Where do you fall on the path to value-based care?

From building a care management team, to investing in IT and analytics, to economic modeling and managing key payer contracts—there are what might seem like endless activities on the road to population health management.

Why KLAS named Advisory Board a leader in value-based care consulting

But in our research on population health management and through experience with organizations across the country, we generally find that health systems fall on a spectrum—with the most successful organizations investing in the fundamentals of each category before moving on to the next.

Click below to learn about the most common population health profiles. Chances are, your system might relate to more than one.

The Skeptic
The Skeptic

You're enjoying the fee-for-service comforts, without plans to take on full risk

Your system is moving on pace with the surrounding market, which is not signaling a need to take on risk for patient populations—and the value of being the first mover doesn't seem to outweigh the dangers. For the foreseeable future, the priority is to maintain fee-for-service revenues by maximizing high-margin case volumes.

You might have:

  • Arrangements for hospital value-based purchasing and readmission penalties
  • Network alignment through clinical integration to increase referrals from non-employed physicians
  • Structure to promote top-of-license practice through advanced practitioners and expand patient access at lower costs
  • Strategies for market expansion through M&A

What to consider:

  • Investing in infrastructure that supports evidence-based practice to advance care quality, reduce clinical variation, and improve efficiency
  • Setting up basic IT network to connect hospitals and owned physician practices
  • Moving select acute care services out of the hospital to offset losses from Medicare's shift to site-neutral payments
  • Upgrading cost accounting system for accurate reporting on utilization, variation, and procedural expenditures
  • Establishing referral management processes across in-network facilities to improve referral capture and reduce network leakage across the system

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The Intender
The Intender

You've made limited investments, but aren't set on one path

Your market might still be dominated by fee-for-service payer arrangements, so radical care transformation hasn’t become an organizational priority just yet. But to not get left behind, your health system is investing in pilot programs for population health management and is laying down the groundwork for future value-based care initiatives.

You might have:

  • Self-funded employee health plan as first at-risk population
  • Medicare Shared Savings Program (MSSP) participation with the intent of receiving data and experimenting with pilot care management efforts
  • Network alignment through clinical integration and co-management to improve on basic pay-for-performance metrics
  • Care management resources to target readmissions and high-risk populations
  • Tools to measure performance of employee health costs
  • Basic medical home infrastructure with team-based care and proactive patient outreach

What to consider:

  • Taking on risk for employee health to pilot additional population management efforts
  • Restructuring physician compensation plan to tie portion to quality measures
  • Investing in analytics and reporting capabilities to measure physician performance, identify gaps in care, and track clinical and financial outcomes
  • Outlining an economic roadmap for corporate and local value-based care transitions, and identifying market factors to set pacing

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The Builder
The Builder

You're testing the waters, with ambitions to grow

Your leadership has dedicated itself to care transformation, with ambitious value-based care initiatives already underway. But the organization’s “goal state” is not yet defined and there are pockets of resources and capabilities that could be better aligned across the system to leverage scale and standardize practice.

You might have:

  • Shared savings by way of upside-only risk contracts
  • Technology for claims-based patient risk stratification, cost and utilization opportunity identification, and physician performance profiling
  • Care management solutions for high-risk and rising-risk beneficiaries in managed populations
  • Advanced medical home infrastructure including scaled chronic care management, integrated behavioral health, and patient engagement

What to consider:

  • Analyzing patient leakage and referral trends to understand gaps and tighten network management as a means to leverage the population health management investment for growth
  • Enhancing margin improvement efforts by reducing inpatient clinical variation through hospital efficiency improvement program (HEIP)
  • Aligning capabilities and care management activities for managing Medicare Advantage and MSSP subpopulations
  • Assessing telemedicine models, retail partnerships, and other patient access strategies across the continuum of care to address gaps as needed
  • Evaluating partnership strategies for hospitals, physicians, post-acute care, and urgent care to match geographic footprint of managed populations

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The Pioneer
The Advancer

You're in the advanced stages, gearing up for expansion

Stakeholders across your organization and partner network are fully engaged in value-based care delivery, equipped with the tools and resources they need to advance population health management. While expansion is on the agenda, there’s a balancing act of growing while continuing to successfully manage the populations already at risk.

You might have:

  • Multiple contracts to expand pool of lives under management with greater risk and reward, including full risk Medicaid or commercial and direct-to-employer contracts
  • Data-driven processes to improve patient handoffs, and longitudinal management of all risk segments
  • Analytics to monitor utilization, revenue, and cost to pinpoint patients most likely to drive per-member-per-month (PMPM) spending
  • Hardwired network referral management to steer patients to high-quality, low-cost providers and minimize network leakage

What to consider:

  • Evaluating effectiveness of population health management to date to make adjustments for expansion
  • Deploying a patient IT platform for consumer access to health information, communication with the care team, and scheduling appointments
  • Building a central population health services organization (PHSO) from which all providers can subscribe to shared analytics, quality monitoring, and contracting resources
  • Assessing opportunities associated with becoming a provider-sponsored health plan
  • Investing in clinical and financial analytic resources to measure and improve accountable payment results and margin enhancements stemming from reduced network leakage and clinical variability

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The Committed
The Committed

You've built a population health enterprise, so what's next?

As a regional leader in population health management, it’s time to optimize your network for long-term management of cost and quality trends. At this stage, you might find that expanding geographic and population scope is the right move in order to expand value for key populations, connect with new partners, and refine your consumer-oriented approach to care delivery.

You might have:

  • Majority of lives under full-risk contracts and/or a provider-sponsored health plan
  • Centralized and coordinated infrastructure for care model, financial management, and technology resources
  • Strong central governance structure with local physician leadership and engagement across care network
  • Renegotiated payer rates and contracts in light of increased scale

What to consider:

  • Expanding into adjacent markets with proven skill sets or affiliating with other like-minded clinically integrated networks in the region to lock in new populations
  • Aligning contracts to focus on core set of quality metrics
  • Exploring competitive pricing strategies such as targeted discounts, up-front cost estimates for certain consumers, and subscription-based payment models
  • Investing in an integrated EHR and data aggregation platform across all markets to have clinical and data utilization available to care teams in real time

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