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Pathways to Success

Mastering Pathways to Success with Lumina Health Partners’ Daniel Marino

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Recently, I co-hosted a webinar with Lightbeam Senior Advisor Maha Salah-Ud-Din discussing the top three strategies to maximize results for organizations in The Centers for Medicare & Medicaid Services (CMS) Pathways to Success program. There is an undeniable sense of urgency with this topic; by 2028, Medicare spending is projected to exceed $1.5 trillion if the healthcare system does not change course and shift to value-based care.

We in the healthcare space are observing telling signals from Medicare to suggest there will be more value-based care payment structures to choose from in the future, and potentially new commercial payers. As with anything large-scale, to master the Pathways to Success program and implement fruitful measures, we need a plan. Maha and I refined our knowledge and experiences into three key strategies:

  1. Create actionable plans to manage risk
  2. Adopt and integrate analytics
  3. Make sure objectives are aligned

Create Actionable Plans to Manage Risk

Deciding which risk track to take is the basis of the Pathways to Success program. In the reimbursement model perspective, an organization’s standing clinical and financial records help providers decide the amount of downside risk to take on. During the consultation stage, the kinds of questions we ask leaders to explore are:

  • Are we ready to take on risk?
  • What would the most effective speed-to-market care management programs be for us?
  • Which data measures will create the actionable insights we need for successful outcomes?

The answers to these questions typically present themselves during the examination stage. With taking on any risk, we advise leaders to gradually evolve to the status of “risk manager” within their organization. This evolvement takes place in three phases.

Additionally, any organization participating in a downside risk arrangement needs to know the six key drivers that lead to savings victories:

  • The Cost-of-Care: Every organization leader needs their cost threshold to calculate the total cost-of-care per patient per month.
  • Risk Adjustment: ACOs and other organizations implementing value-based care are discerning the best way to position themselves in a risk arrangement. Understanding how to manage risk and stratify for the given population is critical.
  • Provider and Member Attribution: Attribution, or the assigning of patients to providers, is either prospective or retrospective. Organization leaders must know what criterion goes into their attribution formula and how it is modified based on patient and beneficiary movement.
  • Quality Measures and Care Management: Quality measures are for more than reimbursement. They guide the members of a team on how they can do better and ultimately craft initiatives that drive positive engagement. The correct care management approaches are determinant on a practice’s needs.
  • Data Sharing: Sharing cost and utilization data among physicians reveals the highest costs and allows them to update their focus areas.
  • Shared Savings Calculation: Organizations find their shared savings calculation by determining their minimum savings rate (MSR).

Adopt and Integrate Analytics

Value-based care is data-reliant, and organizations transitioning to fee-for-quality models often have more data than they need to take meaningful action. What many organizations struggle with is filtering out the unnecessary from the usable, which is a blocker for full contract performance. In the webinar, we discussed how the ability to access historical claims data for individual patients is vital. Lightbeam Health Solutions aggregates historical claims data to give physicians an idea of a patient’s total cost. 

The progression from the organization to the real-time application of analytics is what we refer to as the multi-generation plan to achieving analytics excellence.

Usable data allows providers to determine where their immediate focus should lie. Generally, we start with the super-utilizers that are the highest risk and therefore, most expensive. These patients make up the top 3% of an organization’s total spend and emergency room visits. From there, the care coordination plans begin, and solutions are designed to streamline into established workflows. The technology enables providers to engage their patients and close care gaps with automated identification. The capability also ensures that individuals attribute their HCC codes correctly.

Make Sure Objectives Are Aligned 

For successful outcomes, everyone involved needs to be on the same page. From the executive directors to the nurses, aligning objectives and reinforcing common goals create a focus for team members. In the early stages, the incentives laid out in an organization’s contracts also serve as objectives to achieve shared savings.

To learn more about these topics in greater detail, we highly encourage watching this and past webinars that are part of Lightbeam’s Thought Leadership Series.

About Daniel Marino, Managing Partner at Lumina Health Partners

Daniel specializes in shaping strategic initiatives for healthcare organizations and senior healthcare leaders at Lumina Health Partners. His specialties include population health management, clinical integration, physician alignment, and health information technology.

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