optimization services customized for ACOs. It reconstructs CMS’s methodology using computer models for MSSP, Pathways, REACH / Direct Contracting (GPDC), Medicare Advantage, and other accountable care programs. Depending on the decision needed, Validate simulates the impact of multiple scenarios at different organizational levels, time horizons, and decision frequencies.
Decisions by Scope: Program, Network, Beneficiary Cohort
Simulations of expected benchmark, shared savings, cash flows and risk exposure are performed for different decision scopes…
PROGRAM Different accountable care models (MSSP, REACH, GPDC, MA, etc.) and program / track selection options (such as BASIC vs ENHANCED track, prospective vs retrospective assignment methodology, etc.). Financial components includes gross and net shared savings, fee-for-service revenues, capitation payments, and negotiated discounts.
NETWORK Adding and removing provider participants at TIN or NPI levels, preferred provider arrangements for post acute care and specialists, and referral pattern alternatives across your contracts.
BENEFICIARY Different beneficiary attribution and churn strategies based on demographic, geographic or diagnosis-based patient cohorts. Includes impact of prospective vs retrospective assignment methodology and considerations for enrollment and voluntary alignment campaigns.
By Decision Time Horizon: Reconciliation, Forecast, Pro forma, Monitoring
Generation of metrics on financials, risk exposure, HCC risk scoring gaps, and modifiable utilization enables key decisions across different time horizons…
RECONCILIATION of final shared savings settlement for past years calculates the financial contribution by provider (at TIN, NPI or custom network levels) in order to identify savings distribution. Analysis of performance trend by provider spanning multiple years provides due diligence for participant selection decisions.
FORECAST of shared savings in advance of actual settlement is used to enable investment in operations, accommodate loss reserving and ensure there are sufficient cash flows. Knowing expected performance by participant provider gives the advantage of more time for participant additions and removals.
PRO FORMA estimates of benchmark, shared savings and other financial metrics are a multi-year future outlook intended for procuring funding from investors and demonstrating due diligence for board meetings.
MONITORING is intended to provide an ongoing feedback loop for measuring progress towards financial targets, either in aggregate or by provider.
By Decision Frequency: Multi-Year, Annual, Quarterly
Planning for decisions to accommodate regulatory deadlines, internal meetings and milestones, and expected project investments happens in different frequencies…
MULTI YEAR The longest term analysis involves multi-year planning, such as market entry and long-term program portfolio strategy.
- Adjust contract portfolio across: MSSP/Pathways, REACH / GPDC, Medicare Advantage
- Select track and other program options: MSR/MLR, savings rate, prospective vs retrospective assignment methodology, etc.
- Assess expansion into new geographies
- Establish risk hedging using reinsurance and offsetting FFS revenues
ANNUAL The medium term decisions are scheduled annually based on the regulatory calendar for each program.
- Estimate year-to-date financial forecasts until payout, in order to invest expected savings or establish loss reserving.
- Distribute savings to providers based on actuarially validated contribution to shared savings.
- Update network design, including participant selection and preferred providers.
- Provide root cause analysis of what might be driving financial performance.
QUARTERLY The shortest term decisions are geared towards improving performance within a year once all the longer term decisions have been made.
- Prioritize work on HCC risk adjustment based on ROI
- Apply beneficiary attribution management and churn reduction plan.
- Focus on biggest drivers of modifiable costs based on incremental shared savings differences for top performing providers.
- Intervene with providers, based on savings contribution, leakage, patient attribution, utilization outliers.