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Health Plan and PACE Formation

Many organizations, including health systems, home health and long term care organizations and physician groups are seeking to launch at-risk programs, PACE organizations and health plans for Medicaid, Medicare and Special Needs populations.  Vendors are targeting their services for key aspects of at-risk programs that take advantage of recent regulatory changes permitting more targeted benefits and care coordination programs.

They are increasingly uncomfortable with their patient populations being dominated by a few large commercial carriers for both Medicaid as well as Medicare services.  However, regulatory requirements and infrastructure costs are making it increasingly difficult for local health plans to survive, no less compete with larger, well capitalized organizations.  At the same time, recent developments have added new and expensive beneficiary populations to managed care, requiring all organizations serving government programs to accumulate significant capital to support increased enrollments, revenues and risk.

Consequently, the remaining smaller local plans or provider organizations that serve these populations are at risk of being squeezed out of the market or are essentially required to sell to larger organizations.  At the same time local plans, PACE organizations and providers may be better positioned to effectively coordinate the care of the target populations because they are more familiar with the local health care environment, patterns of care and social services alternatives.

In many ways health care is – and should be – local.  Clear View Solutions assists our clients to identify cost effective administrative services and access to managed care infrastructure and coordinated care expertise through a variety of approaches including multi-plan partnerships, vendor procurement and other innovative management services organization approaches.

Offerings include:

  • Access to the experience and expertise of seasoned health plan and PACE operating professionals

  • Tools, programs and services to evaluate opportunities and markets

  • Comprehensive provider contracting services to meet State and Federal access requirements

  • Analytics, reporting and HIPAA compliant data warehouse capabilities for all aspects of program evaluation and management

  • Independent Validation Audits and other Audit services to meet CMS and other regulatory requirements

The market for new at-risk organizations is active and robust

Scores of programs are currently under consideration and development.   Several vendor organizations are now offering comprehensive solutions to provider organization seeking to enter the managed care space – at a cost of capital and control.   Clear View Solutions helps clients evaluate these proposals compared to alternatives, and helps organizations make the right choice that balances risk tolerance, governance and control and financial objectives.   Our approach is consultative with the client’s objectives and interests guiding every step.

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