Requirements and Considerations in Building Value Based Care and HMO Models for Your Community

Requirements and Considerations in Building Value Based Care and HMO Models for Your Community

First envision this as a separate living breathing enterprise with incredible potential that needs to be built step by step IN THE CORRECT SEQUENCE.

Where the wheels come off is not focusing on the right sequence. Even the professional managers get it wrong. It is not finance, legal, operations and then marketing.

It is market analysis first to see what kind of health plan fits the employers’ needs in the market and what kind of competition is present, now and in the future to determine if a MSSP product is even feasible. Many low benchmark communities have a very hard time building a sustainable model because the cost to launch and maintain an ACO is prohibitive. What often works better is a joint venture with an existing plan or developing a percentage of premiums for Medicare Advantage contracts.

Next comes legal feasibility to test the vision against state and/or federal laws.

Then there must be a discussion of Operations and the best way to phase in resources over time which logically leads to a budget and some precision on financial issues.

The best business plans discuss current but also future options for growth. Health plans are not a stagnant business; they must grow according to a plan. This means a controlled growth, enrolling members but also leasing networks and selling data. This means not overstaffing and also means using purchased or leased technology in the most effective way possible.

What We Can Do to Guide the Efforts of Your Team to a Safe Launch

DeMarco and Associates and its affiliate Pendulum Health Care are designed to support and enable physicians and purchasers to work together to develop a better exchange of value including improved reimbursement for better quality outcomes.

We assist in the education of physicians and buyers of care using examples and local data to set up realistic goals and benchmarks based upon prevailing practice patterns.

DeMarco and Associates conducts research and feasibility studies to build the foundation for the expectations of both parties and begin moving towards a business plan. Once the business plan is affirmed by both parties, the capital formation can begin with Pendulum Health assisting in funding select programs and/or helping clients raise money through physician and employer investment.

DeMarco and Associates can further assist with employer assessments, marketing to payers and their third party administrators as well as educating brokers and consultants as to the opportunities to use this new ACO network or support the development of a community plan over the present carriers, all of whom represent an inefficient network with very poor patient engagement.

DeMarco and Associates can further assist in finding staff, preparing requests for proposals for software and claims services and finally developing working relationships with reinsurance companies and actuaries to make sure the providers have limited risk and a full opportunity for a return on their investment.

Overall DeMarco and Associates has the capability to research, design and build a locally owned and operated network and product for providers and/or purchasers that represent government beneficiaries as well as private third party payers.