Tag Archives: provider risk sharing

How does risk adjustment affect CMS episode-based payment models?

Each episode-based payment model has its own specific set of risks arrangements for providers to consider. Risk adjustment or risk stratification is present in these alternative payment models to amend payment levels and reflect cost considerations outside a provider’s control.

In this paper, Milliman’s Samuel Bennett and Tom Snook provide a high-level guide on risk adjustment within the broader scope of four episode-based payment models administered by the Center for Medicare and Medicaid Services.

Addressing challenges in the transition to value-based care and alternative payment models

With the shift to value-based payment for healthcare in the United States, an array of alternative payment models (APMs) has emerged that introduce challenges along with opportunities for providers. This paper by Milliman consultants highlights the key aspects of APM payment methodologies and uses the Centers for Medicare and Medicaid Services Oncology Care Model as a case study to illustrate these concepts.

Developing alternative payment models under MACRA

Alternative payment models (APMs) have become a popular way to tie payment to quality of care. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) created incentives for providers to participate in APMs. This paper by Daniel Muldoon and Pamela Pelizzari explores key clinical and financial considerations that need to be addressed in a robust APM proposal.

Implication of coding on risk adjustment and valued-based contracting

Healthcare providers are measured on certain performance metrics that dictate their payment amounts under value-based contracts. Risk adjustment plays an integral role in determining financial performance. In order for these contracts to be equitable for insurers and providers, risk adjustment must accurately capture changes in population morbidity to effectively measure the provider’s true cost impact.

In this article, Milliman’s Rong Yi, Howard Kahn, and Jared Hirsch highlight common data issues that affect risk scores. They also discuss practices that can improve coding efforts related to risk adjustment.

Regulatory capital strategy considerations

Healthcare providers and health plans continue to integrate vertically through consolidation and virtually through accountable care organization (ACO) risk-sharing arrangements. In this article, Milliman’s Dave Liner discusses how providers and health plans can improve their financial performance by considering strategies that optimize regulatory capital.

How capitation arrangements can be applied to deliver the NHS Sustainability and Transformation Plans

Capitation arrangements are traditionally used as an alternative to fee-for-service reimbursement to facilitate a transfer of risk from the funder to providers of healthcare services. The objective of introducing risk sharing between funders and providers is to encourage the delivery of efficient and patient-centred care by incentivising the integration of services and minimising unwarranted variation in care. This paper by Milliman’s Joanne Buckle and Tanya Hayward explores how the principles of a traditional capitation arrangement may apply in a regional National Health Service system where the stakeholder roles differ and the implementation of various key capitation principles is not possible.