Pwc Feasibility Study

Objectives of Shared Savings Program: o Shared savings agreement offers a transparent and consistent way to work with providers to manage cost of care effectively, and to improve clinical KPIs and align incentives o To successfully implement the FQHC strategic alliance program (SAP), Affinity incorporates risk adjustment in its existing process to better understand a provider’s performance and peer-to-peer comparison
1. Individual member risk scores will adjust the provider’s revenue to account for relative riskiness

Deficiencies in the Pwc model impacting MLR: o The current Pwc model has not provided a mechanism to risk adjust the revenue by premium rate group and county; adversely, risk adjustment occurred globally
1. This created an artificial advantage …show more content…
Calculation for baseline: CRG weights for the prior contract year times prior year revenue by rate group and county
2. Contract year membership equals baseline membership o Accordingly, the true-up will measure CRG weights, membership, and revenue for the contract year o Decrease revenue pmpm by 4.75% for “pass-through” dollars; this is a globally calculation for all rate groups o Addition of HCRA at 7.04% for facility claims only, quality payouts & settlements to the expense