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Whatever information may be available, and whatever its limitations might be, some form of expenditure baseline must be established or approximated so as to enable prospective measurement against these performance "benchmarks." Baseline expenditures are critical for both payer and provider to demonstrate the historical track record of payments received for the services delivered. Alignment of homogeneous patient segments with an historical record of payments lends credibility from provider to payer that such performance is attainable and has some degree of reproducibility going forward. The same record lends corresponding assurance to the provider, and establishes a base against which to assert and assess their own costs of delivery, and to forecast delivery of profitable (or cost-recoverable) services.
Organizations pursuing this stage are often seeking to answer key analytical questions such as:
What are our Baseline Expenditures & Care Delivery Costs on these Targets, with this Payer?
How do these Align with our Contract Terms across Payer Types?
The following Action Plans are concrete steps organizations must consider for progressively achieving this stage.
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Assemble historical benchmarks, based on historical actuals, including relevant or corresponding performance projections and/or goals
Establish baselines for patient volumes and mix, service volumes and mix, provider mix and participation, resource consumptions, charges and costs over designated historical time frame
Align Patients with Providers (groups, specialty, location, contract) based on greatest legitimate, substantiated impact, frequency, effort or preponderance of care-related services
Resolve conflicts using reproducible rules, allocations and standards
Determine alignment or non-alignment of Providers with the emerging ACO, and relevance of their provided services to the ACO’s operations
Classify providers by service histories, credentialing, quality and satisfaction scores, costs of services and other metrics
Calculate Anticipated Services, Charges, Costs & Savings Targets
Project charges, costs, margins based on potential discount scenarios for historically-substantiated anticipated Patient and Service mixes, as delivered by substantiated Provider mixes
Assess reproducibility of historical measures, and project impact and implications of various planning scenarios on financial results
Hierarchical Segmentation& Aggregation
Perform analysis on candidate aggregates of Patients, Providers, Encounters and other dimensional segments, for baseline performance on metrics; establish semantic framework for drill-down
Project or simulate drill-down analysis and anticipate adjustments or interventions (actionable) to address performance concerns or issues