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Part II: Leveraging Financial Incentives and Contracting Strategy In Part I of this series, we introduced various models in establishing care management organizations within risk bearing entities (RBE), ranging from fully decentralized to fully centralized model. Within these models, three levers influence care management tactics to varying degrees: financial incentives and contract design, organizational and […]

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As the nation continues to move away from traditional fee-for-service payments, providers are seeking ways to maximize their revenue and maintain a healthy profit. The transition to value-based payment (VBP) has been slower with Federally Qualified Health Centers (FQHCs) as they often run on razor thin margins and traditionally on a volume based revenue model. […]

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The Affordable Care law has survived for nearly a decade despite efforts to upend it, including legal challenges (one pending1 and another that went all the way to the Supreme Court), Congressional attempts to repeal it and executive orders aimed at weakening it. While fiery debate continues over the fate of the roughly 21 million […]

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Background The Health Plan is a not-for-profit health plan in the Northeast that services more than 280,000 members, offering Medicaid, Medicare and Children’s Health Insurance Program (CHIP) plans. The plan has consistently ranked high on the National Committee for Quality Assurance’s (NCQA) quality metrics but had a relatively small footprint in its target markets, despite […]

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Background: A large public health plan in the Northeast was in the midst of the procurement cycle for a state demonstration. The product proposed for the demonstration covered under 65 dual-eligible members, a high-risk population, in which there was a large proportion of chronic conditions and mental health and substance use disorder (MH/SUD) comorbidities. […]

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Overview: As today’s vulnerable populations present with more complexities, designing care models and identifying the appropriate multidisciplinary resource mix is key to delivering integrated, member-centered, outcomes-based care. As the health care industry continues to recognize the need for holistic care that meets the objectives of the Quadruple aim while addressing the social determinants of […]

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Key terms of the proposed extension: 4-year extension Continuation of DSRIP for 1 year 3-year renewal Would span from April 1, 2020 through March 31, 2024 $8B in funding $5B for DSRIP Performance $1B for Workforce Development $1.5B for Social Determinants of Health $0.5B for Interim Access Assurance Fund New structure for organizations participating […]

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The State of New York has released its draft proposal for an extension to its Delivery System Reform Incentive Payment (DSRIP) program as part of the state’s 1115 Medicaid waiver, currently set to expire at the end of March 2020. Asking CMS for $8 billion over four years to extend the program through March 2024, […]

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Background Managed care procurement processes are a required part of public sector care delivery as value-based care continues to advance in the health care industry. As a bidder, one often associates the process with a heavy amount of administrative effort, resource consumption and bureaucratic requirements. While there is truth to this, well-conducted procurement processes can […]

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Background A risk bearing entity’s (RBE) ability to bear financial risk profitably is based on its ability to consistently manage the utilization and health outcomes of its attributed population. In today’s market, to be a RBE is to be in the business of care management. Successful care management is a critical competency that organizations must […]

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