Research hospital executes a challenging shift to more cost-effective clinical care

When one of the country’s flagship research hospitals sought to shift from high-cost academic work to more cost-effective and sustainable clinical care, the organization began a restructuring designed to improve clinical and financial outcomes in its population of approximately 645,000 at-risk patients, with a focus on the Medicare Shared Savings Program (MSSP) and Medicaid.

To address financial inefficiencies in these programs, the organization launched a program of significant cultural and clinical realignment with a heightened focus on population health, early intervention, and physician incentives. It was a collaborative effort that depended on maintaining good relationships with providers by helping to streamline the coding and documentation of chronic conditions.

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Challenge

To implement the population-health focused care management needed to improve its financial position and ensure high-quality care, the organization needed a scalable, sophisticated system of identifying care gaps and opportunities to intervene in the progression of chronic conditions in its Medicaid population. Specific goals included keeping members with chronic conditions like advanced chronic kidney disease, heart failure, behavioral health conditions and dementia healthy and at home as long as possible.

Improving the accuracy of its risk coding and documentation was a critical component of the effort but required improved engagement and performance among the organization’s more than 7,000 physicians.

“Risk capture is really important because if we don’t capture accurately the coding and the disease state of our patients, we’re not going to get the revenue to be able to do the work.”

Head of Financial Planning

Action

To drive cultural change and improve financial outcomes, the organization partnered with Milliman and Milliman MedInsight to strengthen ROI analysis and redesign incentive pools so shared savings were distributed more fairly across affiliates and clinicians.

Working with MedInsight and Milliman actuaries, the team rebuilt its VBC analytics dashboards to add risk-adjusted reporting, formalized and scaled risk capture, and applied benchmarks to assess contract performance.

MedInsight also helped the organization better understand primary care physicians and their attributed populations—supporting engagement and targeted care management. Using the MedInsight Data Mart, the hospital continuously monitors claims (and high utilizers) and integrates clinical and financial data to close HEDIS gaps, improve risk-adjusted metrics, and advance high-quality, cost-effective care.

Results:

The organization aligned financial and clinical outcomes by redesigning incentive pools and standardizing data-driven measures across Medicaid and Medicare populations.

Using Milliman MedInsight Value-Based Care (VBC) Platform data analytics within their electronic health record (EHR), the team was able to close HEDIS gaps, improve risk capture, and identify opportunities to slow chronic disease progression and avoid unnecessary admissions—supporting stronger performance in risk contracts.

Ongoing capabilities to explore:

• • MedInsight Data Mart to analyze and monitor claims (including high utilizers)
  • Milliman IMPROVE to reduce coding errors and documentation gaps
  • Expanded review of pharmacy and claims data to better target interventions

 

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