Competency Area #4: Develop and implement financial models that promote provider and staff buy-in and advance the achievement of quality benchmarks, appropriate utilization of care, and long-term organizational sustainability

The key elements that comprise Competency Area #4 are outlined below. These can be used as touchpoints in determining whether your TA project helps advance your ACO or CP in this competency.

Core Competency #4

Performance evaluation and management: ACOs and CPs bring together financial, actuarial, quality, and clinical leadership expertise to ensure that targets, benchmarks, and measurement strategies are established in a manner that enables them to improve health outcomes and member experience, decrease total cost of care, measure success, and ensure sustainability over time.

Incentive models: ACOs and CPs design incentive and other value-based payment models that successfully engage provider entities, and care team members in the transition from fee-for-service to value-based payments in order to ensure cohesive implementation of organizational strategies for improving health outcomes and member experience, decreasing total cost of care, measuring success, and ensuring sustainability over time.

Organization-wide adoption of financial models and business practices: ACOs and CPs implement and provide support for the adoption of financial models and related business practices, including billing and coding standards, across all provider entities to ensure that all business activities are implemented in a manner that advances organizational strategies for improving health outcomes, member experience, and access; decreasing total cost of care; measuring success; and ensuring sustainability over time.

[For CPs only] Prepare for participation in value-based payment models: CPs develop and utilize financial forecasting tools and strategies, implement new quality and outcome monitoring protocols, and build population health approaches in preparation for participation in value-based payments and risk-sharing relationships with ACO partners.

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Support designing alternative care delivery models in ACO: An ACO engages a TA vendor to help translate the organization’s success in implementing a bundled payment pilot for knee replacements to lessons learned in a primary care setting. The ACO’s providers have expressed interest in piloting alternative ways to providing care that can result in savings. This project also addresses Competency Area #2 in that it explicitly addresses a provider and care team priority related to value-based payments.

Project Examples

Develop strategy for managing ACO’s multi-payer quality measures: An ACO engages a TA vendor to develop a strategic approach to managing various payers’ required quality measures. Providers have struggled with the proliferation of quality measures being tracked across the entity, and are experiencing measure fatigue. Part of the TA project will focus on highlighting the link between quality measures and the day-to-day member experience of care. This project also addresses Competency Area #2 in that it explicitly addresses a provider and care team concern related to MassHealth restructuring.

Preparation for CP participation in value based payment models: A CP engages a TA vendor to identify and analyze the challenges and opportunities of transitioning to value-based payments. The CP aims to establish and utilize models for financial forecasting, identifying measurable success metrics, and incorporate guidance with value-based care model implementation in advance of taking on financial risk. This project also addresses Competency Area #6 in that builds the CP’s knowledge base related to risk-based contracts and value-based payments.

Train ACO staff on medical coding best practices: An ACO engages a TA vendor to provide medical coding expertise and training on coding protocol and best practices. The ACO has identified areas of inefficiency and lost revenue due to coding errors and wants to recoup these losses and redirect them to support a member-facing wellness program.