Risk/Reward: Case Management in a “Payvider” Model of Care

Timeslot: Thursday, October 12, 2023 - 11:15 AM to 12:15 PM
Session Type: Concurrent Session


Value-based partnerships between payers and providers have created the “payvider”. The concept is not a new one − the industry has tested and launched such partnerships between payers and providers for many years. But today, the desire to have a greater role in risk management, generate margin and growth, and gain a competitive advantage are driving a surge in interest from health systems, particularly in the Medicare Advantage space. Under this model the payer and provider share both the risk and rewards of managing member care. UnitedHealthcare and Optum have made significant strides in establishing such a model with Medicare Advantage population by developing and implementing a comprehensive data-driven case management program to actively contribute to meeting the goal of providing highest quality coordinated care. This program consists of comprehensive case management interventions based on patient risk level and healthcare needs. The program utilizes claims-based data that supports case managers by providing them with most up to date analytics and clinical information specific to the patient. Process and outcome measures are tracked utilizing comprehensive dashboards. This program is scalable and is expected to deliver improved clinical outcomes for enrolled patients. Sharing the details of this program could benefit other case management professionals who lead and manage in the era of value-based care and global risk.

Learning Outcomes

  • Understand the "payvider" model of health care delivery

  •  Identify components of the needs driven case management program supported by dashboards and analytics

  • Evaluate the benefits of the partnership between the payer and provider in a value-driven environment