For some years now, risk assuming care entities and provider organizations have focused on increasing the RAF (risk adjustment factor) of the populations they care for by capturing and recapturing HCC (hierarchical condition category) diagnoses. The hayday for this method of decreasing the MLR (medical loss ratio), however, may soon be coming to an end. There may soon be significantly less leeway for linking topline payor pmpm's to the RAF reported by risk assuming care entities and provider organizations.
Instead, care entities and provider organizations may be asked more and more to decrease the MLR by decreasing the absolute TCC (total cost of care) of a population.
Even if that isn't the case yet, reducing the TCC will increase the care margin while reducing patient suffering; it will strengthen the care entity and enhance the care entity's reputation and attractiveness to payors, providers and patients.
We believe that:
- It is possible to significantly reduce the TCC of a population;
- To try to reduce the TCC of a population by rationing or denying care is not only unethical, but is also self-defeating, and will only lead to even higher TCC down the line from untreated disease and unfilled gaps;
- The quickest and most cost-effective way to reduce the TCC of a population is to reduce the TCC of the high risk patients;
- The quickest and most cost-effective way to reduce the TCC of high risk patients is to avoid and reduce severe outcomes in such patients, that is, to avoid severe outcomes and when unavoidable, to reduce the degree of severity;
- To avoid severe outcomes and reduce the degree of severity, it is necessary to detect, manage, and treat or refer for treatment, in a timely fashion, conditions or clinical situations in high risk patients that lead to severe outcomes;
- PCP's can be enabled, quickly and at a low cost, to do the above for high risk patients;
- In fact, for many, maybe even most, high risk patients, PCP's may be the providers best positioned to do the above for high risk patients, and therefore significantly lower the absolute TCC of a population; and finally,
- Most importantly, this can all be done in a quick and very cost effective manner. And it can scale.
Interested? We offer consulting services to help you and your organization achieve these goals. Contact us at df@soaroutcomes.com.
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