As healthcare reimbursement models shift towards value-based care (VBC), chief financial officers (CFOs) are increasingly at the forefront of managing the financial implications of these changes. Not only are CFOs instrumental in assessing and mitigating the risks associated with new contracting models, but they are also responsible for ensuring that their organizations can thrive in an environment where reimbursement is tied to quality and outcomes rather than the quantity of services provided.
Our CFO clients are asking pointed questions like how can they leverage additional insights and advanced analytics to make informed decisions that drive success under these new models? How can advanced analytics and data insights help CFOs monitor and optimize their organization’s performance under alternative payment arrangements? And ultimately, how can these insights empower CFOs to lead their organizations through the transition to value-based care with confidence and precision?
The value beyond the contract: financial insights
The shift from fee-for-service (FFS) to value-based care (VBC) models, such as pay-for-performance (P4P) and risk-sharing arrangements, is designed to incentivize healthcare providers to deliver high-quality, cost-effective care. However, these contracts come with inherent financial risks; in addition to being able to earn additional reimbursement based on performance (i.e., upside) many VBC arrangements come with down-side risk for failure to meet expectations. For healthcare CFOs, the success of VBC is not solely through negotiating favorable terms but in understanding the types of patients their organization serves, the right interventions to drive down costs, and the organization’s appetite for risk. This knowledge, combined with robust data analytics, enables CFOs to make informed decisions that optimize financial performance over time.
Of course, negotiating favorable contract terms is a vital aspect of risk mitigation. CFOs should aim to secure appropriate risk-sharing mechanisms, payment structures, and performance incentives that align with the organization’s capabilities and goals. This involves collaborating with payers to design agreements that balance risk and reward. Key considerations for contract negotiations can include:
What types of patients are you focused on?
- Total cost of care (i.e. all members), LOB based subpopulations, condition based subpopulations (e.g. Diabetes, MSK, etc.)
- Each comes with their own pros and cons
How are you planning on driving down costs?
- What interventions are you planning?
- What are the potential savings from these interventions?
- What does it cost to generate these savings?
What is your risk appetite?
- Are you willing to take downside risk? How much?
- With more downside risk comes more upside potential, finding a balance is key
By negotiating terms that minimize financial risks, CFOs can create a more stable and predictable revenue stream, which is essential for driving sustainable growth and excellence in patient care, even during times of uncertainty.
The role of data and analytics in monitoring and managing value-based care contracts
The role of data analytics in continuously monitoring and enhancing financial performance cannot be overstated. By leveraging advanced analytics, CFOs can gain timely insights into revenue trends, cost drivers, and performance metrics. This data-driven approach enables proactive adjustments to payment strategies, ensuring that financial goals are consistently met. Regularly reviewing and refining payment structures based on performance data helps CFOs optimize revenue growth and maintain a competitive edge in the VBC environment.
Historical data analysis plays a pivotal role in uncovering trends and patterns that can provide invaluable insights for future contract agreements. By examining past performance, CFOs can identify successful strategies and potential pitfalls, enabling them to negotiate more favorable terms and conditions. This retrospective analysis helps in understanding the impact of various contractual elements on revenue and costs, thereby informing strategic planning and risk management efforts.
Forecasting is another powerful tool for CFOs in the realm of value-based care. These models allow for the evaluation of different contract scenarios, providing a glimpse into the financial implications of various choices. By simulating potential outcomes, CFOs can make proactive decisions that mitigate risks and maximize revenue growth. Predictive analytics empower CFOs to anticipate challenges and opportunities, ensuring that their organizations are well-prepared for the future.
With the right analytics in place, CFOs can:
- Optimize performance: CFOs can use analytics to proactively identify and manage key factors that significantly boost network performance and contract revenue. By tracking and analyzing metrics like patient outcomes, provider efficiency, and cost variations, they can pinpoint areas for improvement and make data-driven decisions to enhance overall performance.
- Increase risk management and automation: Analytics can help CFOs effectively administer risk-based contracts such as the Medicare Shared Savings Program (MSSP) and REACH agreements. By automating tracking and modeling processes, analytics can reduce errors associated with manual methods, ensuring accurate and efficient contract management. This also enables CFOs to better monitor and mitigate financial risks.
- Improve ROI: To improve the return on investment (ROI) from value-based contracts, CFOs can leverage analytics to gain a deeper understanding of their impact on overall revenue. By analyzing the relationship between contract terms, care quality, and financial outcomes, CFOs can identify which contracts are most beneficial and adjust strategies to maximize revenue and sustainability.
For example, a healthcare organization may use predictive models to forecast an increase in hospital admissions over the next five years due to an expected aging population. With this knowledge, the CFO can negotiate more favorable contract terms with payers that account for this demographic shift, ensuring financial protection while maintaining care quality.
How MedInsight can help
The Milliman MedInsight VBC Contracts application is a game-changer for healthcare organizations aiming to optimize contract management and financial outcomes. As a cornerstone of the Milliman MedInsight VBC Platform, this application provides unparalleled insights into current contract dynamics and their underlying reasons. By leveraging Milliman’s renowned actuarial methodologies, CFOs can gain a clear and comprehensive snapshot of their financial performance across various value-based care (VBC) arrangements.
Learn how it can transform your contract management:
- Standardization: Handle unique payer data feeds to ensure consistent reporting across all agreements. Our comprehensive repository includes both national and regional payers, enabling projections and settlement calculations tailored to specific needs.
- Detailed analysis: Examine performance metrics at the level specified by the user (such as NPI, TIN, Clinic), helping to pinpoint performance drivers and effectively distribute funds among groups.
- Timeliness: Benefit from early insights into value-based payments, sometimes as soon as a few months into the performance year, reducing uncertainties. MedInsight can process data as soon as it is delivered, resulting in quick turnarounds for projections and VBC reporting.
- Auditing capability: Support ongoing and annual settlements that align with payer outcomes, providing the necessary tools to address discrepancies in data when presenting evidence to payers.
The right data tools lead to success
Healthcare CFOs must go beyond the contract terms of value-based contracts to leverage the true potential of data analytics and population insights. Understanding the population they serve, combined with the right data tools, enables organizations to anticipate risks, design effective care interventions, and drive long-term financial success. Overall, the ability to transform data into actionable insights is a competitive advantage that can ensure sustainable growth and improved patient outcomes in the long run.
How can I learn more about MedInsight VBC Contracts?
Schedule a Call: Connect with one of our VBC Contracts experts.
Our Website: Read more about our VBC Contracts application or explore a use case.