Category Archives: Providers

Identifying rising risk patients can reduce costs for healthcare organizations

Identifying future high-risk, or rising risk, patients can help healthcare organizations reduce population health costs through early intervention. In this paper, Milliman consultants Ksenia Whittal and Abigail Caldwell examine predictive models to determine if an enhanced model can better identify individuals with rising risk relative to traditional prospective risk adjustment models. The authors also assess the capability of these models to select members whose costs will increase in the future year.

An Overview of the Bundled Payments for Care Improvement Advanced Model

In January, the Centers for Medicare and Medicaid Services announced a new voluntary bundled payment model, Bundled Payments for Care Improvement Advanced (BPCI Advanced). This model starts on October 1, 2018, and creates a replacement for the current BPCI initiative. This paper by Milliman consultants Samuel Bennett and Pamela Pelizzari outlines the major provisions of the newly announced BPCI Advanced model.

Maximizing value-based care program performance

Over the past few years, there has been a proliferation of value-based care programs offered by health plans and government payers. These programs, including accountable care organizations, bundled payment programs, and quality incentive programs, often include a multitude of measures related to costs, quality, patient experience, and outcomes, along with various methodologies to determine success.

As the use of value-based reimbursement programs and the associated financial impact increases, it is important for providers to learn the program’s intricacies as well as the analytical, operational, and clinical requirements to ensure its success. In this paper, Milliman consultants Rod Martin and Laurie Lingefelt discuss how success with these programs is possible.

Medicare Shared Savings Program 2016 Track 3 financial results

Under the Medicare Access and CHIP Reauthorization Act of 2015, healthcare providers that participate in a Medicare Shared Savings Program (MSSP) as Track 3 accountable care organizations may qualify for the advanced Alternative Payment Model 5% bonus. Track 3 was first offered in 2016. This paper by Milliman consultants discusses first-year MSSP Track 3 performance and possible drivers of success.

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

Each episode-based payment model has its own specific set of risk 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 Centers for Medicare and Medicaid Services.

Considerations for comparing 30-day unplanned readmission rates

Hospital readmissions can add unnecessary cost to the healthcare system and can adversely affect patient health. Readmission rates are key metrics for measuring the performance of hospitals, health plans, accountable care organizations (ACOs), physicians, and post-acute care facilities because they are tied to financial rewards and penalties for those entities. This article by Milliman consultants Maggie Alston and Michele Berrios identifies key elements that should be considered when evaluating readmission rates across populations or when comparing readmission rates with different methodologies.