Healthcare organization participating in MSSP, or other value-based reimbursement contract types, are facing a barrage of new challenges that center around quality being the new payment mechanism in healthcare. Executives must balance the initiatives required to improve quality with the total cost of services.
This new reality leads to a new set of questions that any executive dealing with risk-based contracts must be able to answer:
- Do I know my attributed population?
- Do I understand my spend by service line?
- Will I lose money this year?
- Should I take on more risk next year?
Question 1: Do I know my attributed population?
Patient attribution begins with a list supplied by the payer. This list documents the patients that a provider is responsible for. The underlying methodology of assigning patients to a provider is based on claims data and varies in complexity across the industry. Typically, providers have little say in which patients are attributed to them. The one exception to this is with MSSP, where providers can choose prospective or retrospective patient attribution. Once the provider organization has a list of attributed patients, that list must be reconciled with the list of patients in the EHR. Today, many organizations employ a manual process to match the member list to active patients.
Enli’s patient reconciliation software automatically processes payer attribution lists with patients in the EHR.
In the reconciliation workflow, only the exceptions are flagged for software assisted review so that the name in the EHR matches the name on the payer list – all other matching happens automatically. With Enli, organizations can automate the patient reconciliation process whenever a new payer attribution list is made available. In addition, providers can be confident that the patients on the payer list are the same patients in the practice’s EHR.
Question 2: Do I understand my spend by service line?
Benchmarks based on attributed lives drive the MSSP reimbursement equation. When your spend is above average, you need to rapidly identify the culprit by examining the financial performance of your various service lines.
Enli’s value-based care analytics software identifies the specific service lines that represent the root causes of excessive spending.
The interactive visual interface allows users to drill-down to identify specific locations of care or providers with with the opportunity to improve outcomes.
Question 3: Will I lose money this year?
The bottom line is what matters most with regards to MSSP and other value-based care contracts. Financial executives are expected to have the answers, yet generating insights is often a manual process with frustratingly little detail.
Enli’s on-demand value-based analytics dashboards surface the data that matters most to the executive team: what is my financial outlook; where am I losing money; where can I make more money?
With Enli, you can drill-down into areas of suboptimal performance for additional insights: are patients not following-through on treatment; are providers missing critical treatment opportunities; do we need additional resources for rising risk populations?
Question 4: Should I take on more risk next year?
MSSP has several Tracks with varying levels of risk. The more risk, the greater the potential reward. There is a minimum pace of increasing risk that is required if you are going to remain in MSSP, but you can go faster than that. If you are certain you will perform well, you can accept more risk to access greater reward.
Enli software forecasts performance using current clinical, claims, and billing data to predict future financial performance under increasing risk scenarios.
In contracts where negotiation is an option, Identifying measure that are historically easy to attain can give you negotiating leverage for measures that are harder to achieve.