The missing link to risk adjustment success

Health plans today face significant challenges. Regulatory changes, financial pressures and the upheaval caused by the transition to the V28 risk adjustment model are reshaping the industry. Recent Optum research has revealed that 42% of payers feel underprepared for regulatory changes, citing resource constraints and lack of expert guidance. In this era of change and challenges, many health plans are reporting plateauing growth and a decrease in Star ratings, which leads to tighter budgets and a greater need for operational efficiency.

As health plans try to do more with less, some are investing in system updates and hiring skilled personnel. Others, especially smaller and mid-sized health plans, are increasingly relying on vendors to handle certain operations. On the other hand, some plans are looking to consolidate vendors to streamline operations. What’s missing? Program orchestration: the ability to harmonize all moving parts into a cohesive, strategic whole.

Why orchestration matters

Program orchestration goes beyond management. While management focuses on tasks and timelines, orchestration helps ensure alignment across systems, vendors and internal teams. It’s about creating synergy so that every component, from risk adjustment to member engagement, works toward shared goals. Multiple data systems, structures, timing and methods of data collection exist, making personalized strategies tailored to each unique stakeholder essential.

The advantages of program orchestration

Program orchestration is the coordinated oversight and strategic direction of all the systems, vendors and processes that health plans use to deliver their services and meet their goals. More than just an administrative function, program orchestration can help health plans remain competitive and efficient in a rapidly changing industry. Some of the competitive advantages associated with program orchestration include:

• Data nuance and strategic insight: Every health plan serves unique populations and geographies, creating nuances in data and provider relationships. Effective program orchestration requires critical thinking and strategic insight to interpret these nuances and make informed decisions.
• Stakeholder relationships: Managing relationships with providers, enrollment teams and other stakeholders is complex. Providers may use different systems and charge fees for risk adjustment claims. Program managers act as liaisons, delivering smooth collaboration and data exchange both internally and externally.
• Performance tracking and continuous improvement: A core component of performance orchestration is value stream mapping, which helps health plans identify bottlenecks and learn from past experiences to improve future outcomes.

Insourcing or outsourcing?

Program orchestration can be performed in-house, but it requires dedicated staff to oversee the process. More commonly, program orchestration is outsourced to a vendor to ease some of the burden placed on staff who may already be stretched thin. An experienced vendor may also offer benefits such as:

• National insights: Vendors bring broad market intelligence, helping plans to benchmark and improve operations.
• Scalability: Health plans can focus on growth areas like enrollment or marketing while vendors manage risk adjustment and operations.
• System updates: Vendors stay current with coding guidelines and interoperability requirements, reducing the burden on internal teams.
• Holistic support: Vendors provide a 360-degree view of plan performance, helping to enable better budgeting and strategic planning.
• Collaborative partnership: True program management is a partnership, not just a service. Regular touchpoints and steering committees support transparency and shared goals.

Special benefits for growing plans

Growing health plans can benefit even more from outsourced program orchestration. While large plans may seek operational improvements, smaller plans often need strategic direction for profitable growth and effective member service. Program orchestration helps health plans in both growth stages, but its impacts are especially pronounced for health plans navigating new markets or rapid expansion.

What to look for in an orchestration partner

If a health plan decides to partner for program orchestration, they will want to look for a partner with deep expertise and market experience. This vendor should also offer end-to-end implementation to cover the full range of operations, as well as performance tracking capabilities for all operations.

It is important to look for a vendor with a partnership mindset. Program operations management is about expanding the health plan’s team, not replacing it. This partnership should be more than just a transactional service. When a health plan partners with the right vendor, it allows the plan to focus on strategic growth while the vendor concentrates on operational excellence and compliance.

In a rapidly evolving landscape, program orchestration stands out as an underutilized strategy to overcome industry challenges. Whether managed in-house or through a trusted vendor partnership, program orchestration can help health plans adapt to regulatory changes, optimize performance and focus on strategic priorities. Ultimately, embracing this approach enables health plans to navigate constant regulatory changes and thrive.

How Optum can help

Optum has a dedicated program management team led by industry experts who design and facilitate end-to-end risk adjustment program implementation — helping to take the burden off your organization from navigating the complexities alone. Rely on our experts to help your plan achieve optimized risk adjustment outcomes, reduce administrative burden and improve overall program performance.