It is an exciting and challenging time to be a part of a health plan right now. New pressures, challenges, and opportunities are hurtling at plans from all directions in the form of providing services with value over volume, actively engaging consumers, and mandates that require a higher level of risk and quality management.
To meet these demands health payers must adapt their technologies, people, and organizations to work more cohesively with a common goal of operating efficiently and with the best interests of their members at the forefront. To do so, many payers are preparing to implement modern enterprise Population Risk Management initiatives.
What is a “modern” Population Risk Management initiative? While most plans are familiar with “Risk” as a singular organizational function or have initiatives already engaged under the Revenue Program Management or Risk Adjustment banner, the new, modern risk approach views risk as a cross-departmental collaboration that underscores the importance of the member experience and emphasizes the use of technology to increase accurate, efficient, and timely delivery of data that supports all departments. To better understand the difference, we can start by breaking down the “old way” and the “new way.”
The old risk management system:
- Predominantly focused on Finance
- Functions within silos with limited communication, collaboration or sharing of information
- Driven only by algorithms or mandates
- Legacy (Finance) goal-driven rather than by new population health (enterprise) ideals
The modern population risk management initiative:
- Begins with an enterprise risk strategy that benefits all functions within the organization
- Encourages the smart and efficient use of new technologies and methodologies to increase accuracy, timeliness, and efficient use of data
- Focuses on new and developing measures that make clinical performance, provider outcomes, and member health a priority
- Acknowledges that inter-departmental competition and politics can keep units from working together and achieving optimum results for the plan and its members. Works to overcome those challenges and fosters collaboration, communication, and teamwork
Because of industry pressures such as increasing MLR administrative cost concerns and quality measures such as HEDIS, Stars, and QRS that are integrated into internal corporate performance metrics, the modern Risk Adjustment movement is emerging quickly. And plans are acting fast to get on board because early results are showing huge benefits. This IS the time to take an honest look at your organization and determine the best way to begin, execute, and manage a new Population Risk Management initiative. Will you manage it internally? Will you collaborate with an outside partner with experience?
In upcoming blogs I (and others) will walk with you through these questions and the best way to strategize for your Population Risk Program, how departments can benefit by working together, and the steps necessary to kick a program off quickly and successfully. As you plan for the year ahead, just know that if you don’t have plans for a modern risk initiative, now is the time to start.