As federal policy evolves, healthcare providers serving Medicaid populations are bracing for intensified financial strain. H.R. 1 will impact Medicaid eligibility and financing, with an expected increase in the uninsured population and decrease in federal health care spending. These changes will place immense pressure on providers to maintain care quality with diminished resources.

The Imperative for Value-Based Care

In this shifting landscape, value-based care (VBC) emerges not just as a lifeline, but as a sustainable solution. VBC models offer a more predictable revenue stream by rewarding providers for improving outcomes rather than maximizing service volume. By emphasizing preventive care, chronic disease management and care coordination, VBC not only helps reduce avoidable emergency department visits and hospitalizations, but also ensures that care is tailored to the unique needs of Medicaid populations. These individuals often face complex health challenges and with socioeconomic barriers, making whole-person care essential.

Building the Infrastructure for Success

To make value-based care work, providers need robust support systems. Data analytics platforms, population health management tools and care coordination infrastructure are essential to track performance and guide interventions. Equally important is fostering strong collaboration among stakeholders, from providers to payers to community-based organizations (CBOs), to create an integrated network of support that addresses clinical needs and social determinants of health.

Case Study: COPE Health Solutions (CHS) in Action

COPE Health Solutions was engaged by a health system with a physician governed clinically integrated network (CIN), and independent physician association (IPA). Our client needed to quickly understand its population health management and VBP gaps to be successful in a transition to full risk for all lines of business. CHS completed an initial gap assessment and then launched a new MSO that supported the IPA’s strategic roadmap of achieving growth, resulting in increased premium access through VBP arrangements and improved performance under those arrangements. In the first 12 months after MSO launch, the IPA:

• Improved IPA value proposition attracting new physicians and growing membership by 30,000+, a 20% increase in growth
• Built a three- year pro-forma and contract analysis for all payers and lines of business, including staffing and infrastructure costs and network growth models
• Launched CHS’ Analytics for Risk Contracting comprehensive population health analytics platform, Data Analytics as a Service and ARC care management workflow platform, which enabled the client to create targeted practice-level quality scorecards and chase lists, ultimately yielding a two-fold improvement in quality gap closure rates across the CIN and increased incentive payouts for participating providers
• Developed processes and policies to make the IPA a fully functioning clinically integrated network (CIN), completing process to achieve single signer authority
• Developed a comprehensive network strategy and Practice Transformation Manual and Protocol to increase provider engagement.

Thriving through Transition

The key to success lies in embracing whole-person care, harnessing data-driven insights and deepening community partnerships. Providers who take this leap are better positioned to deliver high-quality care, achieve financial sustainability and lead the charge toward a more equitable healthcare system for Medicaid patients.

Looking Ahead

As the healthcare environment becomes more complex, Medicaid providers’ ability to adapt is vital. Providers who invest in value-based frameworks today are not only navigating current challenges, they are building a model for tomorrow. With deep expertise in VBC transformation, CHS is ready to help organizations make this strategic pivot.

Contact info@copehealthsolutions.com today to learn how our services can help your organization achieve its goal.