Accountable Care & the Transfer of Financial Risk: 3 Tips for Providers

The transition within the healthcare industry from a fee-for-service model to accountable care structures includes a fundamental shift in who manages risk. As we move toward accountable care models, risk transfers from health insurers to provider groups. This shift will require providers to understand the risks associated with the populations they manage and adopt many of the tools and processes currently used by insurers to manage risk.  

Here Nathan Gunn, MD, chief science officer for Verisk Health, shares three tips for hospitals and other providers as they begin to embrace this shift.

1. Understand the risk in your population.
Most important to an ACO's success is its ability to understand the risk of a population, says Dr. Gunn. "ACOs are going to have to develop skill sets around analytics that once were solely the providence of health plans," he says.

Understanding the risk of a population and the cost associated with that risk is critical for the provider to ensure it receives fair pricing for managing that population's care. "If a population is twenty percent sicker than expected, the provider needs to make sure it's getting 20 percent more for that care," says Dr. Gunn.

2. Thoughtfully allocate resources. In addition to estimating risk, analytics can help providers identify where resources should be allocated to get the most bang for the buck. "Predictive models can show providers who in a population they should focus their time and effort on," says Dr. Gunn. "Identifying the riskiest one percent who are most likely to require expensive care allows providers to focus more disease and case management efforts toward these patients and hopefully reduce their costs."

After identifying the patients most likely to become sick, the next step is looking for gaps in care, which requires further analysis of claims or EMR data on an individual patient level. Such analysis can identify gaps in care that may have contributed to that increased risk and allows providers to fill these gaps. For example, a provider could determine if a diabetic patient has received regular eye exams and blood tests for sugar level or if those have somehow not occurred. "[Identifying care gaps] allows for better care coordination and helps inform the condition-specific decision pathways that guide physicians' care."

3. Profile internal providers. Health insurers have been profiling providers for some time in an effort to direct patients to high quality, cost effective providers; however, their attempts have been largely unsuccessful in terms of actually shifting consumers to these providers. This idea, though, should be adopted by ACOs with multiple providers. "A medical director of the ACO should understand which of the clinics or hospitals in the ACO has the best quality and efficiency," says. Dr. Gunn. Identifying top performers can help ACOs to identify and implement best practices across the network as well as reward them for the performance, he says.

Learn more about Verisk Health.


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