Watch the recording

Bailey Fields: All right. Hello, everyone. Welcome. We'll give everyone just a few seconds to join in.

Bailey Fields: All right. Hello, everyone. Welcome. We'll give everyone just a few seconds to join in.

 

Bailey Fields: See everyone joining. Hello. Welcome, everybody.

 

Bailey Fields: Hello, hello! Alright, we've got a lot of good content to cover today, so we're gonna go ahead and get started. So today, you're going to be hearing from the Optum team on driving ACO success through integrated value enablement.

 

Bailey Fields: Before I turn it over to the Optum team to officially kick it off, I do want to just mention a few housekeeping notes. So you will notice that your camera and mic are going to be off for the duration of the webinar. This is just going to be for your privacy.

 

Bailey Fields: But if you do have any questions, please place those in the Q&A box found at the bottom of your screen. The team is going to do their best to answer those at the end of the webinar today, but if there's any that they're not able to get to, not to worry, they will reach out and follow up with you directly.

 

Bailey Fields: So without further ado, I'm going to turn it over to the Optum team for further introductions.

 

Pooja Panchamia: Great. I can go first. So, hi, everyone. Thanks for joining us today. My name is Pooja Panchamya. I'm a senior consultant with OptimumSight, part of the Risk and Quality Market Solutions team, focusing on go-to-market strategy for ACOs and health systems.

 

Pooja Panchamia: Being part of Optum for 3 years now has spent close to a decade working across healthcare technology, corporate strategy, and investments, so excited to spend the next hour discussing the trends that are shaping the ACO market and what organizations like yours can do to succeed in this.

 

Pooja Panchamia: value-based care environment.

 

Brett Superfine: Thank you, Pooja. Hi, everybody, Brett Superfine, I'm Director of Value-Based Care Innovation here at Upton

 

Brett Superfine: Been at Optum for the past decade, have held a variety of different roles across consulting, go-to-market and growth strategy, and product innovation. Really looking forward to speaking with you all, and hopefully you all learned something today. Pooja, pass it back to you.

 

Pooja Panchamia: Red. Red

 

Pooja Panchamia: So I'll quickly run through the agenda that we are covering today before I jump into slides. So the

 

Pooja Panchamia: Focus today is that we'll start by discussing the new reality of ACO performance and the trends that we are seeing, which is shaping the market today. Then we'll explore the core capabilities that influence ACO success.

 

Pooja Panchamia: And how they could work together to drive the performance. And then, finally, we will discuss how organizations can translate those priorities into action across each of those core areas.

 

Pooja Panchamia: One theme that you will hear throughout today's discussion is that achieving shared savings

 

Pooja Panchamia: It's no longer about optimizing a single function. Success really depends on how well organizations are able to connect strategy, operations, and care delivery across the ACO journey. So that's really focused for today's webinar.

 

Pooja Panchamia: So with that, let me move to the…

 

Pooja Panchamia: trends that we are seeing in the ACO market today. And what we're seeing is not really a single CMS policy change or new development that's come through. It's just multiple regulatory and market shifts that's happening at the same time. And collectively, these changes are pushing ACOs towards

 

Pooja Panchamia: Greater accountability, long-term participation, and more sophisticated performance management.

 

Pooja Panchamia: Starting with the trends here, the first one is the two-sided risk. Today, more than 80% of MSSP ACOs are participating in two-sided risk arrangements.

 

Pooja Panchamia: And CMS has now shortened the upside-only participation window from 7 years to 5 years.

 

Pooja Panchamia: So that's a significant shift from the early MSSP days when organizations could remain in upside-only models for much longer. So the message is clear. Question is no longer about whether organizations will take downside risk. It is about when.

 

Pooja Panchamia: What this also means operationally for an ACO is that you need more stronger forecasting capabilities, earlier intervention strategies, and just greater confidence in how you're managing both quality as well as total cost of care.

 

Pooja Panchamia: Moving on to next one here, which is the new long term pathway, you might have heard and know about the new lead model that's come out, which is the long term enhanced ACO design that's introducing a potential 10 year participation pathway focused on high needs, rural and dual eligible population. What's also notable is the market response. CMS recently welcomed more than 300

 

Pooja Panchamia: provisionally accepted lead applicants into this new stage of program and with signaling good industry interest.

 

Pooja Panchamia: But what all of this tells us is that organizations are now moving beyond short-term participation and making more long-term investments in value-based care, and at the same time, they're preparing to take on more financial accountability over a period of time.

 

Pooja Panchamia: Third one that we have here is the flexible participation rules.

 

Pooja Panchamia: So for MSSP especially, the 5000 beneficiary threshold has been relaxed across the benchmark years and new ACOs now have until year three to meet that requirement. So this actually opens door for a lot of smaller and physician led organizations that may have previously struggled to meet those participation thresholds.

 

Pooja Panchamia: Which is a good thing for access, but it also means that more organizations are entering into this environment that requires a level of sophistication with respect to capabilities that many are still building towards.

 

Pooja Panchamia: The next one here that we have is innovation and care delivery where especially with like CMS we have seen continued evolution where they are expanding accountability across the healthcare ecosystem.

 

Pooja Panchamia: Historically, the way we understand value-based care has primarily been focused around PCPs and population health management, but today CMS is expanding and introducing models that bring in specialist chronic diseases, episode-based accountability, all into the value-based care framework.

 

Pooja Panchamia: And for example, ACCESS is one of the models that came out that focuses on chronic conditions such as diabetes, hypertension, depression, MSK. There was team model which came out which introduces episode-based accountability for selected procedures and it's mandatory for participating markets.

 

Pooja Panchamia: There is also ASM model, which is ambulatory specialty model that puts the responsibility at an individual NPI level for selected specialists that are treating heart failure and low back pain. So these are just some examples, but at an ACO level, what this really means is that success now depends on managing relationships across the care continuum.

 

Pooja Panchamia: You need to engage your specialists, coordinate post-acute care, and ensure alignment across your providers who may not traditionally view themselves as part of an ACO strategy.

 

Pooja Panchamia: The next one here is around benchmark rules, where CMS is refining how benchmarks are calculated, even with the lead model that we're seeing with respect to rebasing. There's more focus on prospective trend methodologies, where cost trends are set up front.

 

Pooja Panchamia: population adjustments, and just overall greater emphasis on encounter-based documentation. So for many of you, this changes both how contracting decisions are made, and also how performance is managed on a day-to-day basis, because

 

Pooja Panchamia: It again reinforces the tight connection between provider workflows, documentation, and the financial outcomes that an ACO can achieve.

 

Pooja Panchamia: And lastly, over here, we have quality.

 

Pooja Panchamia: And, CMS is now introducing the use of more digital quality measures, including, like, electronic clinical quality measures. And what this means for many of you is that

 

Pooja Panchamia: There is a growing need for stronger digital reporting capabilities and better visibility into your quality performance throughout the year. And because quality is also something that directly impacts the shared savings that you will generate, we are also seeing more organizations now focus on identifying and closing those care gaps proactively.

 

Pooja Panchamia: So, I said a lot over here, but across these six trends, there are three themes that really stood out to us. One is that CMS is increasing accountability through downside risk and expanding the value-based care across a broad set of providers and stakeholders.

 

Pooja Panchamia: Second is that CMS is now creating more long-term pathways for value-based care through models such as LID.

 

Pooja Panchamia: And third is that success is now becoming even more dependent on data, documentation, reporting, and operational execution, which makes it more important for you to, like, think of it as a value-integrated enablement, where you are focusing on all these different aspects.

 

Pooja Panchamia: And really, the conversation has shifted from getting organizations into value-based care to actually helping them perform and succeed in that kind of arrangement. So that really takes me to the next slide here, which is…

 

Pooja Panchamia: Discussing about where organizations are today in their journey, and across those different stages, what kind of performance and capabilities it makes sense to invest in.

 

Pooja Panchamia: And one thing that we've also learned working with ACOs over the years is that

 

Pooja Panchamia: This journey is not always linear. Organizations could often move through these stages at different speeds and many are operating across multiple stages simultaneously as well. But what is common is that the questions that an ACO asked at year one are often different from what they would be asking in year five.

 

Pooja Panchamia: And as I walk you through these stages, I would encourage you to think about where your organization stands today and what are some of the capabilities that could be useful at each of those stages. So starting off with formation and readiness.

 

Pooja Panchamia: That is usually the first stage, like, first couple of months when your ACO has just been set up. It's the early stage where you're still asking the foundational questions, whether do you have the governance structure to support accountable care, or do you have the provider network or infrastructure.

 

Pooja Panchamia: To support them to participate and do you really understand the population that is going to be attributed to you and what their needs are? So focus here is really less on performance but more on building that foundation for future success, establishing those right leadership structures.

 

Pooja Panchamia: Defining who your participating providers are, and assessing the capabilities that you would need going forward.

 

Pooja Panchamia: And that takes us naturally to the next stage. Once you've formed your ACU, the next stage is like contracting and identifying what kind of risk model makes more sense for you. So how much risk you are prepared to take, how favorable is your benchmark position, what financial exposure are you willing to accept? And given all the changes we discussed earlier around

 

Pooja Panchamia: Downside risk increasing and evolving CMS models.

 

Pooja Panchamia: These decisions have become even more important because success at this stage is really about creating that right strategic and financial foundation through contracting that will influence your performance for years to come.

 

Pooja Panchamia: The next one here is building competency, so this is usually year one and two, where you're still early on, you're in the upside model, getting the lay of the land, and this is often when organizations start encountering the first operational challenges, because there is a

 

57

00:12:14.530 --> 00:12:20.290

Pooja Panchamia: There isn't a lack of data, but it's also big data is all fragmented across your network.

 

58

00:12:20.300 --> 00:12:36.650

Pooja Panchamia: And the challenge is like, how could we turn those insights into provider action? So at this stage, the focus could be bringing all those insights, integrating claims, clinical data, engaging your providers, operationalizing care management and quality programs.

 

59

00:12:36.650 --> 00:12:40.939

Pooja Panchamia: and embed value-based care into everyday workflows.

 

Pooja Panchamia: The next one here is where you've been around like in the value based arrangement for a couple of years. Now you're moving into a more advanced risk arrangements.

 

Pooja Panchamia: where performance management becomes more critical. And at this stage, you're taking downside risks, so you're really wondering which are the providers that are driving that variation, which is the population that is creating the greatest risk, and there is opportunity to improve in those areas.

 

Pooja Panchamia: Where are we likely to maybe miss our quality targets? What are some opportunities to support that? And how could we really influence our performance before the year ends?

 

Pooja Panchamia: So at this stage, you really need strong forecasting capabilities because you're taking on more risk. You need better visibility into your risk and quality opportunities and also more targeted intervention strategies for population that need it the most. So shift here is again moving towards more proactive performance management.

 

Pooja Panchamia: And actively identifying what those opportunities are that could influence the outcomes.

 

Pooja Panchamia: while there's still time at that performance year.

 

Pooja Panchamia: All this takes us to the last stage, which is more of a sustained performance. You've been in this VBC arrangement for a few years. You've likely developed programs.

 

Pooja Panchamia: that are focused on optimizing that performance. And at this point, you have a good understanding of where the gaps and opportunities are.

 

Pooja Panchamia: But then if you haven't already, this is often the stage where organizations start building more deeper capabilities around managing that utilization, coordinating specialty and post-acute care, understanding really the event level drivers of your cost and quality, and looking beyond traditional clinical factors that could influence outcomes. So at this stage, it's not really driven by a single

 

Pooja Panchamia: Initiative of program, it requires a more continuous mindset at an organization level and operational discipline to sustain that long term performance.

 

Pooja Panchamia: So…

 

Pooja Panchamia: The key takeaway over here is that maturity is not really defined by how long you've been in an ACO, and it's really defined by how effectively you're turning that data insights strategy into operational action and how that's impacting your readiness to absorb more risk as you move through the tracks within the ACO.

 

Pooja Panchamia: And I'm sure every organization here is somewhere on this journey, but not necessarily at the same place across each of these capabilities that we spoke about. So with that in mind, I wanted to hear from the audience.

 

Pooja Panchamia: Where do you see your ACO requiring the most support to help improve the VPC performance?

 

Pooja Panchamia: Is it the contract strategy and benchmark performance, or is it total cost of care and utilization, or is it point-of-care insights, or is it quality performance and care coordination? Or if it's anything outside of this, then you can select other option, but we would really like to understand where you stand today.

 

Pooja Panchamia: Definitely see more participants selecting total cost of care and utilization, but I'll wait till the poll is completed.

 

Pooja Panchamia: Okay, so, yeah, I think that's correct. That's the…

 

Pooja Panchamia: That's the biggest challenge at the barrier right now, and it's also consistent with what we are seeing across in the market, and what we are hearing from the audience with respect to cost and quality, and

 

Pooja Panchamia: usually that's where the organizations are feeling the most immediate financial pressures and has a more direct impact than the shared savings that you are able to earn. But

 

Pooja Panchamia: regardless of where that gap is, what we also see consistently is that these capabilities don't operate in isolation. So I… I want to use this information and take you to the next slide, where we see which are some of the largest four pillars.

 

Pooja Panchamia: across the ACO performance, and

 

Pooja Panchamia: How it would be useful to build capabilities across them.

 

Pooja Panchamia: So, over here, you can see these are the four

 

Pooja Panchamia: pillars that we've listed out. And while every ACO invests in some of these areas, what often differentiates a high performing ACO is that it's not any single capability, but they're actively thinking about how these capabilities could work together. And that's what we define as integrated value enablement.

 

Pooja Panchamia: So starting off with the foundational base, which is contracting and benchmarking.

 

Pooja Panchamia: This is this is usually the first step because you're entering into an ACO arrangement. And before organizations can even think about what they should be doing for improving outcomes.

 

Pooja Panchamia: They first need to understand how that performance will be measured. That includes model selection, benchmark positioning, your attribution dynamics.

 

Pooja Panchamia: And without having that foundational understanding of what is your financial framework, performance levers and benchmark drivers, it's really difficult to know where you should be focusing those resources and improvement efforts.

 

Pooja Panchamia: And then that takes us to the next one, which was the most popular on the poll earlier, cost and utilization management, which we believe is the, again, the most important pillar while you are building out the capabilities, and usually.

 

Pooja Panchamia: Once organizations have a good understanding of your contract and performance drivers, the next area is building visibility into what your utilization patterns are.

 

Pooja Panchamia: if there is any variation in your care delivery patterns and what are the factors that are influencing your total cost of care. And with more organizations now moving into two-sided risk arrangements, understanding and managing that utilization just becomes even more important.

 

Pooja Panchamia: Next pillar that we have here is clinical insights and documentation. And I did touch upon earlier that CMS is now continuing to emphasize on encounter-based documentation. There is more prospective trend methodologies in place as well. So organizations like yours, you really need to think about what are the capabilities that could connect?

 

Pooja Panchamia: Data workflows, care delivery, and AI also plays such an important role at this stage because AI could help identify.

 

Pooja Panchamia: What those insights are which has the highest opportunity and push that at prospective point of care workflows that create greater visibility into your patient risk and at the same time support your provider action at the time of encounter and then lastly that we have here is the quality and care transformation which is

 

Pooja Panchamia: Really, the goal of all these efforts is improving patient outcomes at the end of the day, so organizations that have the ability to identify and close those care gaps, coordinate that care across your settings and member population, and then depending on which members require

 

Pooja Panchamia: Targeted interventions, maybe it's like complex high-risk population, you are able to have programs that

 

Pooja Panchamia: That is able to support that. So…

 

Pooja Panchamia: This is just a quick picture of the capabilities that we see are the most important for an ACO. And when you look at these independently, this might look like four separate capability pillars.

 

Pooja Panchamia: But really, the integrated value enablement is connecting these capabilities into a single operating model, so the improvements in one area really support performance in others as well. So, I'll give you a quick visual of what that looks like.

 

Pooja Panchamia: So as you can see, this is a quick flywheel of how these capabilities influence each other.

 

Pooja Panchamia: And when you think about ACO performance and maximizing shared savings, there are really two main fundamental objectives. One is improving the benchmark performance and second is reducing the total cost of care. So starting on the left side of the flywheel, you can see that there's contracting and benchmarking that sets the foundation. We discussed about contract structure, risk track attribution

 

Pooja Panchamia: decisions that all shape the ACO's benchmark.

 

Pooja Panchamia: And that has the ability to influence the shared savings as well and then there's clinical insights and documentation built on that foundation that provide a more complete picture of the population that you are serving and

 

Pooja Panchamia: The whole purpose of clinical insights and accurate documentation is that your benchmark is able to reflect what the actual patient acuity is and it reflects the expected cost of care.

 

Pooja Panchamia: So that is on the left and on the right side you can see there's cost and utilization management that focuses on reducing avoidable utilization, unnecessary spend, all of which could influence the total cost of care. Similarly with quality and care transformation that can strengthen the preventive interventions that you could take.

 

Pooja Panchamia: care coordination efforts that are required, and which could improve the patient outcomes as well. So, really, the key message here is that

 

Pooja Panchamia: Balancing all these four different capability areas, but at the same time.

 

Pooja Panchamia: all these different pillars also influence each other, and they are not independent. So, just to give you an example.

 

Pooja Panchamia: Say, a better documentation at the point of care that creates a more accurate view of your patient risk.

 

Pooja Panchamia: which in turn strengthens your benchmark accuracy, and that also in turn helps the organizations to focus which are the population that require care management and quality efforts, and all of which, again, plays a role with respect to reducing any

 

Pooja Panchamia: avoidable utilization and bringing down the cost of care. So all of these are interconnected and that's the whole point here where improvements in one area creates like more downstream impact across the others and creates more compounding effect on your entire shared savings potential.

 

Pooja Panchamia: So, with that, I think the next question comes to how do these organizations, like, how could you operationalize all these capabilities and translate them into action? So, to answer that, I'll pass it on to Brett, who could walk you through that strategies.

 

Brett Superfine: Thank you, Pooja. Phenomenal job walking through that. As Pooja alluded to, we're going to talk more about how do we translate these ACO priorities into action?

 

Brett Superfine: What was interesting to me?

 

Brett Superfine: we're on. If you could go to the next slide, Pooja. Perfect. What is interesting to me is on that poll, and I'm not shocked. The contract strategy and financial performance that was lowest on the areas that need improvement that you all feel. However, this is oftentimes

 

Brett Superfine: a underlooked and underestimated decision that ACO… successful ACO organizations, really kind of… they don't emphasize enough, because it's a one-time… it's a one-time effort, typically, that impacts your decisions for the next five to seven

 

Brett Superfine: years. However, the best ACO and value-based care organizations really think of contract strategy and financial performance as an operational and a financial discipline. It's continuously monitoring against their contract terms.

 

Brett Superfine: And ensuring that their organization is set up for success in the years to come, not just in the immediate future. The first question that most ACO leaders ask is, what model and what risk track fits best for them?

 

Brett Superfine: Each year CMS seems to come out with a new model or a new variation or changes to the regulatory environment. What's really important when these organizations are deciding what model and what risk track fits them both.

 

Brett Superfine: is that they are looking at different scenarios. They're looking at what is the worst case, what is the most likely case, what is the best case, and what are all the in between scenarios. This is important when it comes to understanding how much risk your organization is willing to take, and then also what is the ceiling that you are gonna put onto your organization.

 

Brett Superfine: And then, ensuring that your organization has the right capital and governance structures currently set up, and or plan to be set up in the future, months and years to come.

 

Brett Superfine: We also, what is important is to understand what are some of the timelines and some of the deadlines.

 

Brett Superfine: This is something that seems very fundamental. However, what we oftentimes see with different clients and different ACO organizations is that they are scrambling in the last day or two to get an application done. They might need to take shortcuts when it comes to their actuarial or financial modeling, and therefore that impacts the track and decisions down the road. So ensuring that your organization has

 

Brett Superfine: a submission plan to make sure that you're hitting the CMS deadlines.

 

Brett Superfine: And making sure that you have the right ownership and governance within your organization to have the TINs being participating signed up and make sure that you are ready from a documentation standpoint.

 

Brett Superfine: And the last thing is.

 

Brett Superfine: Which drivers are going to shape your performance? As Pooja alluded to, you have those four key capability areas. They all influence the overall performance of your organization. However, you can't be a subject matter expert and a superstar at all those at the very start. So how can you focus on some of these high impact areas? And then as your organization continues to mature and you start to be successful and get

 

Brett Superfine: to a better state on those initial areas.

 

Brett Superfine: Then you can start to expand the breadth of your organization. And ultimately the contracting contract and financial strategy, it sets up the ceiling and the opportunity and also the floor for your organization.

 

Brett Superfine: And what this really helps with is the next lever that I'm going to talk about, and that's the cost of care and the utilization. That's how do you actually capture and how are you actually successful with the contract decisions that you all make.

 

Brett Superfine: So when we saw the results of the poll and total cost of care and utilization was the one top of mind, that also isn't that surprising. And the reason it's not surprising is that is where you see the most visible ROI.

 

Brett Superfine: And this is also where we are seeing a shift in technology, in AI, and this is one of the areas that most of the value-based care organizations see the greatest impact.

 

Brett Superfine: And this is really switching from a reactive framework to a proactive framework. How can you leverage AI, machine learning models, large language models.

 

Brett Superfine: technology and data processing. How can you leverage all of these technology advancements to help the insights that are being generated, not to get more, but to become more precise, more actionable, and therefore have a greater impact on your organization.

 

Brett Superfine: So where we where the first step typically is, is understanding where is the avoidable spend concentrated? Is it the ED? Is it the inpatient setting specialty? And then what are these high cost cohorts that are really driving your PMPM trends?

 

Brett Superfine: And one of the, I would say, areas of opportunity that a lot of organizations have is they really look at the aggregate level.

 

Brett Superfine: this is useful when it comes to the overall performance, to see how you all are tracking. However, what is most important is getting deeper.

 

Brett Superfine: And the aggregate tells you a high level picture, but what really is where the value is generated is those lower level, higher granularity cohorts. So this could be certain providers, this could be certain procedures, certain conditions that are really driving the cost of your populations.

 

Brett Superfine: what we oftentimes see is the high risk members. They're often the ones that are polychronic. They're polypharmacy. They're the ones that are typically the highest utilizers.

 

Brett Superfine: Those are the ones that drive the spend. They drive the readmissions. They drive these high acuity encounters with different clinical team members. However, what

 

Brett Superfine: AI and technology has really enabled a lot of organizations to focus on is the rising risk group. This is the group that is balancing between, I would say, being stable or being healthy and ultimately becoming one of those high risk members. That is where your organization can start to focus some of your resources.

 

Brett Superfine: And start to deploy interventions to ensure that those rising risk members do not get to the highest acuity levels, which is the high risk, polychronic,

 

Brett Superfine: Levels of…

 

Brett Superfine: stratification. What this also does when you start to understand at a population and cohort level is you're able to really deploy condition-specific care pathways. You're able to have more proactive outreach, and you're able to tailor your operating model to focus on these key areas that are really driving the greatest spend for your organization.

 

Brett Superfine: and then often. Then the next thing is to consider what levers can we do to reduce the avoidable cost? Is there certain referral patterns or referral leakage that your organization

 

Brett Superfine: is dealing with. Is there post-acute variation? Are there higher levels of post-acute, if it's special needs facilities, instead of outpatient? Is there an intermediate ground? Are there ways that you can start to have a better care transitions program for your organization?

 

Brett Superfine: And how do you ensure that when you are trying to drive these changes to reduce these avoidable costs?

 

Brett Superfine: How do you have the right ownership? We often see that organizations, they have analytics, they have dashboards, they see it at monthly business or quarterly business reviews.

 

Brett Superfine: But when it comes to the actual ownership of how do we drive change? And how do we influence these different levers? That is oftentimes where we see organizations really fall flat, and where there's the greatest area of opportunity.

 

Brett Superfine: And once you know where these opportunities lie, the next most important thing is how do you activate on it? How do you ensure that the right insights are getting to the point of care?

 

Brett Superfine: So when we think about the point of care and the clinical documentation, would you be good in the next slide here? Perfect. Thank you. This is really when I think about where do you actually drive the change?

 

Brett Superfine: And this is where the, when we say point of care, this is really that interaction with the member or the patient.

 

Brett Superfine: And historically, when the term clinical documentation was was mentioned.

 

Brett Superfine: The first thing is risk adjustment benchmarking. That is where the mind typically has gone in the past. However, with CMS's push to really focus on point-of-care documentation, that mindset needs to shift.

 

Brett Superfine: And this, when we think of clinical documentation, it is not just financial, it is not just focused on risk adjustment, it's really ensuring that your organization has an accurate and comprehensive picture of each of your members and each of your patients. And what this enables is to ensure that your members or patients, they are

 

Brett Superfine: They're going to the right care management program and then it helps from an operational workflow standpoint to ensure that at the point of care your physician is

 

Brett Superfine: The provider has all the latest and greatest information and a full 360 member view of that member.

 

Brett Superfine: This is also another area where AI and technology is really making advancements.

 

Brett Superfine: And where it's really making advancements, as I alluded to, it's not about the quantity of insights that get to the providers. It is the ability to deliver high impact and precise

 

Brett Superfine: Data insights to make sure that at the point of care it is working efficiently.

 

Brett Superfine: And one of the most common

 

Brett Superfine: Pushbacks that we hear from different provider organizations is alert fatigue.

 

Brett Superfine: That means they are getting too many alerts. You keep pushing different alerts to the Ehr. Well, that becomes overwhelming.

 

Brett Superfine: And these physicians, they want to work at top of license. We don't want them to have to necessarily go through a checkbox of 50 to 100 different items. We want them to really focus on what is the highest impact and what is ultimately going to drive better care for the members. So how can you ensure that your organization and your teams, your technology, your workflow integrations are set up in a way that you're really

 

Brett Superfine: sending the highest impact.

 

Brett Superfine: Insights to the point of care so that these physicians can really help drive change and better member outcomes.

 

Brett Superfine: And then after that point of care, this is another area where we oftentimes see organizations fall flat, is the disconnect between what happens at the point of care, then the documentation that follows, and then also the follow-up care plans.

 

Brett Superfine: We know that when you have an organization that has a very strong technology ecosystem where you have insights that are flowing to the point of care, and then what happened at the point of care gets put back into the different technology and different models.

 

Brett Superfine: We know that those are the organizations that are set up for sustained success. However.

 

Brett Superfine: If there is a gap where what is happening at the point of care does not have a mechanism to get back into the ecosystems, that is where there is an opportunity to get better, and that is where the technology advancements that we're seeing in today's day and age, we believe there is a really strong opportunity for that.

 

Brett Superfine: And ultimately, when we think of this point of care intelligence, we can call it, it really sets up for the next downstream impact. That's the quality and care coordination story. And

 

Brett Superfine: Yes, it's important at the point of care to make sure that you're getting all the right insights, but what does that actually do in the long term? It's improving the member's quality of life, it is improving the quality of care, and ultimately it is driving a transformation for the member's health outcomes.

 

Brett Superfine: As these value-based care models from CMS continue to evolve, quality has taken a front seat.

 

Brett Superfine: it is extremely important that we are thinking of quality, not as a compliance checkbox, but as an operational and a financial lever, because the Aco and value-based care organizations that are set up for sustained long-term success.

 

Brett Superfine: They are focusing on this quality and the care transformation, because not only does this impact the members.

 

Brett Superfine: and their outcomes, it impacts financials. Oftentimes.

 

Brett Superfine: the quality gates or quality thresholds, they are the key to unlocking shared savings for your organizations. You might be able to address total cost of care and do a phenomenal job reducing your total cost of care by

 

Brett Superfine: 2%, 3%, 4%, 5%. But if you are not hitting quality thresholds, oftentimes that really doesn't mean as much because you're not able to access the value that your organization generated through your total cost of care efforts.

 

Brett Superfine: And when we think about focusing on the quality improvement efforts for your organizations, what's really important is that you're able to stratify, prioritize, and really

 

Brett Superfine: Put these members into different cohorts to really be effective from an operational standpoint.

 

Brett Superfine: This is where driving care transformation, this requires some change management, changing provider behavior of how they were historically operating from more of a volume and unit utilization based framework to more of a quality and value based framework. This is difficult.

 

Brett Superfine: We hear this every single day from all different clients, from health plans to value-based care organizations to provider groups.

 

Brett Superfine: It is tough to change what has historically been done for decades and decades.

 

Brett Superfine: However, we are really at this inflection point where we now have the regulatory bodies really driving for this value-based care, trying to get all these Medicare members into a value-based care arrangement by 2030. And then, in addition, we have technology that is really helping to expedite and help be a catalyst.

 

Brett Superfine: to successful transitions and migrations within the value-based care.

 

Brett Superfine: So… I leave this to say.

 

Brett Superfine: All of this, what Pooja and I have talked about over the last 45 minutes here.

 

Brett Superfine: They are all important. However, when we think about the most successful ACO organizations, value-based care organizations, it really all stems back to that integrated value enablement.

 

Brett Superfine: Your organization needs to be able to focus across these different core capability areas, these core domains, to be successful.

 

Brett Superfine: And with that, you need to ensure that your organization has the right internal governance, operational framework.

 

Brett Superfine: And where needed, the right partners and subject matter expertise. And that is something that organizations oftentimes, they struggle with. They believe that they have, and they know everything that they need to be successful, and that is where finding the right partners becomes really important.

 

Brett Superfine: And I leave you all with that and I'm gonna pass it back to Pooja to kind of finish off with a couple additional poll questions.

 

Pooja Panchamia: Good, thank you.

 

Pooja Panchamia: So with that, we did discuss about.

 

Pooja Panchamia: all the different, like, trends and, like, ACOs are continuing to face this rapidly evolving environment.

 

Pooja Panchamia: Brett also spoke about the four primary pillars across contract, cost, clinical insights, quality, and why value.

 

Pooja Panchamia: integrated value enablement plays a role. And we also touched on how these translate into your organization strategy and how that changes depending on the stage of your organization. But we also wanted to do a quick poll again to really understand what do you see as the biggest barrier for sustaining that ACO performance, especially over the next two to three years.

 

Pooja Panchamia: Is it keeping pace with the CMS changes and the benchmark improvements that are coming through? Or is it adopting AI and integrating those insights into your workflows?

 

Pooja Panchamia: Or is it engaging your providers in more value-based care models? Or is it still managing total cost of care across, but more focused on specialist and post-acute settings? And lastly, is it coordinating care for complex and high-risk population? So…

 

Pooja Panchamia: Let me see if the poll is open.

 

Brett Superfine: Pretty mixed results here.

 

Pooja Panchamia: It.

 

Brett Superfine: Hopefully, you all kind of see, when you see these polls, you hear the topic that we're talking about, you realize you all aren't alone. The challenges that you all face

 

Brett Superfine: They are very common and we hear those common threads whenever we talk to different organizations. If the value-based care health system, small independent provider group health plan, we hear very similar themes.

 

Brett Superfine: And…

 

Brett Superfine: There's, it's an ever changing model. It is, it's hard, it's hard stuff to make these fundamental changes and transformational changes.

 

Brett Superfine: So with that, said Pooja, I think we should. Let's move on to a little bit of the Q. And a.

 

Brett Superfine: So one of the questions in the chat, will we send the recording and the slides,

 

Brett Superfine: Yes, we will. Please reach out to myself or Pooja. Our contact information will be, provided at the end here, and we'll be sure to, have… if you have additional questions, or, you want to see the slides of the presentation, we'll be happy to distribute it there.

 

Brett Superfine: The next question I see in the chat, what would be a commonly occurring example of reducing the cost of care with inadequate quality?

 

Brett Superfine: This is oftentimes when we think about utilization. We see this the most, where how do you, prevent

 

Brett Superfine: members from going into the physicians. Yes, this lowers the aggregate total cost of care, but what this really does

 

Brett Superfine: is it alleviates those touch points where you can start to drive that proactive clinical impact for that care journey. You want to ensure that you are having these members getting into the right PCPs, the right specialists.

 

Brett Superfine: So then, you can make sure that the quarterbacks of those, those members, their cares, that they are actively involved, with that, their care journey and their care pathways.

 

Brett Superfine: Pooja, anything to add for that question?

 

Pooja Panchamia: I think you covered it all. It really depends upon like you still prioritize the opportunities and if there are certain care pathways or member interventions that are still important for certain high risk or complex population, you still prioritize that for quality purposes. But yeah, I think the common example would be like cutting down on some of those efforts to reduce the cost of care, but that really

 

Pooja Panchamia: impacts the care that's getting delivered to your patients. It's more about

 

Pooja Panchamia: Doing a fine balance and maybe finding different ways to deliver that care, but that also kind of optimizes on the cost that's incurred.

 

Brett Superfine: Okay.

 

Brett Superfine: Pooja, here's one for you. Many organizations struggle with provider engagement and value-based care. What approaches have you seen work best when introducing new workflows tied to MSSP performance?

 

Pooja Panchamia: Yeah,

 

Pooja Panchamia: Especially, I think, when we think about engaging providers in value-based care, and this is something we've consistently heard also, and Brett also touched on alert fatigue while he was talking through the different pillars, and it's really not so much about.

 

Pooja Panchamia: data problem like that. There's different insights that are coming from Ehr other vendors that you would be leveraging. There is a lot of information that's flowing to the providers.

 

Pooja Panchamia: But they are also managing a lot of these like different information that may not be directly flowing into their workflow. So where we see the really the most success with organization is where we are able to deliver those right inside at the right workflow at the right time. So right before your patient visit that's happening within those existing workflows that your providers are already comfortable with.

 

Pooja Panchamia: So, you know.

 

Pooja Panchamia: Definitely, like, prioritize more prospective point-of-care opportunities where providers could take action within the clinical workflow itself and does not have to navigate into different platforms, but

 

Pooja Panchamia: When we think about engaging the providers also, it could also involve like creating the right incentives, the right goals, also identifying like if they need support with provider education, coding education, what are really the reasons why they're not engaging with the workflows or the insights that's coming out to them. And once you identify those.

 

Pooja Panchamia: Creating solutions or programs that could help incentivize them to do that.

 

Brett Superfine: Perfect. Thank you, Pooj

 

Brett Superfine: I think I'll take this next one here. With more MSSP ACOs operating in two sided risk arrangements, what changes most significantly in how leaders should manage performance throughout the year? It's a good question.

 

Brett Superfine: Really, when it comes to two-sided risk, the margin of error, it's… It's smaller.

 

Brett Superfine: And the impact of these errors or the lack of execution, it's greater. And when you have this exposed downside risk.

 

Brett Superfine: The leadership team, the operations team, you become a very… you become more of a fragile ecosystem.

 

Brett Superfine: And you need to have greater confidence in the underlying capabilities. Underlying capabilities can be your operational framework, it could be your technology, it could be the insights, it could be

 

Brett Superfine: your overall provider network. Ensuring that there is confidence and trust across the full ecosystem is really where we see successful value based care organizations take off.

 

Brett Superfine: And then… Even more important is the change management and the ability to pivot.

 

Brett Superfine: Just because you make a decision at the beginning of the year, if you start to see in the data over the first 6 months that what you thought was going to be a high-cost driver, let's just say a diabetes, you thought that that was a high-cost driver because that was what

 

Brett Superfine: it was last year, but now it actually turns out to be CHF is one of your organization's greatest cost drivers.

 

Brett Superfine: You need to be able… your organization needs to be able to be flexible and really pivot the operational processes to address whatever has came back from your financial and your actuarial team and your clinical operations teams. So really ensuring that your team has the right framework and the right,

 

Brett Superfine: enabling capabilities is really becoming more critical, and then making sure that you are thinking in that proactive mindset. You have ongoing forecasting. Your organization, it's not just an end-of-the-year reconciliation, it's that ongoing management and observation of your population.

 

Pooja Panchamia: I think I can take the next one. We have a question saying, from a peer perspective, what's really the most effective way to support your provider partners that are participating in BBC arrangements without creating any additional administrative burden for them? So we're just

00:47:37.600 --> 00:47:50.310

Pooja Panchamia: This is a good question, and there are more and more, like, health plans, and even at a system level, organizations are thinking about how they could support their providers in creating that right

 

Pooja Panchamia: Both economic as well as operational environment, so as I would say, as providers are taking on more risk, they are also

 

Pooja Panchamia: In a way required to invest in capabilities around care management, quality, population health, cost of care.

 

Pooja Panchamia: But at the same time, a lot of these like providers, they might be struggling with like budget constraints and where they should be prioritizing those resources for. So there is one way where payers could help support that transition for providers moving and taking on more risk under value based care is by aligning incentives, providing more visibility into some of their high risk population performance drivers.

 

Pooja Panchamia: And in some cases even really help fund or support programs that could help improve those outcomes and reduce cost of care for their provider partners.

 

Pooja Panchamia: Anything you would like to add, Brett?

 

Brett Superfine: I think you got it.

 

Brett Superfine: You, you nailed it there.

 

Brett Superfine: What is a webinar today without a question about AI? So, where do you see the most practical opportunities for AI to support ACO performance today?

 

Brett Superfine: I alluded to this a little bit earlier when I was speaking through, regarding cost and utilization, clinical insights, but to me, it's…

 

Brett Superfine: Really, something that is oftentimes overlooked is…

 

Brett Superfine: When we say there's AI in healthcare, it is not replacing the human.

 

Brett Superfine: At all, it is not replacing the clinical decision making. It is making those humans, making those physicians smarter. It is equipping them with insights to make better decisions, more efficient decisions.

 

Brett Superfine: And then ultimately, how can we alleviate the administrative burden so that they can really focus on acting top of license?

 

Brett Superfine: And it might sound cliche, but one of the things we oftentimes hear is the providers don't want more documentation, they don't want more alerts. Yes, that does happen sometimes, but really it's about focusing on not the quantity of that and the quality of those actions.

 

Brett Superfine: How can we ensure that when it comes to the insights that are being surfaced, they are only the ones with the highest impact and they are the ones that are going to drive the biggest change when it comes to the care for the members.

 

Brett Superfine: And then when it comes to clinical documentation, how can we alleviate some of the administrative burden for these providers when it comes to accurately recording what happened during the visit? Is it AI support when it comes to the actual documentation? Is it ambient AI that is helping to transcribe?

 

Brett Superfine: the the visits.

 

Brett Superfine: There's a lot of innovations that are going on and that are really making that point of care much more efficient.

 

Brett Superfine: and impactful for both providers and the members. Another area where I see that AI is

 

Brett Superfine: Going to really help drive change for the better is predictive analytics.

 

Brett Superfine: And it's how can you identify who is that rising risk? So then you can bend that cost curve, you can bend that care curve so that they don't continue to progress, so they can become stable, they can become healthy. How can you.

 

Brett Superfine: more proactively earlier and earlier identify those members that are at the greatest risk to go into the ER, go into the inpatient setting, and then they are having continuously rising acuity. So.

 

Brett Superfine: I really think that AI, there's a ton that it can do, and same with technology. I know AI is the one that gets the most buzz, but

 

Brett Superfine: The ability for analytics to.

 

Brett Superfine: be processed to be updated. For when I first started, at Optum, it could take weeks for data to process, claims data to process for a single health plan. Now we're talking hours or days.

 

Brett Superfine: So, it's those type of improvements that enable better decision-making

 

Brett Superfine: faster decision-making, and then enables organizations to become more successful and more efficient in different areas. So it's really that precision and that proactive nature that I believe that AI is really gonna drive, change and success within ACO.

 

Brett Superfine: and IE-based care performance.

 

Brett Superfine: Here's one, Pooja. For organizations that are earlier in the value-based care journey, where should leadership focus first when it comes to building capabilities needed for long-term success?

 

Pooja Panchamia: Pressing 1, and

 

Pooja Panchamia: I think it aligns to a lot of the stages that we spoke about, and where you stand with respect to your… in terms of how much risk that organization is taking, and what capabilities they already have today. But say, if you are still very early in your value-based journey, I think what would be important is to really understand

 

Pooja Panchamia: one is your population, and second is your provider network. With respect to population, it's important to have, like, good visibility in terms of

 

Pooja Panchamia: Which providers they are attributed to, what is really driving the cost and outcomes today. So really doing a base level assessment with respect to where you stand with respect to population, what are some of the opportunities that exist.

 

Pooja Panchamia: And then, secondly, once you have an understanding of that, you could align your

 

Pooja Panchamia: leadership and performance goals and levers and your operational capabilities that is more aligned to that population needs.

 

Pooja Panchamia: But at the same time I I think if you're still very early I think it would be good to like look at and understand like your contract and your especially the levers that we discussed earlier like what kind of flexibility you have like what what stage you are like which track or risk level that you have contracted today and having that in mind like how your even the provider network is spread out like like with respect to your

 

Pooja Panchamia: providers, like how many PCP specialists, if there are any capabilities or technology that they are already leveraging, or are there something additional that could be useful for those providers too?

 

Pooja Panchamia: better engage and prioritize these care gaps and opportunities that are… that could be useful for your patient population. So I would say, like, if you're still very early, I think it's good to just get a good sense with respect to your contracting and needs, and get a…

 

Pooja Panchamia: I would say get good risk insights and assessment both on your patient population and provider network where it stands today and then identify what kind of maybe solutions or technology could be useful to really drive those outcomes that you're looking for.

 

Brett Superfine: Perfect.

 

Brett Superfine: Here's another one.

 

Brett Superfine: As we've spoken with different organizations across the market, what's one trend shaping ACO performance that you still think is underappreciated?

 

Brett Superfine: I'll take this one. I think there are…

 

Brett Superfine: There are a couple things. We've touched on it before when it comes to

 

Brett Superfine: the core foundation, the contracting, the financial performance. How are you… are you making sure that your organization is prepared for what taking on upside and downside risk actually entails? That is underappreciated and overlooked. Oftentimes, organizations are…

 

Brett Superfine: Narrow-minded when it comes to the upside of it, but they're not thinking about the negative.

 

Brett Superfine: They're not thinking about if you are… you might be able to have greater revenue and greater, air quote, success with some of these riskier arrangements, but are you actually going to hit whatever that maximum threshold is? Are you going to be able to be successful? So, I think that

 

Brett Superfine: sometimes organizations, they get ahead of themselves and their value-based care maturity, and I think that's something that needs to be

 

Brett Superfine: considered a little bit more than sometimes it actually does. For these organizations, you need to have the right scenario modeling, you need to run the right Monte Carlo simulations to see where your organization is

 

Brett Superfine: don't likely to fall. And to put it to your point, understanding.

 

Brett Superfine: Where they're likely to fall based on your population.

 

Brett Superfine: You can't just take macro trends. Every population is going to be very specific. They're going to be very unique.

 

Brett Superfine: So how do you ensure that you are understanding those detailed, kind of, micro trends within your population? So I think that's one area that's underappreciated, and I think another area that I would say

 

Brett Superfine: It's not underappreciated, but I would say it's…

 

Brett Superfine: a little bit underdeveloped, and it's something that is very tough to address. And that's about specialty specialists and specialty care.

 

Brett Superfine: Value-based care and ACO organizations have historically focused on the primary care physicians, and that is… that's correct. That is absolutely… that they are the quarterbacks of care. However, most of the cost takes place outside of their four walls.

 

Brett Superfine: So how can you ensure, how can your value-based care organization ensure that you have the right mechanisms to be successful and monitor the specialists, monitor your post-acute providers?

 

Brett Superfine: And how can you ensure that they're continuously being held to a high standard and really raising the quality of care for your members and your patients?

 

Brett Superfine: Bailey, I know we're almost at time here, and I know that there were some questions in the chat that we did not answer.

 

Brett Superfine: I welcome sending a message to myself, to Pooja, and we'd be happy to have additional dialogue about any of the questions that we weren't able to be answered. There's quite a few in here, so I really appreciate the engagement that you all had.

 

Brett Superfine: We hope that you learned something. We would love to continue the conversation and the dialogue with you, so please don't hesitate to reach out to one of us, and we really thank you for the time. So, with that being said, I'll pass it to Bailey for some final remarks.

 

Bailey Fields: Yeah, thank you so much to the Optum team, especially Brett and Pooja, for today's presentation. A lot of great information.

 

Bailey Fields: Just as we're wrapping up today's webinar, you will see a post webinar survey that's going to pop up on your screen as you close out. So if you could just take a moment to complete those few questions for us, it'd be greatly appreciated. Again, thank you everyone for attending and thank you so much to Optum for sponsoring today's webinar and we look forward to seeing everyone on the next one. Have a good one.

 

Brett Superfine: Thank you, everybody.

 

Pooja Panchamia: Hi, everyone.