Large multistate health plan implements value-based care transformation solution to support the ACO model

Client background

A large multi-state health plan covering more than 15 million lives.

The business challenge

Our client was aggressively pursuing a network strategy of negotiating new Accountable Care Organization (ACO) shared savings arrangements with integrated health systems in their network. Their goal was to promote financial risk sharing and incentivize providers to deliver higher quality care, more efficiently. Many of the business processes and systems needed to achieve these changes did not exist.

• Organization structures, roles and responsibilities: The implementation of ACO agreements required integrating impacted departments in very different ways from what was needed for a traditional fee-for-service (FFS) model. These gaps led to a critical need to define new roles, responsibilities and processes.
• Legacy systems and processes: In order to achieve the scale desired as the number of ACO contracts grew through the network, the introduction of new technologies and the integration with existing technologies was necessary.
• A new experience: Our client needed to operate in an environment where the details were constantly evolving, the demands of the business focused on rapid delivery to keep up with the market and best practices were not yet well established.

The number of health systems entering into these agreements was increasing every six months. Simultaneously, the client was dealing with many other projects driven by regulatory and compliance changes impacting the industry.

The Baker Tilly approach

Baker Tilly provided program and project management guidance, organizational change management services and experienced project execution resources to help the client implement their transformation to an operational state ready to support ACOs. Together with our client, we:

• Defined organization structure, processes and responsibilities: Provided change management leadership to define future state processes, with a heavy focus on interdepartmental process integration. Analyzed the impacts of change, and created a communication plan to help manage the organization and stakeholders through the change.
• Implemented customized technology: Helped design and implement multiple solution components, including more than 10 custom SAS analytical algorithms, a custom application to manage workflow and security for key operational processes, a vendor solution to deliver provider facing reporting and quality outcome measurement and enhancements to existing applications to enable provider payment and self-insured employer group billing.
• Enabled compliance with a national organizational mandate: Helped translate high-level mandate requirements into technical specifications and processes.
• Program and project management: Provided project management leadership around more agile approaches to project execution, decomposition of scope, creation of project plans and execution tracking. Created design documentation, created and executed test plans, constructed specific system components, tracked defects and supported release management.

The business impact

Our client has successfully built new teams and adopted new processes and systems to allow them to administer and grow their ACO model.

• Scaled programs: Expanded the number of participating provider partners in their programs from three ACOs at pilot program launch to more than 100 ACOs, spanning group, retail and government program members.
• Membership growth: At pilot program launch, there were approximately 150,000-200,000 members covered by providers participating in the ACO program (commercial PPO). Today, nearly two million of the state plan’s eight million members are covered across 100 ACO contracts and multiple lines of business.
• Improved processes: Business processes are executed on an ongoing basis to define ACO populations, deliver data to health system partners and manage payment and funding transactions. Hundreds of analytical programs are executed each month, delivering multiple data sets and reporting to each provider partner. Automated financial processes support execution of all required types of value-based transactions each month.
• Improved technologies: Significant demand from other network providers to participate in our client’s value-based programs continues. They are now positioned to achieve the desired scale of the program via improved technologies and automation of business processes. The platform has expanded to additional value-based programs, including Episode of Care based reimbursement, with other specialty programs in the pipeline.

For more information on this topic, or to learn how Baker Tilly specialists can help, contact our team.