Analytics for Risk Contracting (ARC) helps organizations manage and succeed in risk-bearing payment arrangements such as Medicare Direct Contracting (MDC). The ARC platform can help prospective Medicare Direct Contracting applicants address key business decisions related to MDC-specific requirements and operational parameters required to become a Direct Contracting Entity (DCE).
Medicare Direct Contracting applicants can leverage ARC’s state-of-the-art analysis and reporting platform to construct a detailed claims based pro-forma/financial model(s) using data provided by CMS for MDC applicants. The resulting model(s) will inform financial assumptions and business considerations for pursuing a MDC. ARC dashboards produce reports in the following areas:
- Market specific projections with relation to attributed membership (as informed by CMS data)
- Revenue and expenses (P&L and cash flows)
- Clinical strategies and initiatives recommended to achieve target Medical Loss Ratio (MLR)
- Funds flow models to participant and preferred providers
Additionally, Medicare Direct Contracting applicants can use ARC to inform the decision to continue or withdraw from the MDC contracting application process – as permitted by CMS post-application.
The ARC Suite also pinpoints opportunities for improving care delivery and population health, as well as the resulting net financial effect of those opportunities, by leveraging financial statements, member eligibility files, medical claims, pharmacy claims and provider roster files. Additionally, the platform integrates cost accounting data, social determinants of health (SDOH) data and biometric data, among others. ARC offers an established, stable and fully integrated population management and financial modeling software solution with key capabilities such as:
1) Financial Modeling and Forecasting
- Project ROI for at risk entity and identify opportunities to financially align providers through funds flow model
- Summary 3-4 year financials, target utilization and membership to achieve optimal Medical Loss Ratio (e.g. balance sheet, projected cash flows, funds flow and provider incentive funds flow template for shared-savings)
- Understand your organization’s capitation management maturity and ability to impact total cost of care under the available Medicare Direct Contracting risk arrangements through a current state analysis of medical spend and projections based on ARC internal benchmarks
- Assess how capitated payments under available Medicare Direct Contracting risk arrangements can be distributed among your organization’s Participating Providers through the “Physician Compensation Strawman” tool
2) Claims Data Analytics
- Project beneficiary alignment (claims based and voluntary) by utilizing a combination of analytic algorithms and market experience to inform application parameters (i.e., whether to apply as a standard, new entrant or high needs DCE)
- Assess whether there are sufficient beneficiaries likely to be attributed to pursue the Standard vs the New Entrant model and how reasonable is it to meet the New Entrant annual growth requirements if contracting as a New Entrant
- Use claims-based Medicare fee-for-service (FFS) panel size by provider and preponderance of evaluation and management (E&M) codes to refine member alignment panel assumptions
- Identify potential initiatives and strategies to manage total cost of care and population health (e.g,. care management, disease management, telehealth, care transitions, post-discharge clinics, high risk member management and member stratification)
- Segment attributed population by variables such as socioeconomic conditions or access to care services and design an initiative specific to this cohort
ARC is a subsidiary of COPE Health Solutions, formed through a LLC between COPE Health Solutions, Montefiore Health System, Adventist Health, and Dr. Richard Merkin, owner of Heritage Provider Network Inc. Montefiore Health System and Adventist Health have been strategic partners with
COPE Health Solutions in developing and using the cloud-native ARC tool.