Deploy robust provider performance management programs, informed by analytic insights, that strengthen partnerships and enable providers to succeed in value based care
The past decade has brought an increased focus on value based care as a way to drive affordability while improving quality, aligning provider incentives and enlisting providers as partners.
Changes within the provider ecosystem, such as employment trends, private equity acquisitions of care delivery, rapid acceleration of new clinical pathways to deliver care, demand a different approach to managing provider partners.
Pressures on the provider ecosystem are escalating and rapidly evolving as there is increasing product innovation of network chassis (e.g., shifting to digital, broad networks that still feel curated) and traditional providers and facilities are facing economic pressures.
Managing this complexity requires enhanced understanding of provider performance, enablement of provider capabilities, new and innovative partnerships, more flexible/nimble approaches to delivery of products, and efficient management of provider relationships and contracts.
Common issues we help our clients solve
What does variation of provider performance look like across the network? Where is there the most variability (by provider type, by episode, by geo, by line of business, etc.)?
How and where should we push to drive value based care models across our network and how do we best partner and enable providers to perform in them?
What are the most likely market impacts of taking a more active hand in provider evaluation and enablement?
How should we evolve our provider evaluation approach, considering our specific provider programs and contracts today?
What are effective ways to work with providers to roll out new enablement approaches and/or build joint capabilities with providers?
How should we source our provider enablement capabilities: build, buy, or partner to deliver?
What enablement capabilities would be needed to support our providers as they develop new clinical care models to tackle particularly challenging population cohorts (i.e., polychronic or complex patients)?
What provider incentive and quality programs should we deploy and how can we make the mateiral and impactful?
1. Performance/transformation capabilities: Shared capabilities (including payer-and provider-led functions) that enable transformation across clinical, health management, quality, risk coding, and member engagement activities
2. Payment/economic model: Evolve the value proposition ranging from traditional reimbursement to deeper financial partnerships required to align provider economics
3. Emerging care models: Capabilities to enable delivery and monitoring of new and emerging provider care models
4. Data and integration approach: Data, analytic, and operational integration required to support provider relationships as well as customers and internal stakeholders
Performance/transformation capabilities
Clinical practice change
Comprehensive, shared operating model for transforming how care is delivered for a specific population/episode
Quality performance
Comprehensive quality program with
structured provider role in supporting clinical quality and other key metrics
Risk adjustment and revenue management
Structured approach to managing
revenue and provider documentation activity
Population health management
Medical management and care
management activity aligned between payer and provider
Experience/engagement
Member service, outreach, and
support model to meet experience and engagement expectations
Payment/Economic model
Reimbursement and risk arrangement
Aligning payment model across LOBs to support provider transformation and partnership
Investment
Investment/co-investment in practice and/or to build new capabilities or services (e.g., on-site transfusion, ambulatory surgical facilities)
Joint Venture
Joint venture to open new service lines or sites of care
Practice ownership
Full ownership of practice or group
Emerging care models
Contract and reimbursement management
Financial/analytical capabilities to
define, measure, and administer provider risk arrangements
(incl. hierarchies, cross-program coordination)
Pop health analytics and
integration
Sharing bi-directional data,
metrics, and insights to enable clinical activity changes to improve
performance
Provider financial reporting
Capabilities to provide regular
financial reporting on risk arrangement performance
Customer and internal reporting
Capabilities to measure and report
customer and internal segment level impact of provider risk arrangements
Data and Integration Approach
Data: Necessary data and associated transparency required to support foundational capabilities
Integration approach: Method for aggregating data and insights from various foundational systems to support all capabilities (including development of interface layers / aggregation approaches where needed)
Provider performance measurement insights drive optimized network performance outcomes
Source: Oliver Wyman analysis
Goals for provider performance measurement
Risks to avoid
Oliver Wyman partners closely with our clients to design and develop provider enablement capabilities and solutions based on evaluation and deep understanding of provider performance and maturity.
Developed a care management solution to support physicians deploying patient care models for practices ranging in size from 70 physicians to 300+ providers. Read more
Developed the near-term approach to deliver provider enablement “must haves”, while laying the foundation for longer-term enablement capabilities to improve network performance. Read more
Defined a comprehensive framework for the full set of provider enablement capabilities needed to enable value-based contract success. Read more
Facilitated an understanding of the current state of the provider quality space and developed an organizing framework for provider quality improvement initiatives. Read more
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