Healthcare Innovation

We partnered with a large payer to design, implement, and evaluate one of the nation’s largest payment-innovation initiatives. This covered more than $7 billion of spend, more than two million members, and 15,000 providers through episodes of care and a patient-centered medical-home model—including integration of data related to social determinants of health.  To support the effort, we deployed a build, operate, and transfer model, including development of analytics and reporting tools for providers.  In the first year in which both programs were launched, total cost avoidance achieved was $120 to 180 million.

We applied strategic insights, proprietary tools, and co-designed analytics to help a national payer transform networks in dozens of markets and multiple lines of business. This enabled over 200-basis-point (bps) of medical cost savings in some markets, improved member access to higher-value, high-quality providers, and strengthened competitive market positions. We co-developed market-specific, multi-line network strategies and tailored portfolios of initiatives, including broad and value network optimization; traditional and value-based contracting with systems, facilities, specialists, primary care physicians, and ancillary providers; and high-value provider and member referral programs. We helped the payer build an operating model and capabilities to sustain network innovation and performance management on its own going forward.

We supported a large, public sector payer on the design and launch of one of the most significant episode-based payment models.  To date, the program includes more than 45 episodes launched.  We worked closely with payer to help facilitate more than 750 stakeholder interactions to incorporate clinical feedback into episode design as well as the overarching model.  Results reported to date show improved performance on more than 65 percent of quality measures linked to payment and estimated savings more than tripled by year 4 of the program as the episode model continued to scale.

We partnered with a major national payer to develop a strategy around SDoH driven by analytics, focusing on using claims paired with SDoH data to identify the areas of greatest addressable spend, set goals, and create a roadmap for implementation. This has positioned the payer to lead in SDoH capabilities, and to impact the health and well-being of ~40M members—especially the most vulnerable.