Transformative Provider Payment Models

This session will discuss several transformative provider payment models. These include a variety of Value-Based Risk Arrangements redefining the relationship between provider and payer. With these arrangements, the providers are moved from a fee-for-service payment model to one that focuses on reducing the total cost of care. These arrangements also include mechanisms to ensure quality does not suffer. Through data analytics, providers look for innovative ways to reduce unnecessary utilization while optimizing the most effective clinical practices. The presentation will include examples of case studies where these techniques have been established. One case study will highlight what Geisinger has done through their integrated delivery system with primary care redesign,which moves unnecessary care out of the emergency room and back to the primary care setting. We will demonstrate how to reduce the overall cost of care by driving care to the right setting, at the right time and at the right cost (similar to the triple aim). To help keep the session engaging, we will use polling to survey the audience's understanding and experience with value-based models at the beginning and the end of the session. At the conclusion of this session, attendees will be able to: • Define a value-based arrangement • Demonstrate their understanding by identifying examples • Design their own value-based arrangements for their own organization • Describe challenges and preferred outcomes of these arrangements • Create their own models supporting data analytics

Cory Gusland, FSA,MAAA

Cory’s areas of expertise are alternative payment models, managed care, provider sponsored health plans, employer sponsored medical, and international medical insurance. Cory has experience working across commercial, Medicare and Medicaid populations. His current responsibilities include assisting healthcare providers and integrated delivery systems as they transition to risk bearing entities. Recent projects include but are not limited to health plan feasibility studies, review of payer provider shared savings contracts, capitation payment analysis, provider reimbursement benchmarking, health plan M&A, and cost and utilization projections for healthcare providers. Prior to joining Milliman, Cory served as an actuary for a leading population health management services organization. While in that position, Cory led the firm’s actuarial efforts in economic projections for health systems pursuing value based care strategies. This included the analysis of health plan launches, as well as shared risk arrangements with both private and public payers. In addition to these responsibilities, Cory assisted health systems with the design, negotiation and implementation of shared risk partnerships with private health insurers.

Karena Weikel, ASA,MAAA

VP Risk and Revenue Management

Karena is directly accountable to the Chief Financial Officer/Chief Actuary for Geisinger Health Plan. She is a risk professional with 16+ years of healthcare experience. She is responsible for managing GHP overall cost of care (expense, vendor), trend mitigation, data management, vendor relations, underwriting, provider economics, risk adjustment, operational and regulatory reporting, rate filing support, and organization-wide healthcare analytics for all lines of business (Commercial, Medicare Advantage, Medicaid). Karena leads a team of 110 highly skilled and experienced professionals including underwriters, actuaries, data and business analysts, and certified professional coders. Her team informs and makes decisions that lead to profits, savings, stability and continued services to our healthcare community and membership.

Sarah MacDerment, FSA, MAAA

Sarah is a pricing actuary, with over 20 years of experience working primarily in the Commercial space. Her expertise include ACA rate filings, modeling and valuing benefit designs. In her current role at Geisinger Health Plan, she leads the Commercial pricing team and is responsible for the actuarial methodology and forecasting for all commercial markets, managing the reinsurance contracts, and works closely with the Underwriting team designing and maintaining their tools and models. Sarah has worked closely with several state departments on initiatives, coordinating with a variety of internal and external teams.

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