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Reforms cause payers to rethink market approach


One of the initiatives for reimbursement and care delivery within the Patient Protection and Affordable Care Act is to promote better outcomes and drive greater efficiencies within the Medicare and Medicaid programs.

In the commercial marketplace, there is a fundamental shift from a volume-based reimbursement methodology to an outcomes-based reimbursement methodology, and clearly, accountable care is underway.

Accountable care has the potential for driving better outcomes while reducing costs, but achieving these goals will require changes in organizational structure and operational workflow within the healthcare provider and payer communities. These organizational changes, coupled with regulatory requirements, create a unique set of challenges.

Each macro consideration creates a list of additional micro considerations.

For example, the recent provisions linking Medicare Advantage payments to quality of care and patient satisfaction creates a new strategic consideration regarding the inclusion of this product line in a payer's portfolio. Now a plan must rethink its approach to member satisfaction, preventive care, clinical outcomes and disease management related to its Medicare Advantage offering. Payment variances will now be linked to these variables.

The accuracy of Consumer Assessment of Health Plans Survey (CAHPS) scores and Medicare Health Effectiveness Data Information Set (HEDIS) scores as well as the efficacy of medical management programs, chronic illness intervention strategies and customer satisfaction programs will be accentual in securing increased Medicare Advantage payments.


Other micro considerations payers must evaluate include determination of appropriate levels of financial risk being transferred to providers, vehicles for mutual validation of that financial risk, evolving definitions of vicarious liability, new exposures related to the exchange of medical and financial data, financial exposures related to the regulatory risk of Medicare/Medicaid billing errors, and directors and officers' liability implications related to changes in organizational governance that will come with integration and realignment efforts, to name a few.

Moving forward, any healthcare risk consultant that serves the risk and insurance needs of the payer should possess the core competencies necessary to help identify, mitigate, transfer and/or manage those unique risks as they evolve. Risk consultants should have the resources necessary to assemble a team of professionals equipped to support all of the macro and micro considerations. As the payer community navigates its way through the evolution of reform, the expertise of a healthcare risk consultant partner should be accretive to the overall success of the payer's mission.

Ron Calhoun is managing director of Aon's Health Care Practice

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