Grow

Performance Excellence for improved Health Plan membership and margins

Optimized Payer Network Performance

Payer ecosystem stakeholders are being asked to look beyond premiums and benefit plan design.

The market is demanding innovative solutions to manage the total cost of care, provide equitable access to care and improve health outcomes for all.

We can help.

Network Management and Provider Performance Optimization

SCALE’s network management and provider performance optimization team is comprised of experts in physician recruitment, contracting and population health management. Partnering with health plans to align care within high performing networks to contain care costs and improving the quality of care.

Sales and Distribution Channel Strategy

Scale can assist with your connection to employers through deploying a collaborative consultative sales approach with your sales team and insurance brokers. Expertise in selling within a highly competitive healthcare landscape.

Growth, Marketing and Client Retention

Member engagement and satisfaction are driving foundations of the SCALE marketing team. Bringing innovative education platforms to your membership to improve their health status and connections with providers.

Value Based and Total Cost of Care

Risk reimbursement models are here and expanding beyond primary care. SCALE provides the connection between providers across the care continuum to optimize provider performance in value based reimbursement models thus reducing the total cost of care.

Overview

Execution

Results

CASE STUDY:

Value Based Care

Client Profile

Overview

  • The Client is a Medicare-focused population health company
  • The client was an early participant in the Direct Contracting Entity (DCE) Program since 2021
  • The client membership increased by 570% from 2021 to June 2022. Client membership is expected to increase by 390% from 2022 to 2023.
  • The client has been approved for the ACO Reach Program in 2023
  • The client is on a growth trajectory and is seeking new capital to support anticipated exponential growth over next 18-24 months
  • Increased reserves are needed to support increased Medicare membership

Needs & objectives for engagement

Lender engaged SCALE to complete an evaluation of the client with focus on:

  • Historical and projected performance
  • Growth & Development
  • Operational Execution
  • Market Research

Execution

SCALE deployed a team consisting of individuals from the Consulting & Payer Strategy business divisions, as well as external subject matter expertise

  • Interviews / meetings with the client & sponsor group leadership
  • Review of diligence materials provided (network overview, financials, growth & development competitive landscape, organizational charts, structure between the client & affiliated practices, DCE & ACO REACH materials, operations program, pipeline)
  • Data analysis
  • Interviews / meetings with Client & Ascend leadership
  • Review of diligence materials provided (network overview, financials, growth & development competitive landscape, organizational charts, structure between the Client & affiliated practices, DCE & ACO REACH materials, operations program, pipeline)
  • Data analysis
  • Cross-department collaboration resulted in a comprehensive and effective final report
  • Utilized external SME expert to assist with CMS Quality Measures & Risk Score Assessment
  • 5-week execution timeline

Results

  • First 6 months of 2022 data indicate MLR (Medical Loss Ratio) between 80 – 100+ percent, with shared shavings. Given limited performance, the current MLR is found to be consistent with similar CMS programs.
  • The client performed in 2 out of 3 quality measures in early 2022.
  • The client’s managed care structure appears operationally sound with best practices in care coordination, disease management, and quality performance. Improvements are recommended in the areas of clinical documentation & coding tied to their risk structure.
  • The client has a strong and experienced management team with specialties in managing capitation and population health.

Download our one-page fact sheet to learn more about Optimize Health Plan and Payer Performance.

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