ACO Business Goals
Validate Health developed the PRISM (Programs, Risk, Investment, Size, Margins) 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.
Validate Health gives you the analytical and planning capabilities payers use
…With a financial optimization service that’s purpose-built for your ACO’s business goals.
Enabling These Goals
Validate Health provides services focused on enabling the decisions that drive these business goals.
GROW MARKET SIZE
For ACOs wanting to grow their geographic footprint, add participant providers, or optimize beneficiary attribution.
Recruit Providers Recruit new participant providers in your target geography by determining…
- Attributable beneficiaries by provider
- Provider competitor ranking based on procedures performed
- Referral patterns and leakage / keepage assessment
- Recent migration of beneficiaries between providers
- Patient loyalty index and “joiner – stayer – leaver” breakout as proxy for quality and likelihood to retain beneficiaries
Retain Providers Defend and retain your best providers by knowing…
- Their exact financial contribution to shared savings and compensating them appropriately
- Who else might be competing for them in their geography
Attribute Beneficiaries Increase beneficiary attribution by understanding…
- Prioritized target beneficiaries for voluntary alignment and Medicare Advantage (MA) enrollment campaigns
- Geographies with highest opportunity based on local competition across programs and their respective attribution rule methodology
- Existing and prospective provider participants for reaching target beneficiaries
Reduce Churn Decrease beneficiary de-attribution (churn) by identifying…
- Root cause for losing assignment and to which competitor
- Beneficiaries at risk of de-attribution and possible interventions
GROW MARKET SIZE
For ACOs wanting to grow their geographic footprint, add participant providers, or optimize beneficiary attribution.
Recruit Providers Recruit new participant providers in your target geography by determining…
- Attributable beneficiaries by provider
- Provider competitor ranking based on procedures performed
- Referral patterns and leakage / keepage assessment
- Recent migration of beneficiaries between providers
- Patient loyalty index and “joiner – stayer – leaver” breakout as proxy for quality and likelihood to retain beneficiaries
Retain Providers Defend and retain your best providers by knowing…
- Their exact financial contribution to shared savings and compensating them appropriately
- Who else might be competing for them in their geography
Attribute Beneficiaries Increase beneficiary attribution by understanding…
- Prioritized target beneficiaries for voluntary alignment and Medicare Advantage (MA) enrollment campaigns
- Geographies with highest opportunity based on local competition across programs and their respective attribution rule methodology
- Existing and prospective provider participants for reaching target beneficiaries
Reduce Churn Decrease beneficiary de-attribution (churn) by identifying…
- Root cause for losing assignment and to which competitor
- Beneficiaries at risk of de-attribution and possible interventions
INCREASE MARGINS
For ACOs wanting to maximize their shared savings given their current program selections, provider network and competitive advantage.
Negotiate Payments Negotiate better Advanced Payment arrangements and price reductions with providers by understanding…
- Simulated expected impact to income based on historical claims
- Referral patterns and strength of patient relationships
- Local geographic competition across programs and available capacity
- Market intelligence on available specialists, their practice patterns, efficiency, capacity and outcomes
- Calculation of expected improvements in shared savings based on referred beneficiary cohorts
Prioritize Attribution Increase profitability of attributed beneficiaries by understanding…
- Expected shared savings profitability per beneficiary cohort
- Highest ROI methods for attributing targeted cohorts
Risk Adjustment Close HCC risk coding gaps by…
- Quantifying the ROI and payback period of closing the gaps in order to allocate sufficient resources
- Focusing only on a subset of prioritized beneficiaries, rather than assuming all gaps need to be closed
Modify Utilization Identify avoidable expenses and modifiable utilization by…
- Benchmarking against providers with best long term financial outcomes
Identifying beneficiary cohorts with highest ROI of available interventions
INCREASE MARGINS
For ACOs wanting to maximize their shared savings given their current program selections, provider network and competitive advantage.
Negotiate Payments Negotiate better Advanced Payment arrangements and price reductions with providers by understanding…
- Simulated expected impact to income based on historical claims
- Referral patterns and strength of patient relationships
- Local geographic competition across programs and available capacity
- Market intelligence on available specialists, their practice patterns, efficiency, capacity and outcomes
- Calculation of expected improvements in shared savings based on referred beneficiary cohorts
Prioritize Attribution Increase profitability of attributed beneficiaries by understanding…
- Expected shared savings profitability per beneficiary cohort
- Highest ROI methods for attributing targeted cohorts
Risk Adjustment Close HCC risk coding gaps by…
- Quantifying the ROI and payback period of closing the gaps in order to allocate sufficient resources
- Focusing only on a subset of prioritized beneficiaries, rather than assuming all gaps need to be closed
Modify Utilization Identify avoidable expenses and modifiable utilization by…
- Benchmarking against providers with best long term financial outcomes
Identifying beneficiary cohorts with highest ROI of available interventions
OPTIMIZE PROGRAM PORTFOLIO
For ACOs wanting to identify the ideal mix of provider participants across all their programs and contract types.
Analyze Portfolio An investment portfolio-like comparison across all of your contracts including legacy MSSP and BASIC/ENHANCED Pathways ACO tracks, Realizing Equity, Access, and Community Health (REACH) / Direct Contracting (GPDC), and Medicare Advantage (MA) by quantifying…
- Pro forma benchmark opportunity by beneficiary cohort
- Downside risk exposure
- Capital requirements
- Interactions among overlapping programs such as primary care models (PCF/CPC+), kidney care models (KCF/KCCC), and bundled payments (BPCI)
Track Selection Make track and option selections within each program, including MSSP/Pathways BASIC Level A-E vs ENHANCED tracks, REACH / GPDC Global vs Professional model, and ACO Enabler* contracts by simulating…
- Expected shared savings for each option across multiple performance years and agreement periods
- Performance under multiple combinations of provider participants or beneficiary cohorts
- Possible outcomes under prospective vs retrospective assignment methodology
- Estimated payments under Primary Care Capitation (PCC) or Total Care Capitation (TCC) vs Fee-for-Service (FFS)
- Profitability impact from competing ACO, DCE, MA plan and other VBC programs in your geography
Participant Selection Identify the best program for each provider by examining…
- Historical track record of shared savings contribution
- Risk exposure with their attributed patient population
Threshold Strategy Attain optimal MSR/MLR payout, reduced risk exposure, and other favorable terms by identifying…
- Combinations of tracks and participant selections which surpass the thresholds to qualify as a “Low Revenue ACO”, “Inexperienced ACO”, or “New Entrant ACO”
- Combinations of methods for attaining Qualifying APM Participant (QP) status for 5% incentive payments and exclusion from MIPS
OPTIMIZE PROGRAM PORTFOLIO
For ACOs wanting to identify the ideal mix of provider participants across all their programs and contract types.
Analyze Portfolio: An investment portfolio-like comparison across all of your contracts including legacy MSSP and BASIC/ENHANCED Pathways ACO tracks, REACH / Direct Contracting (GPDC), and Medicare Advantage (MA) by quantifying…
- Pro forma benchmark opportunity by beneficiary cohort
- Downside risk exposure
- Capital requirements
- Interactions among overlapping programs such as primary care models (PCF/CPC+), kidney care models (KCF/KCCC), and bundled payments (BPCI)
Track Selection Make track and option selections within each program, including MSSP/Pathways BASIC Level A-E vs ENHANCED tracks, REACH/GPDC Global vs Professional model, and ACO Enabler* contracts by simulating…
- Expected shared savings for each option across multiple performance years and agreement periods
- Performance under multiple combinations of provider participants or beneficiary cohorts
- Possible outcomes under prospective vs retrospective assignment methodology
- Estimated payments under Primary Care Capitation (PCC) or Total Care Capitation (TCC) vs Fee-for-Service (FFS)
- Profitability impact from competing ACO, DCE, MA plan and other VBC programs in your geography
Participant Selection Identify the best program for each provider by examining…
- Historical track record of shared savings contribution
- Risk exposure with their attributed patient population
Threshold Strategy Attain optimal MSR/MLR payout, reduced risk exposure, and other favorable terms by identifying…
- Combinations of tracks and participant selections which surpass the thresholds to qualify as a “Low Revenue ACO”, “Inexperienced ACO”, or “New Entrant ACO”
- Combinations of methods for attaining Qualifying APM Participant (QP) status for 5% incentive payments and exclusion from MIPS
MANAGE RISK
For ACOs needing to hedge downside risk and find custom alternatives to CMS payment models.
Actuarial Support Provide your ACO with access to actuarial services that support key financial decisions throughout the year, such as…
- Mitigating COVID-related impacts due to care avoidance, beneficiary de-attribution, risk adjustment challenges and application of episode exclusions
- Evaluating higher risk and higher reward track options for upcoming performance years
- Ensuring your proposed payment discounts are actuarially sound
Customize ACO Track Design your own customized ACO track that results in a program tailored to the needs of your organization by…
- Layering risk hedging instruments and financial contracts on top of the CMS-provided payout calculation methodology
- Identifying methods for entering programs with higher upside potential (such as GPDC/REACH over Pathways or Pathways ENHANCED over BASIC
- Level E), while staying within your risk tolerance limits
- Matching your participants to specific ACO/DCE contracts based on their performance and readiness for risk;
- Comparing the outcomes of participation across available contracts with ACO Enablers*
Procure Reinsurance Understand your downside risk exposure and select reinsurance options to accommodate your risk tolerance by…
- Quantifying risk under different program, track and network scenarios
- Taking into account offsetting cash flows from FFS revenues, capitation and provisional settlement
- Evaluating the cost effectiveness of reinsurance quotes, including comparisons to CMS-provided coverage where applicable
MANAGE RISK
For ACOs needing to hedge downside risk and find custom alternatives to CMS payment models.
Actuarial Support Provide your ACO with access to actuarial services that support key financial decisions throughout the year, such as…
- Mitigating COVID-related impacts due to care avoidance, beneficiary de-attribution, risk adjustment challenges and application of episode exclusions
- Evaluating higher risk and higher reward track options for upcoming performance years
- Ensuring your proposed payment discounts are actuarially sound
Customize ACO Track Design your own customized ACO track that results in a program tailored to the needs of your organization by…
- Layering risk hedging instruments and financial contracts on top of the CMS-provided payout calculation methodology
- Identifying methods for entering programs with higher upside potential (such as GPDC/REACH over Pathways or Pathways ENHANCED over BASIC Level E), while staying within your risk tolerance limits
- Matching your participants to specific ACO/DCE contracts based on their performance and readiness for risk;
- Comparing the outcomes of participation across available contracts with ACO Enablers*
Procure Reinsurance Understand your downside risk exposure and select reinsurance options to accommodate your risk tolerance by…
- Quantifying risk under different program, track and network scenarios
- Taking into account offsetting cash flows from FFS revenues, capitation and provisional settlement
- Evaluating the cost effectiveness of reinsurance quotes, including comparisons to CMS-provided coverage where applicable
SECURE INVESTMENT / FUNDING
For ACOs needing due diligence and actuarial projections to support investment and ensure sufficient cash flows.
Due Diligence Enable investment from private equity, venture capital or participant providers by…
- Calculating pro forma estimates of benchmark, shared savings and cash flows under different programs and decision scenarios
- Presenting the results to stakeholders through board meetings, investor decks and financing applications
Manage Cash Flows Ensure there are sufficient cash flows to sustain operations and make investments in future growth by…
- Identifying expected timing of payouts for shared savings and Advanced Payments based on CMS schedules
- Incorporating revenues from fee-for-service payments, capitation and provisional settlement
- Financing expected cash shortfalls using income projections, loss reserving and a repayment mechanism
Capital Reserving Enable capital reserving in preparation for expected losses, investments in future operational improvements, or savings distributions to stakeholders by…
- Providing a range of conservative to aggressive shared savings forecasts across multiple years
- Calculating the expected FFS revenue projections and incorporating expected loss limits
- Taking into account the parameters of the repayment mechanism
- Complying with the ASC 606 accounting standard
SECURE FUNDING
For ACOs needing due diligence and actuarial projections to support investment and ensure sufficient cash flows.
Due Diligence Enable investment from private equity, venture capital or participant providers by…
- Calculating pro forma estimates of benchmark, shared savings and cash flows under different programs and decision scenarios
- Presenting the results to stakeholders through board meetings, investor decks and financing applications
Manage Cash Flows Ensure there are sufficient cash flows to sustain operations and make investments in future growth by…
- Identifying expected timing of payouts for shared savings and Advanced Payments based on CMS schedules
- Incorporating revenues from fee-for-service payments, capitation and provisional settlement
- Financing expected cash shortfalls using income projections, loss reserving and a repayment mechanism
Capital Reserving Enable capital reserving in preparation for expected losses, investments in future operational improvements, or savings distributions to stakeholders by…
- Providing a range of conservative to aggressive shared savings forecasts across multiple years
- Calculating the expected FFS revenue projections and incorporating expected loss limits
- Taking into account the parameters of the repayment mechanism
- Complying with the ASC 606 accounting standard