Budgeted health care programs such as Medicaid present a unique set of challenges for payers and managed care organizations (MCOs). Because the total dollar amount that can be spent is fixed, there is no ability to make adjustments by charging more if populations become sicker than expected (requiring more resources), or more people sign up for benefits. Payers and MCOs must simply determine how to stretch the budgeted dollars further to meet their responsibilities. To do so, they must adopt innovative means to control costs using value-based reimbursement concepts such as bundled payments and other alternative payment methods. They must also find ways to discover and encourage high-quality providers to join their networks so they can deliver better health outcomes to those who are sick or injured while keeping members healthier so they consumer fewer resources. These are challenges many payers and MCOs are unprepared to face due to outdated technologies and manual processes. But with trends suggesting more members signing up as budgets stay flat or go down, they must find ways to address them quickly.
This webinar will examine the value-based strategies payers and MCOs need to adopt to succeed with budgeted healthcare programs moving forward. It will examine how the use of big data analytics can help organizations design and negotiate bundled payments and other alternative payment programs with providers that ensure quality health outcomes with reliable reimbursement levels that help them manage their budgeted dollars more effectively. It will also detail how the data can help them build high-performing networks that include a tiered structure for providers and facilities, directing members to lower-cost alternatives (such as acute care clinics rather than emergency departments) as well as encouraging them to see providers proven to deliver top-quality outcomes at a lower cost. The presentation will then demonstrate how realigning incentives around building a strong patient/provider relationship, creating an exceptional patient experience that encourages members to seek interventions earlier, and delivering responsible, long-lasting care focused on maintaining wellness can drive both better outcomes and lower costs.
Kate Grohall, Product Executive, SKYGEN USA
Kate Grohall is responsible for oversight, development and implementation of SKYGEN USA’s value-based healthcare strategies, services and products. She helps the organization’s clients by approaching healthcare as an ecosystem where the interests of all stakeholders must be balanced by engaging them in performance measures across cost intelligence, quality clinical outcomes, and the patient/provider care experience. Ms. Grohall carries a passion for translating the concepts of value-based healthcare to the front lines where the impact is demonstrated daily to patients, providers, staff, employers and the community. She has been a speaker on healthcare value delivery and partnership for healthcare payment reform programs at national and state healthcare quality conferences, and holds a Master’s of Science in Organizational Leadership and Quality from Marian College of Fond du Lac.
Deborah Gracey, Principal
Deborah Gracey has extensive experience leading large-scale delivery system transformation with supporting financial mechanisms. Since joining HMA, Deborah has connected the payor and provider through her expertise in value-based payment structures and implementation, healthcare finance, alternative payment models, Medicare, Medicaid, dual eligible models, delivery system integration, and provider strategies for success with managed care and value-based payment structures. Deborah has deep knowledge of Maryland’s All-Payer Model and played a key role in the development of Maryland’s 10-year transformation plan, Care Redesign Amendment and two of the initial programs designed to align physicians with hospitals, upgrade the care of high- and rising-risk Medicare patients, and offer the potential for hospital incentive payments to physicians to support the transformation. Prior to joining HMA, Deborah was president of Humana’s Medicare business for the Great Lakes region, where she was responsible for the profitability and growth of a $1.2 billion business with 35 Medicare Advantage plans in Illinois, Michigan, and Wisconsin.