Alignment Healthcare, Inc. (Alignment) operates as a next generation, consumer-centric health care platform that is purpose-built to provide seniors with high quality, affordable care with a vastly improved consumer experience.
Enabled by the company’s innovative technology and care delivery model, the company focuses on improving outcomes in the Medicare Advantage sector. The company’s operations primarily consist of Medicare Advantage Plans in the states of California, North Carolina, Nevada,...
Alignment Healthcare, Inc. (Alignment) operates as a next generation, consumer-centric health care platform that is purpose-built to provide seniors with high quality, affordable care with a vastly improved consumer experience.
Enabled by the company’s innovative technology and care delivery model, the company focuses on improving outcomes in the Medicare Advantage sector. The company’s operations primarily consist of Medicare Advantage Plans in the states of California, North Carolina, Nevada, Arizona, Florida, and Texas.
The company’s model is based on a flywheel concept, referred to as its ‘virtuous cycle,’ which reflects its unique ability to manage healthcare expenditures while maintaining quality and member satisfaction.
To execute upon this concept, the company starts by ingesting medical and demographic data through its proprietary AVA technology platform. AVA’s predictive algorithms provide unique insights into each member and identify those most at risk of an acute event. The company’s information-enabled care model is then combined with clinical engagement by its employed clinical teams, known as Care Anywhere, to improve healthcare outcomes for its members. For example, the company’s high-touch clinical model proactively manages chronic conditions and assists with post-discharge care navigation to reduce unnecessary hospital admissions and readmissions, which, in turn, improves health outcomes and quality while lowering overall costs. The company then reinvests medical cost savings into richer coverage and benefits, which propels growth in revenue and membership while maintaining margin discipline. The strength of the company’s model is further reinforced by delivering a premium member experience. The company’s concierge and clinical service hotline is available 24/7 at no additional cost to its members, and its state-of-the-art in-house call centers provide it with more consistency and control over member-facing functions.
Results: Predictable, Recurring Revenue Positioned for Long-Term Growth
The company has developed a business model with a predictable, recurring revenue stream that provides significant visibility into its financial growth trajectory. The company generally contracts directly with CMS as a licensed Medicare Advantage plan and receives a recurring per member per month (‘PMPM’) payment in exchange for bearing the responsibility of its members’ healthcare outcomes and expenditures. These contractual arrangements, combined with the fact that the majority of its net membership growth occurs effective on January 1 of a calendar year after the annual enrollment period (‘AEP’), provide a higher degree of visibility to its full-year projected revenue early in the calendar year, subject to its ability to model for in-year member growth, as well as revenue PMPM, which, in turn, depends on member health and mortality trends.
Technology: AVA Provides Timely and Actionable Insights
AVA empowers the company’s employees and provider partners with timely and actionable information to improve the health experience and outcomes of the company’s members.
The company’s position in the healthcare ecosystem as a Medicare Advantage plan affords it differentiated access to large amounts of member data. The company applied its clinical and technical expertise to build AVA, a proprietary platform that forms the backbone of its care delivery efforts, whether done through provider partners or directly through its care teams. AVA is a highly sophisticated engine that ingests longitudinal data from more than 200 sources to provide an accurate assessment of each member and actionable information to care teams in real time. When triggered by relevant data, AVA delivers prescriptive insights that guide providers’ workflows to deliver personalized care to members. Examples of workflows include ordering a prescription, alerting a caregiver, transferring information from a lab to a doctor, and developing a treatment plan.
The company and its provider partners use this data every day to power care interventions that may be missed in traditional healthcare relationships. AVA improves the care outcomes and care experience of its members, while also providing everyone in their ecosystem — from doctors to nurses — real-time data and operational indicators to deliver the right care, to the right member, at the right time.
AVA incorporates high-security controls around member data, and it is subject to regular vulnerability tests and strict authorization protocols. It also uses machine learning and artificial intelligence to help predict various scenarios such as hospital admission and readmission risk, member satisfaction, disenrollment risk, and various disease propensity scores, as well as how to best intervene. These models are based on hundreds of thousands of historical outcomes, which have shaped their predictions and accuracy, and are constantly updated with new data sets, enabling them to get smarter and more effective.
Additional details on AVA’s capabilities include:
Consumer Experience: AVA offers a digital ecosystem that enables the company’s members and their support system to get the information and care they need, when and how they need it. With their AVA-powered member portal and mobile app, seniors have many self-service capabilities and can get 24/7 care, send secure messages to their concierge and care teams, check their rewards and ACCESS On-Demand Concierge Card balance, and view their health history, including medical claims history, pharmacy, and benefits data.
Internal Care Delivery: The company’s ability to efficiently and effectively deliver care via its internal care teams is critical to improving outcomes and managing costs. AVA is vital in its ability to identify and manage its highest risk, most complex members, and to ensure that every intervention opportunity is optimized by the most relevant and effective data available.
External Providers: AVA transforms care delivery by shifting the paradigm from ‘silos of care’ to physicians and payors working together as partners through technology enablement. Medical group leaders, doctors, and front-line administrative staff are provided comprehensive information to streamline and support the coordination of member care. AVA provider applications drive workflows and action lists to improve member outcomes at a lower cost and lower visit frequency. Providers are given access to AVA applications to track utilization, gaps in clinical care, and health risk assessments. This data is utilized to prioritize which members to see, and which members may benefit from various health engagement strategies.
Health Plan Operations: By leveraging a single source of accurate information, the company fosters improved cross-functional communication and execution across its key value drivers. With the support of AVA, the company’s operational leaders can make faster, data-driven decisions, which leads to improved outcomes and greater efficiencies as it grows its membership base.
Growth Operations: The company is able to create greater brand differentiation in the market with its external brokers and its internal sales team by providing them best-in-class digital solutions such as the AVA Broker Portal and mobile app. These tools streamline application submission and management, client management, commission tracking, and a variety of self-service capabilities specifically for Medicare Advantage.
When paired with the company’s operational expertise, AVA is integral to its ability to drive its operations and business outcomes consistently across markets. AVA provides the company with the flexibility to adapt its operating models to meet the needs of local communities and providers, while achieving high-quality, low-cost care in each market.
Clinical Model: Proactively Managing Member Care to Improve Outcomes and Reduce Cost
The company engages regularly with members as part of their daily lives and proactively manages their chronic conditions to improve outcomes and reduce costs.
The company’s clinical model is designed specifically for seniors and is managed across multiple disciplines (medical, social, psychological, pharmaceutical, and functional) and sites of care (home, inpatient, outpatient, virtual, and others). The company’s internal care teams and external providers use AVA to coordinate high-quality care for members and manage the complexity of the healthcare system. Given the prevalence of comorbidities within its chronically ill members, coordination across a multi-disciplinary care team is vital to providing a medical and behavioral care plan that drives improved outcomes.
The company’s care delivery model creates a highly personalized experience that is unique to each member. Using insights from AVA, the company organizes members into four categories to provide optimized care: healthy, healthy utilizer, pre-chronic, and chronic. The data below represents a sample of its population stratification from 2024.
Healthy: The typical member in the ‘healthy’ category requires low levels of medical care. Healthy members comprise approximately 71% of the company’s membership base but account for only 5% of the institutional claims submitted.
Healthy Utilizer: The typical member in the ‘healthy utilizer’ category is an otherwise healthy senior who has had isolated or unexpected health challenges requiring significant medical care. Healthy utilizers comprise approximately 8% of the company’s membership base and account for 16% of the institutional claims submitted.
Pre-Chronic: The typical member in the ‘pre-chronic’ category is identified as high-risk by AVA but has yet to incur significant healthcare expenditures. The company also refers to these members as on the ‘launching pad,’ and by deploying its targeted care programs towards this population, it works to prevent or slow their increasing acuity levels. Pre-chronic members comprise approximately 8% of the company’s membership but account for only 1% of the institutional claims submitted. The company’s active approach to monitoring gaps in care and acting before emerging health problems worsen is reflective of the culture of care embedded in its organization, and its focus on being a persistent advocate for its members.
Chronic: The typical member in the ‘chronic’ category is generally a complex patient with multiple chronic conditions in need of significant, coordinated care. Chronic members comprise 13% of the company’s membership but account for 78% of the institutional claims submitted.
Care Anywhere: Proactive, Coordinated Care Delivers Results
While the majority of healthy and healthy utilizer members’ care needs are managed by the company’s network of local community providers in conjunction with its support and oversight, its pre-chronic and chronic members are in its Care Anywhere program. Care Anywhere is an advanced clinician-driven model of care that is staffed by Alignment-employed physicians, advanced practice clinicians, case managers, social workers, and behavioral health coaches to assure the execution of cross-functional care plans. Unlike many managed care plans, the company has built these services in-house to provide valuable, high-quality care to members for free, which complements the care provided by its provider partners for their most challenging and resource-intensive patients.
Key features of the Care Anywhere program include proactive outreach, 24/7 access, highly detailed personalized care plans, and enhanced coordination of care and social needs. Standardized care programs are targeted to seniors based on their underlying conditions, such as chronic heart failure or chronic obstructive pulmonary disorder, which are then personally tailored based on each individual’s underlying circumstances. The company proactively engages with this high-risk group of seniors based on their preferences for care delivery, which is typically in their homes or through telephonic and video consultations.
Based on data gathered and analyzed using AVA, the company’s Care Anywhere program creates several benefits for its high-risk, complex members: improved quality of life, high patient satisfaction, reductions in unnecessary emergency room visits and inpatient care, and lower readmission rates. This also allows the company to establish a more direct relationship with seniors, building member loyalty and brand recognition. The company’s Care Anywhere program has an NPS score greater than 78, underscoring the positive impact it has on its most vulnerable members.
The company’s collective investment in its care model and technology platform has produced strong clinical outcomes for its seniors. In 2024, the company achieved a hospitalization rate of approximately 152 hospitalizations per every 1,000 at-risk members, which is approximately 39% lower than the 2019 Medicare FFS performance in its markets. Further, the company has achieved approximately 152-159 inpatient admissions per thousand on its at-risk membership for the last seven years in a row, despite its significant membership growth over that period of time.
Regulations
The company’s operations and those of its affiliated entities are subject to extensive federal, state and local governmental laws and regulations. These laws and regulations require the company to meet various standards relating to, among other things, reports to CMS, personnel qualifications, maintenance of proper records and quality assurance programs and patient care. The majority of its regulation and oversight comes from CMS, which regulates almost every aspect of the company’s business, including its provider network, benefits, member enrollment, risk adjustment program, plan offerings, claims payments, quality improvement programs, and appeals and grievances.
The company has entered into standard form agreements with CMS pursuant to Sections 1851 through 1859 and Sections 1860D-1 through 1860D-43 of the Social Security Act (‘SSA’), pursuant to which the company has agreed to operate its plans in accordance with applicable laws and regulations, and CMS has agreed to make payments to the company under the SSA.
In addition to the SSA, CMS regulations, and the company’s contractual obligations, the company must also comply with a variety of other laws:
The company is subject to data privacy and protection and breach notification laws and regulations that apply to the collection, transmission, storage, and use of protected health information (‘PHI’), and other types of personal data or personally identifiable information (‘PII’), which, among other things, impose certain requirements relating to the privacy and security of such PII.
Certain of the company’s businesses are also subject to the Payment Card Industry Data Security Standard (‘PCI DSS’), which is a multifaceted industry security standard that is designed to protect credit card account data as mandated by payment brands and acquiring banks.
Certain significant provisions of the Health Care Reform Law include, among others, mandated coverage requirements, mandated benefits and guarantee issuance associated with commercial medical insurance, rebates to policyholders based on minimum benefit ratios, adjustments to Medicare Advantage premiums, the establishment of federally facilitated or state-based exchanges coupled with programs designed to spread risk among insurers, and the introduction of plan designs based on set actuarial values. Some of these changes impact the company and other entities that offer Medicare Advantage plans. In addition, the Health Care Reform Law established insurance industry assessments, including the Comparative Effectiveness Research Fee to fund the Patient-Centered Outcomes Research Institute.
History
Alignment Healthcare, Inc. was founded in 2013. The company was incorporated in 2014.