Value-Based Care, Risk Arrangements, and Accountable Care

As the health care reimbursement landscape evolves, navigating payment and delivery reforms impacting the commercial and government insurance markets has become increasingly critical for providers, accountable care organizations (ACOs), payers, management services organizations (MSOs), value-based payment enablers, and employers.

The traditional fee-for-service paradigm has been shifting to payment models focused on value, emphasizing quality and cost savings. While value-based care arrangements offer significant opportunities, they also present unique challenges that require informed guidance and strategic planning.

At Epstein Becker Green, we help organizations thrive in this rapidly evolving landscape. Our experienced team—which includes seasoned consultants from our affiliate EBG Advisors, Inc.—guides clients through the complicated process of establishing, implementing, and operationalizing delivery system reform and value-based purchasing models. Whether building new value-based business models or transforming legacy fee-for-service systems, we position clients for success under value-based payment arrangements.

Decades of Insight into Value-Based Contracting

With over 50 years of experience in value-based contracting, ACOs, and reimbursement risk arrangements, Epstein Becker Green helps clients unlock economic value by enhancing clinical efficiency and driving quality improvement. Our national Health Care and Life Sciences practice offers valuable insights into the diverse strategies employed by government and commercial payers and providers across the country. We’ve partnered with providers, MSOs, and enablers to effectively organize and contract for voluntary and mandatory Center for Medicare and Medicaid Innovation programs. And for decades, we have structured and negotiated risk-sharing agreements between plans and various types of providers that align incentives, protect clients’ interests, and deliver measurable results.

Comprehensive Services for Accountable Care and Value-Based Purchasing

Our team helps payer, employer, and provider clients address stakeholder concerns across all types of value-based contracting and care delivery models. Below is a sampling of our comprehensive services:

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Strategic Formation and Corporate Structure

Clients receive insight and guidance on forming new legal entities, such as ACOs, MSOs, independent practice associations (IPAs), clinically integrated networks, risk-bearing organizations, value-based payment enablers, integrated delivery systems, professional corporations, and limited liability companies. We also advise on operational tools, strategies, and governance models for these entities.

Contract Development and Payment Models

Clients rely on our advice on all types of payment models, including shared savings, capitation, bundled payments, and percent of premium arrangements. Our team develops participating provider contracts for ACOs, IPAs, and other integrated entities, assisting clients in participant contracting to achieve both clinical and financial integration. We have worked extensively with payers and provider health systems to develop total cost of care, episode-of-care, and other bundled payment arrangements, as well as quality performance bonus programs and various shared-risk programs.

Regulatory Navigation and Risk Management

We simplify the complexities of federal and state structural and regulatory frameworks, guiding clients through such areas as multistate organizational licensure, multistate utilization review licensure and certification needs, care management, and care coordination. Additionally, we help clients ensure compliance with the Stark Law, the Anti-Kickback Statute, privacy and security laws, antitrust laws, insurance laws, and the corporate practice of medicine doctrine. For risk-bearing entities, our team advises on state-specific requirements, including those in California (such as the Knox-Keene Act), New York, and Florida. Because numerous health, employee benefit, and labor laws apply in the accountable care and value-based context, we assist employers in documenting benefit design to align with value-based strategies. Additionally, we support providers in enforcement actions.

Readiness and Technology Assessments

Success in value-based arrangements requires advanced models of care and robust operational capabilities. Our team includes former clinicians and care management operators who conduct clinical and operational readiness assessments to evaluate the maturity of a client’s business processes. We also provide technology assessments to address requirements for claim systems, care management platforms, data warehouses, and data interchange and interoperability solutions.

Actuarial Modeling and Contract Simulation

We help clients connect strategy with the underlying economics to make value-based models more profitable. Our proprietary contract simulation models dynamically illustrate the financial impact of managed care contract structures. By integrating complex financial and legal logic, we can simulate payouts, volume, profits, and risks for providers, MSOs, and health insurers under multiple performance and reimbursement scenarios.

Transactional Support

Health care providers and payers look to us to handle the transactional work associated with value-based purchasing arrangements.

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