Our client’s need

After creating an effective, integrated healthcare delivery structure (an accountable care organization), one of Baker Tilly’s hospital clients was approached by a large health plan to participate in a value-based incentive program. The health plan had significant commercial and Medicare advantage membership receiving care from the ACO’s primary care physicians. The hospital client reached out to Baker Tilly to help them ensure they were being represented as true partners in their shared savings arrangement.

Prior to conversations with the health plan, the hospital developed a physician-led, clinically integrated ACO consisting of hospital employed physicians and selected primary and specialty physician practices in the hospital’s service area.  The ACO provided a vehicle for improving the quality of care, managing costs, improving outcomes, and thereby increasing patient satisfaction. 

Baker Tilly’s solution

Our healthcare consulting professionals performed a series of assessments and data analyses in support of the ACO. Baker Tilly promoted enhanced ACO and provider compensation to support new patient care coordination activities within the practices to achieve improved quality. They also coordinated the selection of nine HEDIS metrics included in the quality section of the shared savings model to ensure the targets were attainable and the ACO could track performance via actual claim data. Baker Tilly thoroughly vetted the member attribution methods used by the health plan and cost of care components in the calculation of shared savings to ensure the ACO would have an opportunity to realize shared savings

Results achieved

After some negotiation, the ACO executed a five-year agreement with the payer. The agreement included an upside only shared savings program based on improved quality as well as cost containment through the efficient use of healthcare resources. This engagement was a great example of how a provider organization and a health plan can work together for mutual benefit:

• The ACO primary care provider achieved a higher than market fee schedule for participation in the shared savings arrangement
• The agreement allowed the ACO to participate in a shared savings program with a large health plan with no downside risk, only upside gain; specifically, the ACO can realize up to 55 percent of total savings achieved
• ACO providers were given access to a reporting infrastructure, training, and funding to support care management activities within their practices
• The health plan secured a collaborative relationship with providers to improve the quality of care, achieve cost savings, and align their goals for population health management with participating providers
• Health plan members received better care through improved coordination among caregivers

For more information on this topic, or to learn how Baker Tilly healthcare specialists can help, contact our team.