in order to meet cost reduction targets, CMOs * Share patient data across ecosystems * Embed shared organizational intelligence * Establish guidance for quality & cost within physician workflows * Prepare physician leaders to create a culture of continual improvement

1. Quality first:
The mission of margin growth
CMO strategies for creating a culture of continual improvement.
Presented by Optum®

2. Improving outcomes and performance
These days, reimbursement is increasingly tied to quality. Outpatient care continues to expand, and alternative
payment models are taking hold. Health care CMOs are tasked with improving quality and outcomes while elevating
network performance and reducing medical costs.
These demands are leading CMOs to reconsider staffing strategies and reimagine care models while petitioning for
a digital infrastructure that spans the ecosystem. Cost-containment has shifted from being a good business practice
to a vital element of improving care, maintaining compliance and succeeding with value-based arrangements.
This eBook will illustrate how cost-cutting goals can be an effective tool to streamline workflows, reshape your
network and improve the quality of your services. It will help you achieve the mission of margin growth with
successful organizational initiatives such as population health management, improved network performance,
and risk and quality management.
Introduction.......................................................................................................................................................... 2
The changing role of the CMO............................................................................................................................ 3
Moving from traditional to transformational strategies................................................................................... 4
Data & Infrastructure ...........................................................................................................................5-6
Utilization...............................................................................................................................................7-8
Care Variation.......................................................................................................................................9-10
Risk & Quality......................................................................................................................................11-12
Workforce...........................................................................................................................................13-14
Sustainable Growth................................................................................................................................. 15
Assess your approach......................................................................................................................................... 16
Meet our contributing experts.......................................................................................................................... 17
About Optum .................................................................................................................................................... 18
2

3. The changing role of the CMO
The country is clamoring for health care to improve — and that includes clinicians. In response,
organizations are asking for new levels of leadership from their C-suite, and the CMO is no exception.
Achieving quality is central to the premise of the medical profession. It’s also a business imperative. With
today’s rising aging population, many of whom are suffering from multiple chronic conditions, CMOs
are under added pressure to manage more complex patients while they strive to improve outcomes.
Care is often uncoordinated, leaving many consumers with a fractured experience and diminished health.
CMOs must lead the integration of care touchpoints and extend them well outside of hospital walls.
Physician burnout and clinician shortages threaten capacity and impact patient safety and well-being.
Recent reports suggest the U.S. could see a shortage of as many as 122,000 physicians by 2032.1
That’s why CMOs must attract and retain talent while at the same time creating a nimble and more
adaptable workforce.
Costs are too high for consumers, employers and the government to maintain. CMS is clamping down
on reimbursement, and more employers are considering whether to self-insure. Meanwhile, consumers
are looking for more convenient, low-cost alternatives or are avoiding the system altogether.
The modern CMO has a responsibility to understand the financial implications of all care decisions and
eliminate any medical expense that cannot be linked to improved outcomes. But in order to meet their
cost reduction targets, CMOs must discover how to share patient data across the ecosystem and embed
guidance for quality and cost within physician workflows. With this shared organizational intelligence,
they prepare their physician leaders to create a culture of continual improvement.
Achieving the mission of margin growth begins with a patient-first approach
to improving quality and outcomes.
These objectives cross
clinical, financial and
technology territories.
Today’s CMO must:
Bring clinical considerations
forward to inform all strategic
decision-making
Think beyond the in-patient
structure to cross-continuum quality
Create a physician-led culture of
improvement and accountability
Strengthen organizational capacity
to share clinical and business
information
Break through silos to advance
system-wide initiatives
Align physicians with system goals
3

4. These opportunities represent a chance to reshape your organization to take a patient-first approach to care.
Forging partnerships can help you fill operational and technology gaps, expand staffing capacity and complete the care
models you’re striving to implement. When you work to become more efficient by improving quality and outcomes,
you set up your organization for future growth.
An investment in quality interventions is an investment in an ideal future — one in which your care strategy is focused,
your governance is centralized, and your physicians are leading the way. In this future, your organization directs its own evolution
and performance. Your leaders are ready to deploy assets in order to optimize human resources, facilities and network
relationships. Your organization serves customers well and is promptly and properly compensated. It’s a financially sustainable
future that fully supports your mission and your growth.
This future can be achieved through strategies that promote sustainability.
Choosing opportunities: Traditional, transitional and transformational
The following pages will examine opportunities in each category:
Achieve operational
superiority
Implement radical
operating discipline
Eliminate clinical
care inefficiencies
Drive non-hospital value
Improve
care quality
Grow market
relevance
Data Infrastructure
Utilization
Care Variation
Risk Quality
Sustainable Growth
Workforce
4

5. Improve data and infrastructure
Meeting the pressure to improve
Part of putting patients first is freeing clinicians from administrative burdens that pull their attention away from valuable
face-to-face encounters. Modern technology can ease that burden but may require an investment in tools and training.
Another element of the patient-first approach is providing patients and their care teams with actionable clinical and financial
information. This calls for data sharing between health plans and providers and requires the infrastructure to do so.
With access to integrated data, health organizations can create more complete patient views, embed intelligence to anticipate
needs, automate tasks and speed information sharing. These actions create powerful new workflows that streamline
administrative activity, engage the consumer and facilitate care team collaboration.
LEADERSHIP
CHALLENGES:
Data and technology initiatives can reach across health plan
and provider organizations and involve a broad spectrum
of stakeholders.
ACTION STEPS:
Obtain senior leadership support for a data-driven approach
to quality improvement.
Identify physicians who can lead initiatives.
Share metrics that promote patient-centered care initiatives.
SYSTEM
IMPROVEMENTS
Data and analytics are not being fully shared and integrated.
As a result, the organization does not have a complete picture
of a patient’s health.
Share data to collaborate on population health management.
Embed intelligence into the workflow.
Utilize data and analytics to assess connections between interventions
and outcomes.
LABOR
IMPLICATIONS
Physicians and nurses are suffering from burnout and many
cite administrative burden and poor team communication
as a contributing factor.
Empower physicians to lead data integraton and EMR upgrade initiatives.
Facilitate the automatic dissemination of care best practices to care teams.
Provide clinical and financial decision support tools directly in EMR workflows.
Data Infrastructure
Data analytics
• Identify high-frequency patients and
determine why they keep returning
for urgent or emergency care.
Patient categorization
• Classify patient risk factors such as: gaps in care,
health-related barriers, and social determinants
of health. Share with physicians to guide care
decisions and their design of care interventions.
Workflow enhancement
• Embed a complete view of each patient’s
health-related activities. Share across the
ecosystem for more integrated clinical
decision support.
Innovations that lead to quality outcomes and margin growth
5

6. AND
Sustainable benefits
1. Consumer Experience
Meeting consumers where they are with convenient care access, self-service options and cost
information lets them make more informed decisions and engage more easily in their care plans.
Consumers rate their satisfaction levels based on easier access to more coordinated quality care.
2. Health Plan/Provider Relationships
CMOs for both health plan and provider organizations desire quality outcomes and must meet
them to satisfy CMS guidelines. They can foster a mutually beneficial relationship by combining
their clinical and claims data and collaborating on the development of holistic, population
health programs.
3. Physician Satisfaction
No matter what initiatives your organization introduces to improve quality or health outcomes,
your physicians will ultimately be responsible for adopting and implementing them. That’s why
it’s imperative that physicians are empowered to lead, the interference of technology is reduced,
and evidence-based best practices are thoroughly communicated.
Near-term growth
Start to build more complete patient views and
obtain an accurate picture of your health care
consumers. Identify what you’re best at and
what matches the needs of your population.
An empowered physician leadership begins
to shift your organization’s culture.
Long-term growth
Use intelligence gathered from your system to create
care pathways that match your populations. Accrue
more data to create an even larger holistic picture
of patient health and grow your overall population.
TIMELY ASSESSMENTS QUALITY MEASURES PARTNER RELATIONSHIPS
Evaluate
quality every
30
90
days
The average commercial
readmission cost is
than an average
initial admission.2
37%higher
• Track overall 30-day readmission rate.
• Track 30-day readmission and ER return rate by
diagnosis and service type.
• Track readmission and return rate by place
of service and physician.
• Reduce rebounds to the ER to less than 6%.2
• Formalize a high-touch approach between
coordinating organizations in order to support reliable
transfer of information.
• Integrate discharge planning, post-discharge follow-up
and ambulatory care management interventions.
• Include health plans, providers and referral partners in
care design.
Signs of success
Data Infrastructure
6

7. Insights and analysis
• Analytics built on combined claims and
clinical data can provide CMOs with
complete views of care patterns and inform
decisions for optimizing service sites and
resource deployment.
Advanced NLP
• Coding and documentation infused with
advanced natural language processing (NLP)
can ensure that the record of each patient
encounter matches the physician’s intent and
supports the utilization of services and referrals.
Artificial intelligence
• AI can speed up first-level utilization reviews
by scanning for risk factors and identifying
complex cases quickly. It can provide evidence,
clinical indicators and supporting research to
justify patient status recommendations.
Innovations that can improve utilization
Utilization
LEADERSHIP
CHALLENGES:
Clinicians need to be able to see and understand where
inappropriate utilization negatively affects outcomes quality.
ACTION STEPS:
Let physicians lead adjustments to utilization protocols and set the standards for care.
Help your organization see these interventions as key to improving patient outcomes.
SYSTEM
IMPROVEMENTS
Underinformed decisions can lead to costly denials, claim
rework and poor patient experience.
Employ clinically intelligent AI to support patient status recommendations.
Embed evidence-based order sets within the EMR.
LABOR
IMPLICATIONS
Utilization has a direct impact on workforce productivity for
health plans and providers. Resources may be redeployed to
better match the needs of the ecosystem.
Use automation to free teams to focus on systemic, high-value objectives.
Evaluate utilization against quality goals
Guiding patient recommendations with automated intelligence
Inappropriate utilization indicates a misalignment between health system quality and financial performance. Consumers depend on
their care provider and their coverage to direct them to the right services at the right time. Yet inappropriate utilization still erodes
margins and hampers the quality ratings that affect reimbursement.
Health leaders can see measurable savings by selectively employing artificial intelligence and natural language processing to enhance
the consumer experience. A comprehensive care management review can measure clinical workflows against CMS benchmarks and
evidence-based practice to identify interventions that are most likely to improve cost and quality over the long term.
Insights from population health analytics can help pinpoint interventions that should be prioritized to improve utilization where it will
have the most impact. In a recent study of Medicare members, a claims-based predictive algorithm helped reduce the likelihood of
an emergency department visit by 20% in one year.5
Appropriate utilization is especially important for health organizations pursuing
managed-care contracts in which reimbursement is tied to cost, outcomes and patient satisfaction.
7

8. Sustainable benefits
1. Consumer Experience
Eliminating labs, services, medications and visits that do not deliver cost-effective quality to
the patient lowers everyone’s costs — including the consumers’. Eliminating care delays builds
consumer confidence and can positively impact net promoter scores (NPS). Holistic utilization
strategies increase engagement in proactive, cost-effective care plans, further lowering costs and
improving outcomes.
2. Health Plan/Provider Relationships
Establish healthy partnerships by eliminating the friction in the inpatient/outpatient admission
determinations as well as irritation and cost of claim denials. Facilitate the immediate exchange
of patient data. Utilization decisions that are based on complete information ensure that
individuals are guided to the right care programs. Confidence in utilization helps health plans
and providers feel more confident in their strategic relationship, and in the knowledge that CMS
mandates and population health management programs can be achieved.
3. Physician Satisfaction
Automated intelligence embedded in clinical workflows ensures that key clinical factors and
evidence-based medical research can help guide patient recommendations. Automated solutions
can decrease disruptive chart audits and improve the accuracy of HEDIS scores. Having a
leadership role in quality improvements compels clinicians to drive change. They take pride in
improving outcomes, and can benefit financially from improved quality metrics.
Near-term growth goals
A commitment by health plans and providers to share
patient data improves utilization decisions earlier
in the encounter — guiding consumers to the right
care pathways. Possessing a clear, complete view of
consumers’ needs allows you to confirm if you have
the right care models to match.
Long-term success strategies
Take a fresh look at utilization strategies with more
complete consumer data, care management and
utilization reviews. Transparent views of performance
metrics help clinicians see the impact of their utilization
decisions and give leaders the insight they need for
further refinement. Additionally, ask consumers for their
input and preferences. When the ecosystem is properly
utilized, consumers feel satisfied, physicians can have
greater impact on health outcomes, and organizations
achieve the quality metrics that drive growth.
ACCURATE PICTURES OF UTILIZATION FEEDBACK MECHANISMS PARTNERSHIP ASSISTANCE
• Health plans and providers can build more complete
patient views and more accurately score HEDIS
measures by combining claims data with medical
chart reviews. Third-party vendors can help
automate this data exchange for both parties.
Utilization
$41.3Bin hospital costs for patients
readmitted within 30 days
of discharge.4
Readmissions
cause
• AI-driven medical necessity and patient access processes.
• Coding and documentation supported with AI and
advanced NLP.
• Benchmarks to evaluate optimal use of each care channel.
• Benchmarks to evaluate outcomes by disease.
• Consumer insights to inform care redesign
and outreach.
• Complete patient views and benchmarks
embedded within the EMR.
• Physician performance dashboards to guide
behavior change.
Signs of success
8

9. Cut down on care variation
Solving for the issue at scale
Unwarranted care variation is among the largest obstacles facing the health industry, accounting for millions in waste and lower-quality
care. Yet this problem is also an opportunity for health organizations to prove that they have a consistent approach for solving for care
variation at scale. Success requires standardizing the process for care variation reduction (CVR).
Savings, quality and improved outcomes occur when evidence-based guidelines can be translated into clinical practice and scaled
across the ecosystem. To build a scalable CVR process, leaders can begin with a care management analysis to identify variations across
the ecosystem and prioritize those that impact multiple service lines. They also can reach out to physicians who see value in CVR and
are culturally ready to lead refinements of care protocols. Additionally, the focus of interventions should be guided by quality
benchmarks — comparing against national and like-organization top quality cohorts.
Assess data and analytics
• Analyze your patient data by DRG to reveal
variable costs, average length-of-stay,
readmission and mortality rates by service line.
Track benchmarks
• Benchmark against top-quality cohorts.
• Pilot CVR recommendations to predict
the cost of the change and value to the
ecosystem if you scale.
Gather internal insights
• A length-of-stay analysis can identify trends and which
DRGs are driving the highest volume of avoidable days.
• Claims data can identify high-cost, low-quality
encounters and support internal discussions.
• Data from across the ecosystem can be used to find
patterns and trends.
Choosing the right clinical opportunity for CVR
LEADERSHIP
CHALLENGES:
Standardize the process to continually solve and
scale CVR. Physicians ‘standardize’ care with
everyday patient care choices.
ACTION STEPS:
Define the leadership, information and technology needed to scale.
Assemble the leadership and governance group with accountability to standardize care pathways.
Determine process and outcome metrics. Define the data sets and analytics needed to manage them.
Dedicate resources to embed care standards into common practice.
PHYSICIAN
ENGAGEMENT
Physicians seek quality, not compliance.
Eliminating care variation is one tool they can
use to improve the quality of their service area.
Identify the clinicians who are most engaged and ready to lead care protocol teams.
Include nurses, therapists and other care team members in the discussion.
Prioritize the easiest wins.
SYSTEM
CHANGES
Clinical specifications and labs, services,
pharmaceutical and med tech recommendations
can be translated into the workflows.
Embed data capture into your EMR.
Provide actionable dashboards revealing cost and quality performance data.
Support care coordination across the service line and ecosystem.
Care Variation
9

10. Sustainable benefits
1. Consumer Experience
Eliminating unnecessary care can reduce patient harm, improve outcomes, and build trust with
the patient. In turn, this consumer trust in your network capabilities and protocols can translate to
brand loyalty and drive growth.
2. Health Plan/Provider Relationships
Reducing care variation results in overall increased quality metrics. This supports specialized care
contracts and episode-based care models.
3. Physician Satisfaction
Standardization of evidence-based care protocols allows physicians to be recognized for consistent
quality and frees them to focus on the complex, unique needs of their patients, applying their
expertise where it is most needed.
Near-term growth goals
Achieve efficiencies in care quality that run across
the system. Lay the foundation for a quality-
driven culture that is guided by shared evidence
and has internalized the benchmarks as baselines.
Compliance will be a natural benefit, but it is not an
effective incentive.
Long-term success strategies
Health organizations can excel in population health
and succeed with alternative models by proving
proficiency within their service lines and across
their ecosystem. Agreed-upon protocols and their
associated metrics can guide physician behavior,
improve performance and attract physicians who
appreciate practice standards.
WELL-DEFINED MILESTONES ANTICIPATED SAVINGS DEDICATED RESOURCES
A typical hospital spends up to
30% more to deliver care with
comparable or lower-quality
outcomes than the top-performing
cohort who had reduced CVR.5
Care Variation
High-quality hospitals
deliver lower-cost care for
82%of diagnoses.5
• Conditions for CVR have been prioritized.
• Root causes of variation are understood.
• Interventions have been recommended.
• Impact of CVR on cost and outcomes
is trackable.
• Subject matter experts
• Physicians
• Nurses
• Administrative champions
Signs of success
10

11. Identify risk and improve quality
Revealing the complete patient health picture
Health plans and providers serving high-risk patients can increase engagement and support reimbursement accuracy by collaborating to:
Size the risk in your
complex population
• Many chronic conditions go undetected or
have incomplete documentation. Examine the
cost-benefit of interventions that ensure reporting
is correct and complete.
Analyze provider-level data
• Comparative reviews of provider
performance can highlight differences in
practice patterns.
Evaluate consumer-level data
• Member data can generate actionable clinical
insights, validate communication preferences
and confirm care delivery preferences.
• Build more complete and accurate profiles to help identify high-risk patients
and their full scope of conditions
• Support the importance of diagnosis to shift the mindset from capturing
procedures to recognizing conditions
• Ensure that patients receive recommended, compliant services
• Accurately report patient data to encourage complete and accurate
capture of health status
• Invest in screenings to confirm a patient’s full scope of conditions
The Medicare population continues to rise, and CMS estimates that more than two-thirds of its beneficiaries have at least two chronic
conditions.6
But many of these conditions go unrecognized or undertreated.
LEADERSHIP
CHALLENGES:
Data has a domino effect on risk assessments, quality metrics and
reimbursement as information travels from the individual provider to the
group to the health plan to the agency that administers the program.
ACTION STEPS:
Audit all data assets to build a more accurate and complete picture
of consumer needs.
PHYSICIAN
ENGAGEMENT
In a fragmented system, physicians are not always aware of care
delivered in settings outside of their practice and some chronic conditions
don’t present themselves without a comprehensive evaluation.
Leverage comprehensive patient data and analysis to identify care gaps at
the point of care.
Encourage investments in actions like health screenings that identify
risk factors.
Develop outreach programs that bring more patients in for health
screenings and assessments.
SYSTEM
CHANGES
The medical code is the source of truth in the health industry, but
oversight agencies treat the medical record or the claim as the source of
truth for DX code reporting.
Implement near real-time feedback on coding and documentation for
more accuracy and completeness.
Risk Quality
Spotting levels of clinical and compliance risk in your network
11

12. Sustainable benefits
1. Consumer Experience
Consumers can trust that their health system is able to proactively recognize their full scope
of needs and attend to them in the most effective manner.
2. Health Plan/Provider Relationships
Chronic illnesses now account for 84% of total health care costs.8
A seamless, transparent flow of
information supports a comprehensive care evaluation.This helps the system and members have
better health.
3. Physician Satisfaction
Physicians can more readily deliver prompt quality care when they have access to a complete
patient picture found directly in the EMR. Being able to prove the quality of their performance
means they can be confident they are receiving appropriate recognition and compensation.
Near-term growth goals
The primary goal during an annual patient visit
should be a complete and accurate evaluation of the
member’s health. This goal will help patients get
into the proper settings for care paired with accurate
reimbursement for care rendered.
Long-term success strategies
Ideally, the complete and accurate reporting
of patient activity will automatically trigger alerts
for underlying conditions within the physician
workflow. Members identified with undermet
needs can be guided into coordinated care
programs that proactively manage their complete
needs in a compliant setting. By driving
engagement in population health pathways,
health plans and providers are well suited for
other risk-sharing arrangements.
REACH MORE CONSUMERS ASSESS CONSUMERS COMPLETELY COLLABORATIVE OPPORTUNTITIES
Americans have pre-diabetes
and yet 90% of them don’t
realize it.7
84M
Risk Quality
• There is a rise in low-cost interventions
like screenings.
• Chronic conditions are identified earlier.
More consumers are
completing annual
checkups and are being
assessed for a broader
range of conditions.
• Health plan-sponsored staff can help
reduce provider administrative burden.
Signs of success
12

13. Build strategic relationships
• Strategic partnerships create flexible access
to additional resources and care settings.
• Outsourcing acts as an extension to the
community, enabling care coordination
teams and enhancing access to care.
Let physicians lead
• Physician leaders are more able
to reflect the needs of patients
and frontline staff. They can
most readily champion change or
appropriately caution against it.
Create an agile workforce
Cultivating a competitive and adaptable strategy
As today’s consumers take on more financial responsibility for their health care, they expect their needs and preferences to be addressed
by their health services. The use of retail clinics is steadily growing, and about 70% of consumers say they prefer digital solutions to in-person
solutions.9
As populations shift and health care moves out of the hospital environment, the workforce must be able to adjust.
CMOs are further challenged with finding enough talent. Efficiencies can come through automation and rightsizing. Teams supported
with smart technologies embedded in their workflows can eliminate low-yield, repetitive tasks and increase their capacity. Outsourcing,
partnerships and innovative employment contracts can enable more flexible staffing models.
To stay competitive, leaders need an agile strategy that shifts the workforce from a financial burden to a physician-led engine of growth.
Match your population
• Predictive modeling can help you forecast the talent structure
needed to match populations you seek to serve.
• Emerging channels such as telemedicine can extend your reach,
tailor care to specific populations and free up resources.
• Digital tools can make more of the resources you have and
relieve your staff of administrative burden.
Innovations that can strengthen your workforce
LEADERSHIP
CHALLENGES:
Clinical, financial and IT leaders need to ensure that the
organization is flexible enough to make the most of all
available human capital resources.
ACTION STEPS:
Map current and future talent demands to desired business outcomes.
Map potential for staff augmentation that allows greater access and coordination
of care vs. long-term, strategic partnerships.
Foster a culture of transparency, trust and digital skillsets.
ECOSYSTEM
IMPROVEMENTS
As care delivery moves out of the hospital and aging
populations increase, health organizations need a
workforce that can support modern data sharing and
extend the ecosystem into the community.
Embed AI technology to support shared decision-making and automate staff tasks.
Expand virtual care and clinician-to-clinician consultation.
Extend the workforce into retail, community and transitional care pathways.
LABOR
IMPLICATIONS
Turnover is expensive. Physicians want work-life balance
and nurses face an experience gap. Current talent may
not match complex patient demand, the requirements of
a modern revenue cycle or outpatient care design.
Predict staff turnover before it happens.
Align staff to population health demands.
Close the experience-complexity gap.
Consider automation and strategic outsourcing to reduce risk.
Workforce
13

14. Near-term growth goals
Expand your organization’s reach and ability to
engage with consumers where they’re most likely
to engage. Use multiple methods to determine their
preferences, then invest in those labor strategies
to match. Boost quality and savings by redefining
patient pathways and appropriately augmenting
staff. Strategic outsourcing can create agility by
allowing you to test alternatives with less risk.
Long-term success strategies
Sustainable health organizations have the labor
to match their mission. They have the flexibility to
strategically deploy their workforce to deliver better
value. This capacity depends on developing a skilled,
versatile workforce that’s well connected to the
broader ecosystem. Consider partnerships that can
complement your core capabilities, let you focus on
your strengths and dramatically reduce your risk.
CONSUMER LOYALTY CLINICIAN SATISFACTION PARTNERSHIP PRODUCTIVITY
Physician-run
hospitals score
in overall quality.10
25%higher
• Workforce aligns with the health needs
of your consumers.
• Service channels meet consumer preferences.
• Chronic conditions can be identified earlier.
• Care coordination is improved.
• Resources match the level of care demands.
• Administrative workload is reduced.
• Clinician retention levels improve.
• Physicians lead a culture of continual improvement.
• Shared services are available.
• The capacity exists to expand or contract
to meet market demands.
Signs of success
Workforce
Sustainable benefits
1. Consumer Experience
Customers now expect connectivity to their health plans and providers through an expansive
network of acute, ambulatory and digital channels. A skilled, technology-enabled workforce can
help guarantee greater consumer engagement, increased satisfaction and cost-effective quality.
2. Health Plan/Provider Relationships
No one can do it alone. It’s a big task to redefine your workforce, build the right kind of
infrastructure and find the talent you need. The endeavor requires thoughtful governance, smart
investment and a tolerance for risk. CMOs can make the most of their resources and mitigate the
risk by collaborating to develop integrated labor strategies that support their shared goals and
their contracts.
3. Physician Satisfaction
Facing untenable hours, increased bureaucracy and reduced fulfillment, 44% of physicians
have reported feeling burned out.11
Some are leaving the industry and others are reducing their
workload to achieve more work-life balance. Relieving clinicians of time spent on burdensome
administrative tasks can have immediate impact. Transforming the care environment with
intelligence embedded into their workflows is another workforce intervention that will increase
physician engagement and build resilience.
14

15. Are you ready to transform?
To make the most of these transformative opportunities, you need to set yourself up to be a great partner. Identify what you’re good at and ready your
organization — then find the partners that align to your plan and are able to contract with you appropriately.
Transformation is the next step to sustainable growth
Adaptive, holistic ecosystems that are well matched to the needs of local populations are the result of strong
leadership and dynamic partnerships.
While other types of initiatives can reduce cost and improve growth, the goal of transformation is to find
the most competitive approach to creating value for the health consumer while producing a distinct rise
in market relevance.
Transformation can begin as part of a traditional, incremental intervention, but its value is the developed
ability to respond to radical market disruption. It takes a strong leadership team to prepare an organization
for these new dynamics and it typically includes some kind of strategic partnerships.
Sustainable Growth
1. Assess your populations, local market
dynamics and the full potential for revenue.
2. Examine your organizational readiness
for continual improvement and strategic
relationships.
3. Identify initial focus areas that are easy
to measure.
4. Assess your capacity for change
management.
1. Modernize your infrastructure to
support risk.
2. Extend your service channels to match
consumer needs and preferences.
3. Commit to a culture of continual
improvement.
4. Identify potential partners with overlapping
interest and a capacity to engage risk.
1. Engage strategic partnerships with aligned
incentives and shared capacity for risk.
2. Extend the reach of your workforce with
automated technology, flexible staffing
models and outsourcing strategies.
3. Scale your top-performing, evidence-driven
care models.
4. Continue to monitor and improve.
MASTER RISK
GROWTH DYNAMICS
SET THE FOUNDATION PREPARE FOR CHANGE
15

16. Are your strategies traditional or transformational?
Cost savings and growth are interconnected aspects of financial sustainability. Market consolidation, new
market entrants and regulatory shifts continue to pressure health organizations to speed up their reform.
Matching potential strategies to organizational goals, capacity for change and culture are critical to success.
Self-assessment, predictive modeling and strategic partnerships can help define which interventions
and strategies will achieve the greatest advantage. But every health organization must move toward
transformation, or they risk becoming obsolete. Transformation surrounds the consumer with the most
optimal health experience.
Measure administrative proficiency
Optimize current technology investments
Confirm that your workforce is skilled and supplied
with the right technology
Move operations to cloud-based services
Establish the ability to scale or shrink based
on market demand
Close more care gaps
Ensure that referrals stay in network
Keep your network performing at benchmark levels
Connect clinicians with the technology they need
to self-regulate performance
Make sure consumers receive services in the most
effective setting
Quantify the transformative elements of your
vision for risk and opportunity
Identify core competencies crucial to your mission
Recognize non-core competencies that are costly
to support
Pinpoint partners that can mitigate your risk
Improve
care quality
Grow market
relevance
Achieve operational
superiority
Improve
care quality
Grow market
relevance
Achieve operational
superiority
Improve
care quality
Grow market
relevance
Achieve operational
superiority
Transformation begins with a focus on improving quality and reducing costs.
16

17. Meet our contributing experts
To craft our content for health care leaders, we draw upon the expertise of clinical, strategic
and operational professionals. Together, these insights form a holistic overview of what health
plans and providers are facing in today’s health market.
Meet our contributing experts
To craft our content for health care leaders, we draw upon the expertise of clinical, strategic
and operational professionals. Together, these insights form a holistic overview of what health
plans and providers are facing in today’s health market.
JOHN JOHNSTON
Senior Vice President, Advisory Services
Optum
Leads the Optum Hospital Performance Improvement
consulting practice. His work focuses on transforming an
organization’s cost structure and care model, including
reducing the total cost of hospital care, driving non-hospital
value and advancing system integration.
ERIC YOUNG
Vice President, Advisory Services
Optum
Works with Optum Advisory Services clients on a wide array
of health system margin improvement efforts. His areas
of focus include health system finance, cost management,
revenue cycle and reimbursement, debt and capital
management and strategic growth.
MIKE BOBOLA
Vice President, Solution Design
Optum360
Leads a team of operations and consulting experts that seek
to drive cost out of the health care system by establishing
risk-based partner relationships focused on achieving
pre-planned outcomes.
JEFF DUMCUM
SVP, Clinical Performance - Risk, Quality and Network Solutions
Optum
Works with large health systems and strategic health plan
clients on the design and deployment of prospective risk and
quality programs to drive performance and outcomes.
TIFFANY STEFFEN
Client Partner, OAS - Hospital Performance Improvement
Optum
Assists hospitals in improving efficiency and effectiveness
of clinical operations, evaluating productivity, improving
throughput and redesigning processes.
MARK DERUBEIS
CEO
Premier Medical Associates
Serves as a leader, board member, speaker and facilitator
with leading US health organizations driving innovation
across the industry. He currently serves on the board of
the American Medical Group Association and is co-chair
for the Pittsburgh Regional Health Initiative.
ROBERT X. MURPHY, JR., MD, MS
Chief Integration Officer
Lehigh Valley Health Network
CMO, Populytics
Lehigh Valley Health Network
Provides medical leadership and oversight to all LVHN health
plan related entities. Leading strategy and execution of
value-based medical elements in all payer contracts.
GARY SMALTO, MD, MBA
Practice Partner, Optum Advisory Services
Drives continuum of care programs to increase value for
hospitals and health systems through clinical operational
improvements leveraging clinical variation reduction, physician
governance, value management, perioperative services,
throughput and capacity management leading practices.
17

18. 1 Association of American Medical Colleges. The Complexities of Physician Supply and Demand: Projections from 2017 to 2032. Data and Reports page.
Association of American Medical Colleges website. https://aamc-black.global.ssl.fastly.net/production/media/filer_public/31/13/3113ee5c-a038-4c16-89af-
294a69826650/2019_update_-_the_complexities_of_physician_supply_and_demand_-_projections_from_2017-2032.pdf. Accessed January 2, 2020.
2 Kilroy C, Morgan-Solomon D, Landrum P. Preventing patient rebounds: Value-based care organizations should focus on more than just readmissions. Resources
page. Optum website. https://www.optum.com/content/dam/optum/resources/whitePapers/ReadmissionPrevention_WhitePaper_Online_FINAL.pdf. Accessed
December 30, 2019.
3 David G, Smith-McLallen A, Ukert B. The Effect of Predictive Analytics-Driven Interventions on Healthcare Utilization. Research Brief page. University of Pennsylva-
nia Leonard Davis Institute of Health Economics website. https://ldi.upenn.edu/brief/effect-predictive-analytics-driven-interventions-healthcare-utilization. Accessed
December 21, 2019.
4 Hines AL, Barrett ML, Jiang HJ, Steiner CA. Agency for Healthcare Research and Quality. Conditions with the Largest Number of Adult Hospital Readmissions by
Payer, 2011. Healthcare Cost and Utilization Project website. https://www.hcup-us.ahrq.gov/reports/statbriefs/sb172-Conditions-Readmissions-Payer.pdf. Accessed
December 30, 2019.
5 Advisory Board. High-Quality Hospitals Deliver Lower Cost Care 82% of the Time. News page. Optum website.
https://www.optum.com/about/news/high-quality-hospitals-deliver-lower-care-cost.html. Accessed December 21, 2019.
6 Centers for Medicare Medicaid Services. Chronic Conditions Among Medicare Beneficiaries. Chartbooks and Charts page. Centers for Medicare Medicaid
Services website. https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/chronic-conditions/downloads/2012Chart-book.pdf.
Accessed December 21, 2019.
7 Center for Disease Control and Prevention. Prediabetes: Your Chance to Prevent Type 2 Diabetes. Basics of Diabetes page. Center for Disease Control and
Prevention website. https://www.cdc.gov/diabetes/basics/prediabetes.html. Accessed December 21, 2019.
8 Moses H III, Matheson DH, Dorsey ER, George BP, Sadoff D, Yoshimura S. The anatomy of health care in the United States. Journal of the American Medical
Association. 2013;310:1947–1963.
9 Cordina J, Jones EP, Kumar R, Martin CP. Healthcare consumerism 2018: An update on the journey. The Our Insights page. McKinsey Company website.
https://www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/healthcare-consumerism-2018. Accessed December 30, 2019.
10 Stoller JK, Goodall A, Baker A. Why the Best Hospitals Are Managed by Doctors. The Leadership page. Harvard Business Review website.
https://hbr.org/2016/12/why-the-best-hospitals-are-managed-by-doctors. Accessed December 30, 2019.
11 Kane L, MA. Medscape National Physician Burnout, Depression Suicide Report 2019. Physician Lifestyle reports page. Medscape website.
https://www.mescape.com/slideshow/2019-lifestyle-burnout-depression-6011056. Accessed December 21, 2019.
Sources
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