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Risk Adjustment Never Sleeps

A Four-Part Series by Will Stabler

Click here for a PDF of the entire series

About This Series

I wrote this article series in four parts over two months during the height of the coronavirus  pandemic to examine how the pandemic and its lockdowns affected those in the business of risk adjustment, and what happens with the industry as the world returns to “normalcy.”

Articles in This Series

Introduces the series and addresses short-term adaptations in the industry, enhanced support for telehealth services, and reiteration of the need for EHR connectivity and interoperability.
 
2. Planning for the Return to “Normal.”
Examines some of the options for reopening, making the best use of time in the transition, and taking advantage of new opportunities in providing provider/health plan partnerships. 
 
Explores some the gradual reopening of the healthcare industry, including patient outreach and the point of care, how Medicare Advantage and other plans can help support member health needs, and the effects the pandemic has had on the IT interoperability issues in health care.
 
Addresses what the priorities should be in RA in the end of 2020 and beyond, how best to use time and resources in the new environment, and looks on the positive side of what the industry has gained from the COVID experience.

2. Planning for the Return to "Normal" in Risk Adjustment

By Will Stabler

First published on May 10, 2020

The COVID-19 pandemic has sent a tsunami through every industry on the planet, and those of us who work in the business of risk adjustment (RA) are not immune from its effects. Surviving this pandemic means toughing it out, but truly thriving through it is all about finding opportunities and re-imagining how we operate while we are living in a bleak new environment for doing so.

In this series I will look—primarily through a Medicare Advantage lens—at the COVID-19 pandemic from the standpoint of its near-, medium- and long-term effects on the business of risk adjustment and the professionals working in this novel RA landscape. I will also consider changes that are already happening in the broader risk adjustment world in both the government and business sectors because of the pandemic, highlighting opportunities in where things seem to be heading.

As the end of 2020 rapidly nears, it is time for thinking forward toward your goals for the new year, whether you want to call them resolutions or not. For many reasons that I won’t go into detail here, 2021 promises to present less of those situations that take the control of our destiny out of your hands. In this article I want to show you how to put control over your goals into your hands and provide you with tools to help you reach them. Let’s start with your motivation for setting them.

Fits and Starts: Healthcare Begins the Haphazard Process of Opening Up

Indications are that this process will be piecemeal and haphazard at best. In some areas, the pressure is easing up on hospitals and healthcare systems; in other areas it will be a while before that happens. Throughout the country, small hospitals and provider organizations as well as outpatient surgery centers have been decimated by emergency-only care restrictions, with many shutting their doors and furloughing workers to attempt to stop the cash bleeding. Hundreds of hospitals have furloughed workers.

Medical practices are following suit. In a study released in early April by the Medical Group Management Association, 724 respondents from medical practices reported an overall 55% decrease in revenues and a 60% decrease in patient volume, and 97% reported a negative financial impact from the crisis. By April 8, 22% of respondents reported that they had laid off part of their workforce, and 48% reported furloughing workers. When asked at the time what those numbers would like if the crisis persisted another 30 days to May 8, 36% of the respondents projected they would lay off employees and 60% said they would be forced to furlough employees (MGMA, 2020, April 8).

As those providers that still have the resources to do so begin to open up, we will likely see the full scope of the disruption the pandemic has wrought on patients, health plans, large and small providers and the entire health system. Just because a surgery may have been deemed non-urgent, that does not mean it was not critical to the health of the patient/member who needed it. Another tsunami may rock the system as people seek to receive vital treatments—for chronic ailments, cancer, kidney disease, etc.—that have been delayed. This pent-up demand will create fresh challenges for patients/members, physicians and other providers, and payers, and not just because of volume: Many of these surgeries and treatments may be riskier now or less effective because of the health effects those delays in treatment have had on the patients.

When hospitals and provider practices ultimately begin to tentatively ramp back up, their operations will likely take on a different look and feel, given that the virus is still out there and showing no signs of disappearing anytime soon.

That means some of us working in risk adjustment will also be going back to work, or not, and we may be able to collaborate again in person, or not. Whatever the case, someone in your organization needs to be in charge of staying apprised of your latest state and local restrictions, and making sure your organization is operating safely and in accordance with the law. Because remember, in the current environment, your governor, your county chief executive officer and even the mayor of your city may all have different ideas about what “opening up” means for businesses and individuals.

People in all occupations will also grapple with the decision on a personal level. How do I find a daycare center where I know my child will be safe? Do I have to buy a car now, or should I keep taking the bus or subway to work? Is my employer taking the proper steps to ensure our workplace will be reasonably safe?

We’re not even at that “pseudo normal” yet, but we need to be planning for getting there eventually, so let’s back up a bit and see where we have come so far. In the first article of this series we looked at some of the opportunities and operational adjustments that the COVID-19 Pandemic has brought to Medicare Advantage and risk adjustment in general. Here we will look at how to plan for taking advantage of them when opening back up occurs.

Two Steps Backward, One Step Forward

If you are in the business, like I am, of helping health plans improve efficiencies and optimize throughput, these past four months of the pandemic have knocked any progress we had been making in that realm at least two steps backward. Fortunately, though, it has also moved us forward a step in one key area in improving health plans’ member experience and working toward value-based care—using technology to improve healthcare outcomes and costs for both providers and payers.

As we touched on in the first article, that step forward, or maybe it will be seen one day as a leap, happened when the Centers for Medicare and Medicaid Services (CMS) began allowing MA organizations and other organizations to submit diagnoses for risk-adjusted payment from telehealth services. More than 80 new telehealth services are covered under the expanded order, reimbursed at the same rate as in-person services. Physicians and other providers and those involved in the risk adjustment business must be involved in aggressive advocacy to ensure telehealth becomes a permanent feature of our healthcare system. That means they also need to ensure they are doing their part on their end to demonstrate its efficacy and double down on compliant documentation.

Securing Telehealth's Role In Closing Care Gaps

To help gain wider acceptance of telehealth, providers and health plans need to work together to improve our efficacy in capturing and recapturing Hierarchical Condition Categories (HCCs) through this modality. For many HCCs, we will need to innovate modifications to the telehealth visits to ensure we improve that efficacy.

This is particularly important with new patients. For example, in chronic obstructive pulmonary disease (COPD), heart arrythmias, and coagulation defects, to name a few, we can recapture through modified telehealth visits for existing patients because we have the supporting lab work/monitoring data in the health record/EMR. Initially capturing those HCCs for new patients in a telehealth environment during a pandemic is another story, because that background monitoring and lab data is a challenge to collect. Creating solutions for these issues should be a priority once we begin to open up after the lockdown, especially if we need to go back to “stay at home” orders in the future. And we can start working on that now.

Providers and plans can utilize telehealth capabilities to facilitate Annual Wellness Visits (AWV) with members. In some ways AWVs are uniquely suited for telehealth visits. The focus is on care planning and confirmation of status of existing conditions that do not require new tests or diagnoses. To facilitate telehealth AWVs, plans should: 1) provide member incentives for completing AWVs (cost sharing for AWVs is already $0); 2) introduce new or additional provider incentives for telehealth AWVs; and 3) activate members about benefits of visits while addressing lingering doubts about the technology and interaction. 

Another issue we need to solve related to telehealth on a societal/legislative level is broadband Internet access, which is a social determinant of health in the telehealth arena. According to Pew Research, in 2019, 73% percent of U.S adults had high-speed broadband internet access at home. Among all age groups of adults except for those over 65, this ranges from 77% to 79%, but for those over 65, broadband access at home was at 59%, so there is a disparity there in the Medicare Advantage population. Still, the same study shows that 73% of those over 65 use the Internet, so a greater percentage of that age group is apparently able to access the Internet somewhere. Also, 91% of those over 65 reported having cellphones, but only 53% reported having smartphones. Similar disparities also occur among racial and socioeconomic lines (Pew Research, 2019). 

For the highest risk populations with the greatest need, plans might consider very targeted distribution of internet enabled devices to facilitate telehealth interactions with providers and plan care teams.   

 

Teleworking for Greater Health Plan/Provider Partnerships

Again, our industry should work during this time to ensure telehealth/telework becomes a permanent feature of our healthcare system, and not only for patient-care visits and reimbursement. It also has a role in a new, broader definition of telehealth on the operational side that helps us with member engagement and education, and also with one of my pet projects—improving health plan/provider partnerships.

The journey toward value-based care is predicated on trust among payers and providers, and that trust was on shaky ground before the pandemic hit. A just-released study by Xtelligent titled, “Provider Perceptions of Value-based Care” found that good number of providers have little trust with private and public payers, with 16% of specialty care physicians reporting they have no trust in private payers and 11% reporting no trust in public payers. At the same time, 32% reported they had no communication with their private payers and 38% had no communication with their public payers. (Sokol, 2020, May 8)

Because communication is the major issue in trust, it is likely that disrupted communications during the lockdown has the potential to further erode that trust, so health plans need to be mindful of that and continue to reach out to providers using the technological communications tools at our disposal. Also, both payers and physicians must be very cognizant of their language in communication. Both need to reinforce shared goals and cooperation in serving their members/patients.

Telework has great potential for more efficiently and cost-effectively facilitating some of the activities I detailed in an HFM Magazine cover article titled, “Exploring Health Plan-Provider Partnerships.” In that article I outline some of the benefits of these partnerships: 

“If health plans can find ways to streamline collection and analysis of data and relieve their reporting burdens while also relieving some of the burdens for providers, mutually beneficial healthcare analytics partnerships can be achieved. Obviously, partnering to improve processes related to these issues can provide direct financial benefits to both types of organizations. Working together to integrate timing and processes to streamline data collection for purposes of both clinical quality reporting and encounter data reporting can create opportunities for eliminating significant redundancies” (Stabler, 2017).

You can imagine that if we can get key people from health plans and provider organizations together periodically—say, on Skype or Zoom—to work on things like synchronizing the timing of data collection, or improving EMR accuracy, we will be creating an entirely new way of thinking of “telehealth.” We’re working toward improving care for people and keeping their costs down, right? There are millions more people in the world lately who are getting quite a bit more adept at timesaving and moneysaving “telecollaboration,” including me and many of my colleagues. Let’s take advantage of that.

Teleworking for Greater Health Plan/Provider Partnerships

This upcoming “opening-up” phase is a great opportunity to ease into these greater collaborative arrangements that benefit providers, plans and members. I have a feeling that no matter what somebody’s governor or county chief executive officer or mayor says, people and organizations are going to make their own decisions about what operating safely means from here on out. We must anticipate that for some organizations, telework will become a bigger percentage of the operational plan, if not the whole operation.

As the pressure subsides on healthcare providers and provider organizations and they begin seeing patients for things other than COVID-19, health plans will need to ramp up member outreach and support, and jump into reporting. Issues to consider will be closing care gaps, addressing social determinants of health created and exacerbated by the pandemic, and enhancing electronic medical records. I will address these in the next article in this series.

References

Medical Group Management Association. (2020, April 8). COVID-19 Financial Impact On Medical Practices.

Pew Research (2019). Mobile Fact Sheet

Sokol, E. (2020, May 7) Providers report low levels of trust in healthcare payers. Healthpayer Intelligence.

Stabler, W. (2017, December). Exploring health plan-provider partnerships. HFM Magazine.  https://www.hfma.org/topics/article/57110.html