Threat-based Contracting for Worth-based Care, a Founder’s Playbook


COVID has strained our healthcare system, payors are feeling the squeeze of rising prices, and sufferers are bearing the brunt of the present system’s shortcomings. In consequence, healthcare is present process a change, from care that’s predominately payment for service and primarily based on quantity of care to value-based care. Threat-based contracts are vital to constructing companies primarily based on danger and worth, fairly than charges and quantity. We talked to digital well being builders — from Firefly Well being, Pearl Well being, Waymark, Carrum Well being, Eleanor Well being, Patina Well being, and BlueCross BlueShield of North Carolina — on the forefront of the shift to value-based care about tips on how to construct risk-based corporations.

  • The spectrum of risk-based fashions [1:33]
  • The place we’re within the shift to value-based care [3:37]
  • Deciding to go in danger [5:46]
  • Establishing partnerships [13:03]
  • Defining success [19:14]
  • Scaling [24:16]
  • Investor perspective [29:46]

For extra on constructing digital well being corporations:


Julie: Hello, I’m Julie.

Justin: And I’m Justin.

Julie: And welcome to the second piece in our collection on new go-to-market motions in digital well being. For our first video, we seemed on the B2C2B go-to-market strategy. On this video, we’re going to dive into how digital well being corporations are driving in direction of value-based care utilizing risk-based contracting.

To grasp risk-based contracting, let’s first unpack: what’s value-based care? Worth-based care, or VBC, is each a medical strategy that focuses on preventative companies and long-term well being care outcomes and a cost mannequin that permits the suitable incentive alignment to realize these medical targets. It’s oftentimes thought of because the antithesis to the normal payment for service cost system, through which suppliers are paid for particular person models of care utilizing established billing codes.

These payor-provider contracts have actually pushed these payment for service charges by means of the roof, and that’s been a serious driver of why our nation’s healthcare prices have skyrocketed to just about 20% of GDP with no commensurate rise in medical outcomes and affected person expertise. This push in direction of value-based care can be a push to align worth creation with worth seize. And that’s actually the place risk-based contracts are available in. They’re a reimbursement mechanism that aligns incentives. Relatively than suppliers being paid primarily based on larger volumes and particular person procedures and companies, suppliers are rewarded for hitting sure high quality and price outcomes and measures.

The spectrum of risk-based fashions

Justin: We frequently discuss going in danger as if it’s a single strategy, however the actuality is that risk-based fashions signify a broad spectrum. As we transfer throughout the spectrum, a lot of elements can change, but it surely’s primarily the elemental unit of cost and the diploma of possession or accountability that an organization takes on for a given affected person or given affected person inhabitants.
These various factors in the end manifest in varied kinds of risk-based fashions. The primary bucket is pay for efficiency. It’s one thing that rides on conventional payment for service rails, however usually has some form of medical or operational efficiency assure that’s layered on prime.

The second bucket is PMPM, or per member per 30 days. This can be a mannequin the place an organization will usually cost a set quantity for medical companies, so they could obtain $5 or $50 or $150 per member per 30 days, however coupled with that could be a risk-sharing element, the place there’s some restricted sharing of financial upside in opposition to the overall price of care.

As we proceed, the third bucket is bundled funds, and this can be a construction the place corporations tackle full danger in opposition to all the look after a given affected person for a selected episode of care. That episode is usually outlined by a sure time interval or sort of companies — that may be one thing like a bundle for maternity care or a bundle for knee substitute surgical procedure.

Then we get into capitation fashions, and in a capitated mannequin, an organization or a supplier takes a flat price of cost for a affected person, whereas taking up full danger in opposition to a wider vary of companies than we noticed in bundled preparations. In a subcapitated mannequin, the corporate is taking up cost and danger for a subset of medical companies. For instance, they could tackle cost and danger for all main care or all outpatient companies, however on this instance, not essentially for hospital care or for different acute companies or for pharmacy spend.

Within the fullest model of an at-risk mannequin, we now have international capitation, the place an organization takes on full danger in opposition to the overall price of care, or in different phrases, for all medical companies for that affected person. In fashions of world cap, corporations are successfully changing into the payor as they tackle this full actuarial danger for that affected person.

The place we’re within the shift to value-based care (VBC)

Justin: The place are we on this macro degree shift from payment for service to value-based care? In 2021, fewer than 40% of healthcare {dollars} truly flowed by means of a cost mannequin that had any form of substantial worth element to it, and solely 6% of {dollars} had been in subcapitation or international capitation preparations. That being mentioned, we’re consistently listening to about risk-based contracts and value-based care. They’re within the zeitgeist, and that actually has to do with a lot of various things.

A kind of being that over the previous couple of years, COVID has hit the well being system like a meteor. It’s actually uncovered the overall lack of resiliency of a predominantly payment for service system, not simply within the incentive and reimbursement fashions, but in addition within the potential of payment for service fashions to soak up unpredictability. On the similar time, it confirmed that these with larger publicity to value-based contracts had been usually higher positioned than those that are fully depending on payment for service income streams.

Much more broadly, payors are persevering with to really feel the squeeze of rising medical prices, and due to this and are doubling down on risk-based and value-based fashions. For instance, simply this final 12 months we heard from CMS, which is the Heart for Medicare and Medicaid Companies, that they’re aiming to have all Medicare beneficiaries cared for by suppliers in value-based care fashions by 2030. On the similar time, many conventional care fashions and suppliers simply aren’t able to tackle that danger.

Excitingly and optimistically, purpose-built digital care tech stacks have the potential to drive higher danger administration and extra nimble care fashions that be taught over time in methods which might be troublesome for conventional suppliers purpose-built for payment for service. Despite the fact that there are a variety of corporations which have struggled in risk-based fashions, there’ve been a quantity which have additionally outlined the trail of how to do that very well. We talked to digital well being builders who’ve navigated risk-based contracts and who perceive the particular challenges that include constructing and scaling a risk-based go to market. On this playbook, we spotlight their learnings with a concentrate on key phases of the builder journey — first is deciding to go in danger, subsequent, establishing partnerships, defining success, after which lastly scaling.

Deciding to go in danger

Justin: So leaping in, let’s hear how a few of these founders grappled with the choice of whether or not a risk-based mannequin was even proper for his or her enterprise. Like lots of the founders we talked to, Jack Stoddard, who’s the CEO of Patina Well being, which is a virtual-first and home-based main care mannequin for older adults, accelerated their path to danger as a result of they needed to.

Jack: Once you’re coming to market with an orthogonal view of the world, usually it doesn’t match into the present enterprise mannequin constructs. Particularly, in main care, the market is used to paying solely 4-6%. Our perception is when you make investments extra in main care than you possibly can truly take out waste within the different 96% of well being care. As a result of our mannequin is counterintuitive to how the market has all the time approached it, we mentioned, “look, let’s be accountable for outcomes, and let’s in the end construct this for danger.”

Justin: Threat-based fashions can present extra freedom to outline the care mannequin. This freedom can provide area to show out the impression of those novel care fashions, however on the similar time, this path to danger needs to be balanced with the potential downsides. Lots of the founders we talked to took a glide path or a phased strategy to danger. Let’s hear from Rajaie Batniji, the CEO at Waymark, the place they’re constructing a value-based community-driven care mannequin for Medicaid. They took an accelerated path to danger, however Rajaie highlights the place a glide path strategy could make extra sense for a corporation

Rajaie: Threat is alternative. Threat can also be freedom. It’s the liberty to strive new issues, the liberty to interrupt the bounds of what’s the establishment or conventionally thought-about the strategy. Threat is alternative, but it surely’s additionally danger, and there’s sufficient danger in constructing a brand new firm.

I’d not suggest transferring towards danger merely for some form of valuation arbitrage. I believe you do it as a result of it’s wanted to show a brand new mannequin of care, or it’s wanted to cowl one thing that’s simply merely not paid for beneath current CPT codes.

Justin: We heard one thing related from Corbin Petro, the CEO at Eleanor Well being, the place they’re constructing a hybrid value-based care mannequin for substance use dysfunction.

Corbin: In our area, what we all know and what the proof tells us is that creating that means and goal in individuals’s lives actually helps retain them in restoration and assist their psychological well being and wellbeing. Nicely, there’s no CPT code for creating that means and goal in individuals’s lives. It’s a must to work out one other technique to tackle that, and the medical mannequin and the enterprise mannequin go hand in hand. You may’t sustainably ship the medical mannequin with out the enterprise mannequin piece in place.

Justin: Taking up danger is a strong alternative to create alignment between the enterprise mannequin, the care mannequin, and the working mannequin, but it surely’s additionally inherently dangerous. Many corporations in the end resolve to take a glide path to danger, however the place on the chance spectrum is the fitting place to start out?

Rajaie: You most likely arrive on the degree of danger primarily based on what levers you want for the mannequin to work. For instance, when you wanted to regulate in your care mannequin all of utilization administration, the claims cost, and community design, there’s most likely no different means for a payor to let you have got these keys aside from transferring to a real international cap.

Jack: It’s troublesome to leap straight to full danger. Most payors are gonna look so that you can have sufficient expertise and sufficient sufferers and, frankly, sufficient monetary weight behind you that you just even have the power financially to take and handle danger. To do this, I’d say begin sluggish, attempt to align your incentives with the payor the place they wish to show you how to get to full danger.

Justin: However even when you begin on the glide path with payment for service, it may be actually onerous to construct for payment for service and for the final word objective of value-based care in parallel, as we’ll hear from Fay Rotenberg, who’s the CEO at Firefly Well being, the place they’re constructing a well being plan on prime of a digital first value-based care mannequin. They began with payment for service contracts, however they constructed for worth within the working and care fashions from day one.

Fay: Day one Firefly launched with actually primary contracts with payors in Massachusetts, and by primary, I imply payment for service. That was by no means the enterprise we needed to be in, but it surely was what we wanted to get going. We had primary payment for service contract with payors, and actually all that meant was that we had been in community with them.

Even when it meant not getting reimbursed for all the methods we had been interacting with sufferers, in some ways we had been working as if we had been on value-based contracts even earlier than we had been. We comparatively shortly progressed from these primary payment for service contracts to extra strategic subcap agreements, and we had been ready to try this off the early experiential information that we had been capable of present to payors from our preliminary members.

Corbin: You rent people who find themselves mission pushed. They don’t wish to give half the inhabitants one factor and half one other factor, and so we determined our north stars are our outcomes. Let’s actually concentrate on getting quite a lot of proof factors and quite a lot of information displaying that our medical mannequin supplies superior outcomes. We began then persistently delivering our care mannequin throughout reimbursement sorts, payment for service and value-based.

Justin: Now we regularly get the query from entrepreneurs and suppliers is the final word objective for everybody to get to full danger, to get to one thing like international capitation? As we’ve heard earlier than, although, what quantity of danger you tackle in the end is dependent upon what levers you possibly can management on the medical aspect and what in the end finest aligns your care, your working, and your small business fashions.

For instance, in main care, care is extra steady. It’s extra longitudinal. It covers a broader set of levers and circumstances. For that, international cap usually makes essentially the most sense. Then again, different extra remoted specialty circumstances may be a greater match for subcap, the place they tackle a narrower side of care and danger for that affected person. For extra episodic care like surgical episodes, it may be finest optimized by means of bundled funds. Let’s hear now from Sach Jain, the CEO at Carrum Well being, which is a market for top worth care.

Sach: Surgical care felt just like the pure place for us to start out as a result of the span is very episodic, and the associated fee and high quality variation is considerably excessive in surgical care supply. We felt that was ripe for bundled funds.

Justin: For Carrum, taking up further danger solely provides operational complexity.

Sach: When you’re taking an insurance coverage danger in healthcare, you might be ruled by very totally different laws which might be very onerous. Taking any form of danger means your capital requirement to start out the enterprise goes up considerably. We simply felt, given the place we had been, we didn’t wish to increase that form of cash in these early days. Making a mannequin the place we basically keep danger impartial gave us a quicker path to market.

Establishing partnerships

Justin: Wherever on the chance spectrum an organization decides to start out, success in at-risk mannequin essentially is dependent upon aligning with different nice companions, however in a posh panorama of various potential companions, how do you consider the fitting set of companions to start out with?

We’ve persistently heard throughout founders and throughout our payor colleagues that imaginative and prescient and mission alignment are vital, particularly early on, and that in the end begins with aligning across the medical areas of impression which might be most essential, in addition to sharing a dedication to a value-based strategy.

Let’s hear from Mike Kopko, who’s the CEO at Pearl Well being, the place they’re constructing a market that companions with each risk-bearing entities and supplier teams to assist these suppliers tackle extra danger for his or her sufferers.

Mike: In healthcare, I believe we’re in a really darkish age nonetheless the place which suppliers must be managing which sufferers can be a perform of geography and sometimes referral networks, and perhaps somebody that you just seemed up on the Web. We might argue that over time, it’s truly gonna be rather more round who’s efficient with dangers and which medical fashions handle which danger circumstances successfully.

Once we take a look at including new companions, we wish to work with companions that see the longer term that this sort of risk-based administration system goes to be round to remain and really needs to encourage, reward, and in sure circumstances, create subsidies round collaborating in these early days of the shift to danger and worth. Numerous our companions see that. They’re thought leaders on tips on how to make that shift and, frankly, are serving to us to make the price of collaborating in these fashions and the reward of performing nicely in them very accessible for the physicians which might be taking up that chance.

Justin: We’ve heard related themes from our payor colleagues as nicely about how essential it’s within the early days to have alignment round long-term impression, particularly impression that’s tailor-made to their area people. So let’s get the take from Sonny Goyal, who’s the Chief Technique Officer at BlueCross BlueShield of North Carolina, and one of many largest advocates and champions for brand spanking new value-based care fashions.

Sonny: Having a deep understanding of our native inhabitants is absolutely vital. Now we have discovered essentially the most success with these companions that perceive that whereas North Carolina could seem like many different states on the market, we’re totally different and distinctive in quite a lot of methods as nicely. They get deep into the communities, into our native populations, and perceive that you must design the answer to actually match the particular wants of our individuals.

Justin: Having sturdy, aligned first companions, your launch companions, is very essential as you’re getting your small business off the bottom.

Jack: I’m a powerful believer in having an anchor buyer to assist launch a enterprise. In essence, they turn into a co-founder who actually understands your stage, believes deeply in your imaginative and prescient, and actually needs the outcomes that they assume you’re going to have the ability to unlock. If you will get that alignment with an government sponsor, predominantly one who has the P&L, who truly goes to profit from that worth that you just’re going to create collectively, I discover that they’re those who can then assist prepare your group and be a river information by means of the rapids of those well being plans which might be usually considerably troublesome.

Justin: Talking of navigating well being plans, how do you get the fitting stakeholders to the desk, particularly within the early levels?

Rajaie: The benefit of the area that we’re in is these issues actually matter to individuals. We’re not inventing an issue for them. We’re actually serving to them tackle what they acknowledge as essentially the most pressing problem in Medicaid care supply, which is: how do you ship community-based care that meets individuals the place they’re at? That’s normally sufficient to get the fitting individuals to the desk.

Justin: Who’re the fitting individuals to have on the desk? It will rely considerably on the accomplice. For instance, the wants of a giant nationwide payor will be fairly totally different than the wants of an area regional insurer. However, in each circumstances, it’s higher to construct broad coalitions, each vertically with executives and enterprise unit homeowners and horizontally throughout key capabilities.

Jack: In my expertise, there are only a few individuals in these payor organizations who can say sure, however there are loads who can say no. Particularly while you’re doing one thing that’s progressive, that breaks the mould, that challenges their current processes, the additional into the gross sales, contracting, and implementation course of, the extra you stumble upon different elements of the group. Having a broad coalition that features having a powerful exec sponsor, ideally a P&L proprietor on the helm of this ship is most essential. That coalition ought to embody contracting, the medical management, usually the credentialing group, even the attorneys who’re going to be concerned. If there isn’t that understanding, it turns into work, and also you get quite a lot of these stakeholders downstream which might be virtually antibodies, they usually can come again and attempt to assault this innovation.

Justin: Bigger nationwide companions, as a number of the most advanced organizations in healthcare, usually require the broadest coalition constructing. Let’s return to Sonny to listen to the payor perspective on this piece.

Sonny: Once we take into consideration due diligence and who’s conducting it, quite a lot of time that really is my group and my division round our technique and our new ventures group. We’re actually arrange for guiding innovators by means of all elements of our group, critically, clearly participating with our healthcare division, our medical division, for the assist and the consultants to ensure that this stuff come to life and that they’re put into our networks and our processes and our procedures in the fitting means.

Then we’re all the time working with our finance division as a result of what we’re driving in direction of is affordability. Then we go into our authorized and our well being coverage groups, and quite a lot of occasions they ensure that we’re driving in the fitting route and lining up with the place the federal government needs us to go, the place our shoppers need us to go, and actually being considerate about it.

Then final, however definitely not least, is what we name our markets group, whether or not it’s our authorities group or a industrial group, for a way we match this into their merchandise, into their companies, for our clients, whether or not it’s the person, by means of the employer, or by means of the federal government.

Defining success

Justin: Step one in scaling at-risk go to markets is to reach early deployments, however by definition, success in risk-based contracts is in the end judged in opposition to the worth or outcomes which might be created. Due to this, one of the essential steps in laying the muse for scale is defining the way you tactically measure success with companions up entrance. We’ve heard throughout founders and throughout our payor colleagues that you must outline success when it comes to what issues most to every particular accomplice.

Sonny: We’re centered on affordability and actually the overall price of care. You’ll have the very best resolution on the market, but it surely will not be the most important worth or the most important impression to what our members want and the way we drive affordability. Generally innovators miss that as a result of they’re centered on their resolution and promoting.

Rajaie: The query about defining success is just not one thing that you just get into on the finish of 12 months certainly one of your partnership. Whether it is, you’re most likely in bother. There’s nothing extra essential than truly getting that outlined and never simply conceptually, however actually in an Excel sheet, taking a look at it and saying, “does this seem like success to you?” After which understanding contracts to comply with from that.

Justin: Success is commonly outlined on operational and price outcomes, however choosing medical measures is a key element as nicely. We’ve persistently heard in regards to the significance of choosing measures which might be each validated and simply comparable to your companions. For instance, Eleanor Well being focuses on substance use problems for which there are established medical measurements already in place that they will use.

Corbin: We concentrate on psychometrically validated scales and screeners, so we are able to benchmark in opposition to them and say how significantly better we’re. That’s one factor, and definitely payors and others care about that. In addition they care about issues which you could examine just a little bit simpler. We noticed important reductions in ED and inpatient that we collected by means of third events, and so we had been capable of present in a statistically important means that we had been having this impression throughout our populations.

Fay: A part of getting members by means of these preliminary payment for service contracts was simply getting sufficient members actually to get sufficient information to reveal proof factors, together with expertise. NPS truly mattered loads to the credit score of payors. That went an extended technique to truly present all the engagement that we’re having with our members, which is a mean of 41 contact factors a 12 months of clinically important interactions. The flexibility to scale back TME (whole medical bills) on a payment for service contract, what that actually meant was, how are you doing on ER admissions? Are you protecting individuals out of the ER? That was a giant driver for us. How are you doing on A1C readings? How are you doing on behavioral well being? On nervousness? We had been capable of take all of these issues and convey them again to payors and renegotiate our authentic contracts to get right into a PMPM subcap settlement.

Justin: When you’ve established a profitable anchor partnership, the following key query is when to scale these partnerships. One of many challenges of constructing these selections in risk-based contracts is the inherent information delay that we now have in healthcare. Even when the top measures of success are clearly outlined, founders emphasised the necessity for upstream course of and working measures to assist corporations know if what you’re doing is working and is scalable, nicely forward of the final word information readouts that come typically years down the road.

Rajaie: Chances are you’ll elect to ramp up a market earlier than you have got a closing reply on whether or not or not it labored financially. As a result of with the run-out in claims and the reconciliation interval, and even in Medicaid, retroactive authorities changes on charges, it could possibly be actually 18 months till you have got a monetary reply on whether or not the mannequin labored. It’s essential to have the toolkit and the dashboards to know: Can we count on this to work? Is it working from the angle of the nonfinancial indicators that we are able to really feel assured?

Jack: Like most issues in healthcare, it’s not a transparent path between right here and there, between A and B. You really want to maneuver backwards and take into consideration, if these are the top targets that you just’re attempting to hit — be it satisfaction, be it financial savings — what are the interim measures that you should use to get a fairly excessive diploma of confidence that these issues are going to emerge, if that’s utilization adjustments or high quality impression or early indicators of satisfaction or financial savings. Then go even additional upstream, to the diploma which you have got course of measures in thoughts, are your processes outlined? Have they got measures?

You’ve got a speculation as you construct your small business round what steps you’ll take within the worth stream to unlock that worth. I’d encourage you to proceed to place metrics in opposition to these items, so as to take a look at them and say, “Hey, we really feel like we’re on the fitting path.”


Justin: WIth these upstream course of and working metrics in place, how briskly must you broaden to tackle further danger or to tackle further affected person populations?

Rajaie: There’s a steadiness between needing to be sufficient scale in order that operationally, from a unit economics perspective, you can also make it work, and that from an actuarial perspective, you have got sufficient credibility. However not being at a lot scale, or being so uncovered in your danger, that if the mannequin doesn’t work precisely as you hoped in 12 months one it has a massively damaging monetary impression on the enterprise.

Justin: As you develop, there are additionally a number of approaches and techniques you possibly can take to handle and mitigate the dangers that an organization is uncovered to in value-based and risk-based contracts. For Pearl Well being, this was particularly essential as they took an accelerated path to full danger.

Mike: The extra refined fashions are reinsurance and stop-loss insurance policies. One which we take into consideration and a means to assist serve our market is the bigger you get in these fashions, the extra you besides your self from systemic danger. You may successfully defray that, and you’ve got fewer exogenous elements that may be extremely costly. A small apply, for instance, can have a giant swing that’s extremely punishing, however a really giant market like Pearl, the place you have got hundreds or tens of hundreds or tons of of hundreds of members, is rather more proof against these kinds of swings.

Justin: Succeeding in value-based and risk-based contracts comes right down to having the fitting set of medical and operational capabilities. As we’ve heard from a number of founders, it’s vital to construct these capabilities from the earliest days.

Corbin: Expertise and information are actually essential so as to take danger on populations. From day one, we arrange a extremely sturdy information infrastructure. We had been gathering information, each claims information from payors enriched by third events, after which enriching it with our personal psychometrically validated scales and screeners, so we might consider the impression of what we had been doing.

Accumulating that information, analyzing that information, and making adjustments to our care mannequin for a way we strategy individuals, you have got to have the ability to try this from a inhabitants perspective, having the ability to take a look at the claims information to say: Who’re essentially the most excessive danger members? How will we danger stratify? However, as nicely, having the ability to iterate and alter your mannequin primarily based on the proof that you just’re getting and the information that you just’re coming back from your personal interactions and interventions with sufferers is absolutely essential.

Justin: In these early days, while you’re constructing your information infrastructure in your product, what do you purchase and what do you construct?

Rajaie: It may be of venture to say that you just’re going to construct all that your self, and so truly we’re fairly centered on construct versus purchase. What we needed to construct was actually solely the elements of the equation that nobody else had created, that had been proprietary to us, which is: how will we determine sufferers for engagement? How will we automate the care pathways? How will we give our neighborhood well being employees that we’re coaching for the primary time the sample matching of someone with years of expertise? That every one occurs by means of our product that the group is constructing.

When it got here to a few of these core instrumentation items, it wanted to be appropriate with what our well being plan companions had been seeing. It needes to be appropriate with what suppliers had been seeing, and so, there we made selections in order that we might successfully be on the identical enjoying discipline as them, and never be too artistic — too far forward, or too far behind — in how we had been receiving and speaking information and knowledge.

Justin: Past the information infrastructure and the analytical capabilities, scaling at-risk fashions usually additionally requires having the ability to ship care in novel methods, which frequently requires multimodal care, interdisciplinary care, and extra steady care approaches.

Corbin: Now we have brick and mortar clinics. Now we have field-based groups that may join with our neighborhood members in individual. Then we now have a extremely sturdy digital infrastructure as nicely. I believe not delivering only a level resolution of 1 factor, however having the ability to tackle extra of the wants of a inhabitants is essential in these danger fashions.

Justin: This provides fairly a little bit of complexity to risk-based enterprise, relative to it’s payment for service analogs. Due to this, we persistently heard from founders how essential it’s to have the fitting experience across the desk and to construct these capabilities early on, as corporations take off on the glide path to danger.

Rajaie: Wanting it’s, you must herald quite a lot of the experience and course of that you just would possibly see in a bigger, later firm earlier, when you’re going to maneuver down this path, as a result of the stakes are a lot larger. You don’t do that since you assume you’re going to have an consequence which you could level to in 12 or 18 months. You do that since you assume that over a many 12 months interval, doubtlessly a decade or extra, that you just’re going to make an actual impression on care supply. It’s a must to have that persistence and time horizon. Everybody on our group has it, and I believe, equally essential, our traders have it.

Justin: Whereas it’s nonetheless early days for value-based care and digital well being, we’re already seeing the way it can rewire our healthcare system and in addition the affected person expertise inside our healthcare system. As risk-based digital well being corporations develop, a few of them turn into marketplaces or enablement layers that span between payors and suppliers. We’re additionally seeing others which might be successfully changing into payors themselves, as they tackle international capitated danger and accomplice with a spread of different suppliers. After which others are on paths to turn into care platforms with a broad vary of medical companies.

What we search for as traders

Julie: So, how would we take a look at these corporations from an funding lens? We heard earlier how these risk-based contracting fashions will typically require a reasonably non-trivial set of investments into each the medical side of the enterprise and danger administration. In the beginning, we’d merely wish to know, does your plan appropriately account all the required parts? As an example, we’re going to have a look at the expertise in your group and whether or not you have got inner consultants or plan to rent of us who’ve carried out value-based care fashions prior to now and ideally additionally efficiently negotiated risk-based contracts. Completely different ranges of danger would require totally different ranges of capital reserves, whether or not statutory or in any other case, so does your use of funds plan offer you adequate runway to get to a powerful set of milestones for a follow-on spherical down the street?

A second factor we’d search for is whether or not you’ve chosen a affected person inhabitants for which value-based care is sensible. The market readiness for value-based care in numerous areas of the market is very variable and in addition a transferring goal. Validation that you just’ve chosen an space the place the timing is probably going proper is tremendous vital. Associated to that, there may be regulatory tailwinds which might be related to your inhabitants. We’ve seen this with kidney care, with main care, with oncology.

Lastly, a 3rd space that we’d consider is: what are the precise plan and roadmap to get to full danger, or no matter degree of danger you in the end search to take? How do you generate a adequate set of medical proof to have the ability to promote these outcomes to payors? Even when you’re beginning with easy payment for service contracts, having a nicely articulated roadmap and a set of assumptions for what you’d should consider to get to larger ranges of danger over time is one thing that we’d like to see within the earlier phases, together with issues like pricing and margin assumptions and a few type of thesis on TAM. Relatedly, we’d wish to know: do you have got payor companions both lined up or a speculation about which payor companions are able to collaborate with you for the given affected person inhabitants that you just’re specializing in?

Thanks a lot to our founders and payor executives who shared their views on this piece on risk-based contracting for digital well being corporations and to all of you for becoming a member of us. We’d love to listen to from you when you have any ideas or questions and hope that you just’ll proceed to comply with alongside as we roll out the remainder of our go to market playbooks.


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