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Risk Adjustment

A Five-Part Series by Will Stabler

About This Series

I wrote this article series in five parts over two months during early 2017 when there was much discussion of what was termed “value-based care.” This series examines risk adjustment and the role it can play in such systems.

Articles in This Series

As America’s healthcare system transitions toward payment models that reward what many call value-based care, risk adjustment is playing an increasingly important role. For many health plans, it is an integral part of operations.
 
In this article I look at how risk was modeled in the Medicare Advantage program and by the ACA before diving into more advanced risk adjustment concepts.
 
Risk adjustment models and their reporting requirements continue to evolve. With this evolution, it becomes critical for us to appreciate how risk adjustment, quality and care management measures can work together for success.
 
In achieving accurate risk adjustment results there are two main issues where plans fall short: not properly identifying the illness burden of the population, and not closely monitoring and managing their data submissions.
 
5. Risk Adjustment’s Future Lies at the Point of Care
In risk adjustment, variation can be the enemy. It can also provide opportunities if properly managed. The point of care is one place where we can do that.
 

Risk Adjustment's Future Lies at the Point of Care

By Will Stabler

First published on March 7, 2017

Note: This is the final article in this adjustment series. To download a PDF of the entire series, click here.

Providing Value-Based Care is no Longer an Option

According to the latest numbers from the Centers for Medicare and Medicaid Services, national health spending is projected to grow at an average rate of 5.6 percent per year for 2016 through 2025, and 4.7 percent per year on a per capita basis. The figures, released in February 2017, project that health spending will grow 1.2 percentage points faster than Gross Domestic Product (GDP) per year over the 2016 through 2025 period. As a result, the health share of GDP is expected to rise from 17.8 percent in 2015 to 19.9 percent by 2025.

Providing value-based care is no longer an option.

These numbers show why our healthcare system must continue to evolve on this path toward a value-based system, and there is not a lot of wiggle room for error when such a large national financial burden is associated with it. That means high stakes over the next decade for those involved in and affected by risk adjustment.

As providers and health plans throughout the country continue to transition from volume- to value-based payment arrangements and money gets tighter and tighter, predictability is becoming a precious commodity. In risk adjustment, as in other quality improvement activities, variation can be the enemy, but it can also provide significant opportunities. In this climate, those of us with the power to do so need to do all we can to put some reins on variation.

Tackling Variation at the Point of Care

One of the places we are doing that is at the point where our most valuable information originates—with our physicians. There is an old saying in healthcare quality improvement circles: “Garbage in, garbage out.” And it remains true.

Everything starts at the beginning of the process with the quality of the data, and how that data is initially collected, retrieved, and organized. That is why provider engagement, or physician engagement, as it is also called, has become a critical focus in the full cycle of how we manage information used in risk adjustment and healthcare quality improvement. If the buy-in from our clinicians doesn’t exist, every part of that cycle is at risk. We can’t do this without them, and we need to make it as painless as we can for them.

Health plans and provider organizations around the country are finding that physician engagement is becoming critical to any financial or clinical quality improvement effort they undertake. Remember that physicians, at their core, are scientists. They are not fond of additional burdens in clinical documentation, but they do get excited (and engaged) when they see can see data demonstrating measurable clinical and financial success.

The goals of effective provider engagement are many, but the following are some of the key expected outcomes in the Medicare Advantage environment in which I work:

  • supporting the physician’s capture and documentation of patients’ chronic conditions in compliance with CMS documentation guidelines
  • facilitating accurate diagnosis and management of member conditions
  • increasing the accuracy of medical record documentation to supplement patient encounters and increase coding guideline compliance
  • addressing HEDIS measures impacting Star ratings at the point of encounter

On the health plan side, provider engagement can bring more accurate and complete documentation, resulting in improved member risk scores, higher Star ratings and higher quality of care.

A good provider engagement coordination program should be prospective in nature, involving provider engagement coordinators who assist providers with complete and accurate documentation in a non-invasive manner. The provider engagement coordinator or manager is responsible for coordination, implementation, execution, control and completion of medical practice documentation improvement activities. They are also educators and process improvement specialists, always on the lookout for opportunities to improve efficiency and the quality of the final output, while taking the documentation and administrative burdens away from our caregivers as much as possible.

Provider engagement is the starting point for improvement in risk adjustment processes, no matter your business perspective. 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.

There is also no longer a question that there is a significant amount of redundancy in the way we manage information for all of our disparate activities, which are usually focused on two areas: improving care processes and getting paid fairly for our efforts. A holistic approach is needed in order to improve care, maintain our quality workforce, keep costs from spiraling further out of control, and freeing our clinicians to spend more time on the most important part of their jobs—hands-on, one-on-one patient care.