Unlocking VBP Success with Data, Strategy & the ARC Platform

Overview

Sun River Health, a large Federally Qualified Health Center (FQHC) in Downstate New York, is pursuing a “North Star” vision to achieve the quintuple aim—advancing health equity, improving population health, reducing cost, enhancing the care experience, and supporting care team well-being. To do so, Sun River Health is actively engaged in value-based payment (VBP) arrangements through two Independent Practice Associations (IPAs) and a large Medicare Shared Savings ACO.

The Challenge

As part of its push into more advanced VBP, 
Sun River Health entered a shared-risk Medicaid contract with its largest managed care organization (MCO). After modest savings in year one, the organization owed approximately $1 million in shared losses in year two—with little clarity on why. The MCO provided limited reporting, leaving the Sun River Health team in the dark about performance drivers and contract fairness.

Their key questions included:

• Was performance calculated correctly—or were there flaws in the MCO’s methodology?
• Were the contract terms fair, or did they set Sun River up to fail?
• How can performance be improved and managed over time across multiple VBP contracts?

Our Approach

Data Transformation through Extract, Transform, Load (ETL)

COPE Health Solutions (CHS) worked with the MCO’s actuarial and data teams to clean and load monthly claims data into the CHS proprietary Analytics for Risk Contracting (ARC) platform. This involved resolving deep technical issues including:

• Incorrect claim bundling and service category assignment
• Members mismatched to LOB
• Inclusion of omitted zero-dollar claims and gross pay provided at the ClaimID and not claim line level

CHS also collaborated with Sun River to complete business configuration of the ARC platform to incorporate client-specific business elements necessary for customized reporting, including reconciliation of provider rosters and network alignment. ARC was integrated with their EMR to incorporate clinical and quality data—including
real-time visibility into HCC coding and care gaps.

Ultimately, Sun River, CHS, and the MCO achieved alignment on an accurate dataset, uncovering key gaps in the MCO’s methodology and validating the drivers behind the shared losses.

Financial Modeling & Contract Support

Using ARC’s financial modeling capabilities, CHS built a bottoms-up forecast of performance, leveraging claims and EMR data to model contract performance under various terms and cost/quality performance scenarios. This enabled Sun River to:

• Negotiate stronger contract terms for the next VBP contract cycle
• Establish standardized reporting expectations with the MCO
• Model impact of specific cost and quality improvements across different Medicaid products

Analytics & Performance Improvement

CHS conducted deep analysis by Medicaid line of business (adult, child, SSI), PCP group, and practice location to identify clinical and operational performance drivers. Key opportunities and interventions included:

• Expanding prenatal care access to reduce maternal and newborn inpatient costs
• Launching complex care management for high utilizers
• Enhancing behavioral health management and asthma care management programs to address rising inpatient costs and preventable admissions
• Improving transitions of care, including partnerships with CBOs, reducing out-of-state rehab utilization, and connecting to primary care
• Implementing utilization management recommendations to reduce avoidable ED utilization

CHS also trained Sun River leaders and frontline staff on using ARC for population health management, embedding regular reporting and insights into operational meetings and leadership dashboards.

The Results

• $1.1 million improvement in financial positioning through renegotiated contract terms
• $1.7 million annual revenue opportunity from targeted set of clinical initiatives recommended by CHS
• ARC adopted as the central platform for population health management and a key performance improvement tool with the addition of 3 additional payer contracts