As healthcare shifts from fee-for-service to value-based care (VBC), new care models like ACO REACH seek to balance business and financial objectives with optimal, equitable care. The growing participation in alternative payment models (APMs), such as capitation, helps support this balance by providing predictable revenue streams for providers and predictable cost structures for payers.
To account for variations in population health and risk, most capitation arrangements include payment adjustment methodologies that factor in health risks and social determinants and adjust monthly payment amounts accordingly. As a result, the providers who participate in an ACO, and the makeup of their aligned beneficiaries, can have a substantial impact on per-member-per-month capitation payments.
While advanced analytics plays a significant role in provider network design, ACOs often overlook the importance of leveraging a flexible and scalable claims administration system to streamline capitation and complex attribution models. Payment technology that can rapidly support new lines of business will ensure claims administration does not get in the way of your growth objectives.
If setting up a new accountable care organization or expanding into adjacent lines of business seems daunting, we have good news. Cedar Gate’s composable ACO software is designed for optimizing speed-to-market as soon as you identify available opportunities and prepare to move.
Capitation payment models are not new – many organizations will remember the early days of capitation in the 1990s – but they have reemerged as a priority for CMS. Previous capitation efforts created tension for providers, who believed that putting a limit on total payments for each patients’ care would negatively affect quality and access.
Today, APMs like full and partial capitation require providers to meet clinical quality metrics while also hitting cost targets. When provider and payer organizations optimize their ability to manage these risks, those processes often translate to other ACO and VBC opportunities.
For example, existing REACH ACOs might choose to establish a new ACO in a different region based on aligned beneficiary risks and provider performance. Speed to market can positively impact both clinical and financial performance for the organization, so organizations don’t want to start from scratch building out every new line of business.
Finding the right software to support ACO performance is critical. But equally important is finding a tool with the flexibility and agility to pursue new opportunities. With Cedar Gate’s composable solutions, ACOs can:
Cedar Gate offers the most comprehensive suite of composable solutions for ACOs and REACH ACOs. Our fully integrated analytics and capitation software gives you the ability to configure any setup based on current and future plans to expand into new lines of business. Don’t miss out on new opportunities because your software isn’t up to speed. Start building your customizable ACO REACH solution today.
