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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.
 
Examines some of the options for reopening, making the best use of time in the transition, and taking advantage of new opportunities in provider/health plan partnerships. 
 
3. The Gate Creaks Open on a Different World
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.

Risk Adjustment Never Sleeps: The Gate Creaks Open on a Different World

By Will Stabler

First published on May 3, 2020

In the first article of this series I wrote about adapting to the pandemic closure and taking advantage of the opportunities the pandemic has presented in telehealth and managing our operations remotely, or “teleworking.” The second article spoke to creating a plan for opening up and how telehealth and teleworking can be used when we open up to strengthen health plan/provider partnerships. I had no way of knowing when I started this series that over the course of just three weeks, in the real world we would go from total lockdown to opening up again.

In this third article I will address the roadblocks we face as we open up in making our plan/provider partnerships work smoothly, both operationally and technologically, and what we can do about them. The challenges are familiar—creating meaningful and effective member/patient outreach and support, and overcoming interoperability issues in healthcare IT.

Venturing Out Into a New World

Somewhere around the end of April, the lockdown, stay at home, safer at home—or whatever you call it—began to ease up a bit in certain regions of the country. On the front lines of that process were hospitals, physicians and other providers, who began gradually allowing some elective surgeries and non-emergency visits. In some Illinois hospitals, for example, elective procedures began again on May 10, providing some financial relief for strapped hospitals and treatment of unmet needs for patients. Local news outlets in Chicago reported that within days people were flying in from other states for long-delayed treatment.

As family practice physicians, hospitals and outpatient care centers start seeing more patients in-person for conditions other than COVID-19, member/patient outreach and support, I dare say, will be more critical for both providers and plans than it has ever been. Care gaps have been widened and exacerbated by the pandemic shutdown, and they will need to be urgently addressed. The effects of chronic care needs that have gone unmet for several months will become apparent.

Both healthcare provider organizations and us in Medicare Advantage and risk adjustment in general (Managed Medicaid/HIX-ACA) have an urgent mission in common: increasing patient/member engagement through outreach and support. This seems like a good time for us to be working together.

A Focus on Outreach and the Point of Care

Physicians and other providers, and payers in this time need to lock in the capacity to conduct outreach and complete individual health assessments on a prioritized set of members to address whole-patient needs on risk, quality, and medical management. In preparation for opening up, providers and plans should be identifying and prioritizing groups of patients/members for outreach to schedule visits. They should know who in their patient/member population needs expedited care the most after months of being locked out of the healthcare system for non-urgent care.

MA organizations and other plans should be supporting member health needs through various methods, including member outreach messaging, appointment scheduling, adjusting cost sharing particularly related to primary care, outpatient behavioral health, and telehealth in any form. They also should be adding incentive models or adjusting existing ones to encourage appropriate clinical interactions to improve the management of their health. Members, particularly Medicare Advantage, but also ACA and Medicaid, need to be supported and encouraged to utilize different models of care. 

This is where provider engagement comes in—a need that has been thrust upon us during the past three months or so. Well before the COVID-19 Pandemic struck, I wrote an article titled, “Risk Adjustment’s Future Lies at the Point of Care.” In that article, I made the point that providing value-based care was no longer an option because of the explosive growth of costs throughout the healthcare system, and creating value-based arrangements between providers and payers would be key to providing it.

The following are some of the goals of effective provider engagement in risk adjustment that I outlined:

  • helping to facilitate accurate diagnosis and management of member conditions
  • supporting the physician’s capture and CMS-compliant documentation of patients’ chronic conditions
  • increasing the accuracy of medical record documentation
  • addressing HEDIS measures that impact Star ratings at the point of care

“Provider engagement is the starting point for improvement in risk adjustment processes, no matter your business perspective,” I wrote. “For health plans, there is no longer a question of how interconnected all the data we use in clinical quality, healthcare improvement, disease management, wellness and risk adjustment has become.”

I also pointed out that at their core, physicians are scientists, so you can get them excited and engaged when you can show them data demonstrating measurable clinical and financial progress. That is, if you can manage to do it without adding to their already overly burdensome clinical documentation duties. This is where an interoperable EMR in widespread use comes in.

Healthcare IT Interoperability and the Pandemic

Anyone who has been following me over the past few years knows that healthcare IT interoperability is a passion and a sticking point for me. In the summary of the last in a series of seven articles on healthcare IT interoperability I wrote these hopeful words:

“Interoperability should eventually take us to a place where patients and providers are enabled to work as a team toward preventive medicine and value-based care. This is a place where patients have access to their full medical records, and are working in decision-making partnerships with their healthcare providers. When we get there, everyone in the healthcare system can make best use of that patient-generated data, which is predicted to be so valuable in the future. We’re going to get there.”

I said that because at the time, it looked like we were on the way there. So, you can imagine it was disappointing in mid-April to see CMS delaying compliance with interoperability requirements that were set to take effect on Jan. 1, 2021. According to the rule, by that date, the 125 million or so patients/members in Medicare Advantage plans, Medicaid, the Children’s Health Insurance Program, and Affordable Care Act exchange plans were supposed to be provided with free access to all of their personal health data through standardized application programming interfaces (API). In other words, full access via interoperable EMRs. That has been put off now at least July 1 of next year, at a time when that kind of access could have come in very handy for everyone involved, from the providers to the payers to, especially, the patients/members.

Perhaps more unfortunate, in my view, is that when the pandemic hit, the Cures Act final rule was not already fully implemented, with all patients/members having universal access to an interoperable medical record. Imagine if it had been. Patients would have electronic access to all of their medical and claims data. From a public health standpoint, patients would have been able to contribute their data toward a more rapid understanding of what COVID-19 is doing in the population and what the most effective treatments are.

One of our main goals in this new telehealth and telecollaboration reality should be to greatly enhance the EMR for optimal tracking, and convert as much interaction and reporting to digital means as possible, especially if we have to eventually go back into lockdown. However, as we peek out into this new world of telehealth and teleworking, we have to concede that we are still stuck to some degree in our old telephonic and paper-based reality. We need to move away from that.

If we want our world to remain open, we need to ensure that the healthcare system does not become overloaded again. According to a plan laid out this month by the Association of State and Territorial Health Officials, besides testing and public compliance with mitigation guidelines, the key element in the ability to open and remain open is “the ability of the public health and healthcare system to quickly contain future outbreaks and associated healthcare surges. (Fraser, et. al, 2020) ”

That will require a strong system of contact tracing, which will be instrumental in containing localized outbreaks of the virus before they become unmanageable and send us back into our homes. This consists of three elements:

  1. Identifying contacts—Once we confirm a person is infected, we identify as many people as we can who had close contact with that infected person.
  2. Outreach—Once the contacts are identified, these people need to be informed of their status and educated on what they need to do next, which includes self-quarantining to prevent spreading the infection further.
  3. Monitoring and follow-up—Physicians and other health providers will need to monitor these contacts for symptoms and ensure that proper measures are taken to prevent spread of infection. They also need to identify the people who might be at highest risk should they contract the virus.

Healthcare providers are vital in supporting areas 1 and 3 of this effort, especially that last one, and they need the right technological tools to help them do that. These times present an opportunity for providers and payers to strive to create various solutions for integrating information into provider EMRs to address care gaps and COVID-19 pandemic monitoring/follow-up at the same time. A robust EMR, coupled with telehealth and emerging remote monitoring tools and wearables could make the effort much safer and more seamless.

There could be another big side benefit to the process of perfecting a technological solution to the monitoring and follow-up aspects of contact tracing. Remember our problem in the previous article of capturing HCCs in the telehealth environment for certain conditions in new patients? How do we to figure out how to develop and connect apps to the EMR and other patient data systems to improve COVID-19 screening, triage and monitoring, thus addressing both issues at the same time? The pandemic is challenging us to answer that question.

The COVID-19 Pandemic is unmasking our interoperability problem in health care. There has never been a time when it was so critical for public health officials and healthcare providers to be able to easily share a wide range of standardized health information on people. There has also never been a time, arguably, when we needed to have an easily accessible picture of the entire patient, their underlying health conditions and where care gaps lie. Now is the time for health care to catch up and finally solve the interoperability issue.

In the next article, I will wrap this series up by addressing the costs of the pandemic to our industry, and look toward solutions for risk adjustment in the COVID-19 world at our 2020 year-end and beyond.

Reference

Fraser, M., Lane, J. T., Ruebush, E. Staley, D. & Plescia, M. (2020). A coordinated, national approach to scaling public health capacity for contact tracing and disease investigation. The Association of State and Territorial Health Officials. Accessed at: https://www.astho.org/COVID-19/A-National-Approach-for-Contact-Tracing/