April 11 2018 | 0 Comments | 553 reads Average Rating: 3

Risky Business: Three Key Levers to Successfully Manage Your Risk

by Rose Higgins in Population Health

The pace toward value-based care delivery and contracting is quickening and gaining momentum at an increasing rate. Consider the following: The number of Medicare Shared Savings Program Accountable Care Organizations (ACOs) has grown from just 100 in 2012 to 480 in 2017.1 And, enrollment in Medicare Advantage has grown from 24.1% of beneficiaries in 2010 to 31.7% in 2017.2 The challenge for your healthcare organization? Ensuring you stand on solid ground when looking to assume and manage the risk across your organization.

To help you effectively do so, consider the following key levers:

1. Identify where gaps exist:

Start by identifying where gaps exist across your at-risk population(s). More specifically, knowing where documentation and coding gaps related to risk adjustment is instrumental to ensuring you have an accurate view of your risk profile. When coding and documentation gaps exist, providers are flying blind, as they do not truly know how sick their patients are, how to best treat patients and where to allocate resources for proactive/chronic care programs. Accurate documentation enables care givers to provide the right quality care to patients as they have a real understanding of their needs. It will be important to perform a year-over-year comparison to identify where gaps exist and then implement programs to support closing those gaps. A benchmark comparison can help you assess progress by providing a quick snapshot of how your performance compares to established benchmarks, making it possible to target the most critical areas. In addition to coding and documentation gaps, providers strive toward improved quality measure compliance, including Healthcare Effectiveness Data and Information Set, Pay for Performance and Centers for Medicare and Medicaid Services Star Ratings. Knowing your compliance with these measures at the group and individual provider levels can help you understand where your greatest opportunity to impact quality exists.

2. Implement short- and long-term population health programs:

Once you understand exactly where gaps and risk exist, it’s time to develop both the short- and long-term population health programs that can close the gaps and deliver improved health outcomes. In some cases, limited resources are needed to work with a particular cohort of patients on closing care gaps for better chronic condition management, other times you will want to design and develop longer term programs around seeing shifts in overall disease outcomes, such as congestive heart failure. In either case, you should focus on the programs that will result in the greatest return, both in terms of achieving clinical and financial improvements. Doing this requires you to start with the patients in the highest risk groups and then identify the most impactable patients or those who will have the highest financial impact if care gaps are closed. It’s also important to further stratify these patients by intervenability, or those most likely to comply with given interventions, as resources could be better utilized on patients who are more likely to follow care plans. In order to design and implement effective programs that engage patients, one must understand drivers of behavior and what motivates patients and then intervene accordingly as quickly as possible.

3. Optimize network performance:

Once an organization understands their risk and can effectively manage that risk, it can turn its attention to optimizing the performance of providers who are delivering care across their network. The next step involves assessing network performance as an indicator of overall performance. Through this process, you can understand where care is being delivered in and out of network; track and manage outlier providers to ensure optimal utilization; manage provider variation patterns and benchmark and manage provider performance across key metrics (cost, utilization, quality). These are very important parameters for those taking risk in terms of being able to manage the overall value-based equation.

Want to learn more about managing risk-based arrangements? View our on-demand webinar entitled “Key Levers to Manage The ‘Risk’ in Your Risk-based Contracts.” And, keep an eye our for our follow-up blog that will explore how Scripps Health Plan Services is ensuring successful value-based care outcomes.


1. CMS Welcomes New and Renewing Medicare Shared Savings Program ACOs. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/2017-MSSP-Fact-Sheet.pdf

2. Gretchen Jacobson, Anthony Damico, Tricia Neuman, and Marsha Gold. KFF. Medicare Advantage 2017 Spotlight: Enrollment Market Update. https://www.kff.org/medicare/issue-brief/medicare-advantage-2017-spotlight-enrollment-market-update/

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Rose Higgins
SVP & GM, Data and Analytics

With over 25 years in healthcare, Ms. Higgins brings considerable experience and expertise in working with both payers and providers in addressing the challenges of a changing healthcare landscape.

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