LISLE, Ill.--(BUSINESS WIRE)--A big shift has started in the U.S. healthcare system. Driven by regulations in the way providers are paid, as well as a focus on managing the entire health insurance premium through better disease prevention and management, more provider-aligned organizations are launching health plans. To help these providers achieve success, Aldera Chief Technology Officer Daniel Knies and Valence Health Chief Medical Officer Dr. Roy Smythe presented a business and technology roadmap at the Provider-Led Health Plan Forum on February 23, 2016.
“It was only a matter of time before more providers, particularly those with a large regional presence, would start offering their own health plans,” said Aldera’s Knies. “To do it with their eyes wide open, they need to understand the complexity that risk management drives into their traditional business, the strategies around identifying and managing the health of different populations, and the technologies they will need to be successful.”
A former surgeon, Smythe brought the provider’s perspective to the presentation, focusing on both the impediments to success and critical business strategies:
- Accepting and embracing risk in a traditional risk-averse culture, and understanding the change management that needs to occur
- Creating a greater understanding in an organization that taking risks isn’t as risky as it may initially seem given all of the assets that providers can more easily access and use effectively when designing and delivering health insurance products
- Looking at a health plan as both a new business line and potentially a hedging strategy to enable future success
- Understanding outsourcing options that can create scale and efficiency when providers run their own health plans
“Provider organizations should not underestimate the clinical challenges they will face when they move from a conventional care management model—managing patients when they are sick—to an advanced care model, which includes different levels of care for patients at different points in their health cycle,” said Smythe. “They will need to manage three separate patient tiers at one time to mitigate risk and earn rewards. They must manage patients before they become expensive, not after, and they must manage their entire population’s health, engaging patients and clinicians throughout the healthcare cycle.”
Knies noted that becoming a health plan also requires accounting for all of the different ways patients now engage with payers and providers through the healthcare continuum, and understanding the technologies that will help manage risk over the long term. He identified the must-have technologies that provider-led health plans will need to be successful: core administration with portals, care and population health management, electronic medical records, and clinical and financial analytics. He also identified key criteria to help provider-aligned organizations determine how to manage that technology, either on premise or through different service agreements.
Anyone interested in seeing the presentation, can click here to receive a copy.
Aldera provides healthcare payers with a flexible, rules-based and functionally rich platform that enables them to meet industry challenges, improve business performance and future-proof their organizations. Aldera’s platform supports more than 36 million members across all lines of business in commercial and government markets. Aldera’s offerings are available via cloud-based SaaS subscription or term license models. For more information, please visit our website at www.aldera.com, LinkedIn @ linkedin.com/company/aldera_inc, Twitter @ twitter.com/aldera_inc, or call 800-507-3895.
About Valence Health
Valence Health provides value-based care solutions for hospitals, health systems and physicians to help them achieve clinical and financial rewards for more effectively managing patient populations. Leveraging 20 years of experience, Valence Health works with clients to design, build and manage customized value-based care models including clinically integrated networks, bundled payments, risk-based contracts, accountable care organizations and provider-sponsored health plans. Providers turn to Valence Health’s integrated set of advisory services, population health technology and managed services to make the volume-to-value transition with a single partner in a practical and flexible way. Valence Health’s more than 900 employees empower 85,000 physicians and 135 hospitals to advance the health of 20 million patients. For more information, visit www.valencehealth.com.