Category: Provider

Another blow to detached health risk assessments

By Brian Flower, vice president of client solutions, Vatica Health

Health Affairs recently published a study of data from 4 million Medicare Advantage (MA) members indicating that health risk assessments (HRAs) contributed up to $12 billion per year to risk adjusted payments in 2020. This is based on conditions that were submitted exclusively by an HRA (not submitted through another encounter) during the 2019 calendar year. The study implies that HRAs, typically performed in-home by vendors on behalf of MA plans, can lead to inflated hierarchical condition category (HCC) scores. More specifically, of the 44.4% of MA beneficiaries who had an HRA, HCC scores increased on average 12.8%.   

Study authors go a step further by segmenting contracts as low, medium and high, based on the HRA’s effect on risk score at the contract level. This may provide insights into HRA program design by the plan, e.g., which patients are targeted and how HRA outcomes are subsequently attached to care management.   

For nearly a decade, the Centers for Medicare and Medicaid Services (CMS) and the Office of the Inspector General (OIG) have expressed concern with the improper use of HRAs to inflate payments, rather than to improve care and outcomes. While HRAs can be a helpful tool for plans to identify all active conditions on an annual basis, the disconnect or “detachment” arises when diagnoses captured in HRAs are not recorded in a subsequent medical visit. This undermines the purpose of risk adjustment, which is designed to compensate plans based on the expected costs of delivering benefits to enrollees.    

Key observations 

  • The population was designated as follows: 20% low, 15% high and the remaining 64% in the medium cohort. 
  • While comprising only 15% of enrollees, the high cohort accounts for 48% of the total HRA risk-score increase. 
  • The HRA rate was much higher in the high contracts (77.9%) than low contracts (39.5%). 
  • Quality ratings favored low cohort contracts with 85% 4 stars or better vs high cohort contracts at 56%.  
  • Provider and health system integration was dramatically higher in the low vs the high contract cohort.   
  • Comparing the high and low contract cohorts, while the overall HCC score was 18% higher, medical expense was 9% lower (estimating from the plan payment and medical loss ratio values provided). 

Extrapolating on the points above, PCP-integrated risk adjustment solutions drastically reduce the risk of detached HRA outcomes and quality performance. This stands to reason because the patient’s PCP is prioritizing healthcare outcomes and management of chronic conditions, rather than focusing exclusively on code capture.     

The correlation between HRAs and coding intensity is particularly relevant given the Risk Adjustment Data Validation (RADV) Final Rule, which authorizes CMS to extrapolate RADV audit findings beginning with payment year 2018, applying the error rate from a sample, and the associated financial penalties, across a broader population of the Medicare Advantage Organization’s contract. In a RADV audit, conditions supported by a single encounter, like detached HRA visits, are at higher risk because there are no additional medical records to fall back on if there is an access, accuracy, or completeness issue with the primary record.  A PCP-integrated approach encourages follow-up care and additional documentation to support valid diagnoses.   

It should be noted that this study uses the 2020 CMS risk adjustment model.  We expect the exclusive impact of HRAs on risk scores would be tempered by as much as 40% using the 2024 risk adjustment model, which is being phased in now and will take full effect for 2025 dates of service. 

Conclusion  

At-risk entities should evaluate their current risk adjustment programs and focus on solutions that produce accurate and compliant coding accuracy that dovetail with quality and health outcomes. Legacy programs, such as retrospective chart reviews and HRAs completed by in-home assessment vendors, should be augmented with a provider-centric approach. Build a risk adjustment strategy that recognizes PCPs as partners in accuracy and quality capture, as well. PCPs are best positioned to capture all existing conditions and to address the CMS and OIG’s concerns by connecting the dots between accurate HCC capture and improved care and outcomes. 

Improve compliance and financial performance with PCP-centric risk adjustment

Given the regulatory activity relating to the RADV Final Rule and 2023 Final Rate Notice, many speakers at this year’s RISE National conference referenced compliance and performance challenges. Against this backdrop, the presentation sponsored by Vatica Health was timely as it focused on how payers and providers can collaborate to improve financials results, compliance and patient outcomes.

You can view the presentation here, or read on for highlights.

Vatica CEO Hassan Rifaat, MD, kicked off the session with a market assessment. “The game has changed completely,” he noted. “You’ve got to be great, and you’ve got to be compliant. RADV is no longer a speeding ticket. It’s a big fine. There are lots of consequences for doing risk adjustment wrong.”

Rifaat called out the serious deflation in the transition from CMS-HCC model V24 to V28. Based on his experience, he noted that the best course of action is for the providers who treat the patients to code and document via an in-office program. This helps to ensure that all active conditions are captured and treated.

Experience is the best teacher

Robert Tracy, senior vice president of government programs at Independent Health Association (IHA) in Buffalo, NY, described IHA’s evolution in building a successful in-office risk adjustment program. IHA offers Medicare Advantage plans in eight counties of western New York, covering 68,000 members. IHA initially built a paper-based process connected to Annual Wellness Visits. While a significant number of members participated, providers voiced concern about the inefficiency of the paper-based process not connected to their workflows.

IHA then implemented Vatica’s solution that combines clinical resources and technology at the point of care.  Vatica’s extensive pre-visit preparation results in only vetted and validated HCC codes and care gaps being presented, setting the stage for a more effective, efficient visit. Providers appreciate the comprehensive support, which has helped drive participation to include nearly 78% of eligible providers in IHA’s network.

In the process, IHA learned that an investment in primary care is a wise decision that pays off. Patients can be educated to take advantage of the annual visit, resulting in improved care coordination and satisfaction. Tracy noted that an organization-wide effort is needed to succeed, along with a PCP-centric approach that supports PCPs and integrates seamlessly into their workflow and scheduling system.

Hear Tracy’s summary of best practices below.

A firehose of information

Vatica solves this problem by curating only validated conditions and codes, which helps the PCP make the most of their time with patients. “That pre-visit summary gets our providers thinking about not just the conditions but what care management is needed,” he explains. “It helps our providers build trust. We tell our patients that we want to identify all of their conditions so we can take great care of them.”

Charles cited a 10% improvement in risk score accuracy since the practice started using Vatica. He highlighted specific improvements in hemoglobin A1C levels and blood pressure control. In addition, the revenue generated has helped providers in multiple ways. Hear more from Charles about these services and benefits below.

The presenters agreed that in-office solutions such as Vatica should be the core of a risk adjustment strategy for payers and other at-risk entities. Solutions must support PCPs and minimize the time required, allowing providers to work at the top of their license while compensating them fairly for the work they do and the results. This will maximize compliant yield benefiting the payer, provider and patient.

How Vatica can help  

Vatica is the #1 ranked PCP-centric risk adjustment and quality-of-care solution for health plans and health systems. By pairing expert clinical teams with cutting-edge technology, Vatica increases patient engagement and wellness, improves coding accuracy and completeness, identifies and closes gaps in care, and enhances communication and collaboration between providers and health plans. The company’s unique solution helps providers, health plans and patients achieve better outcomes together. With the Vatica team providing the extra resources needed for complete, compliant coding and documentation, physician participation is easier to enlist and sustain. To learn more, visit https://vaticahealth.com/.   

2023 recap: the year’s best content

The risk adjustment industry may have experienced more upheaval in 2023 than the prior five years combined. Major regulatory changes announced by CMS shook up the industry. Vatica Health covered the operational and financial impacts of the Final Rate Notice–moving from V24 to V28–as well as the changing regulatory environment created by the Risk Adjustment Data Validation (RADV) Final Rule. Vatica analyzed these significant developments and provided practical insights on how to navigate these choppy waters. We also covered topics to help providers cope with the challenging environment.  

Regulatory activity 

Payer and provider collaboration 

Vatica has helped lead the industry towards greater collaboration between payers and providers to optimize compliant risk adjustment. Hear directly from payers and providers in these webinars:

Resources for providers 

Provider burnout continued to be a key issue in 2023. We provided tips for easing providers’ coding and documentation burdens here. The impact of Social Determinants of Health and five ways providers can address  them are explored in this blog.  

How Vatica can help  

Vatica is the #1 ranked PCP-centric risk adjustment and quality-of-care solution for health plans and health systems. By pairing expert clinical teams with cutting-edge technology, Vatica increases patient engagement and wellness, improves coding accuracy and completeness, identifies and closes gaps in care, and enhances communication and collaboration between providers and health plans. The company’s unique solution helps providers, health plans and patients achieve better outcomes together. With the Vatica team providing the extra resources needed for complete, compliant coding and documentation, physician participation is easier to enlist and sustain. To learn more, visit https://vaticahealth.com/.

Relieve providers’ admin burden to help combat burnout  

Provider burnout isn’t new. It existed long before COVID and was exacerbated by the pandemic. But it’s rising to new levels. For example, recent labor issues at Kaiser—resulting in the biggest healthcare strike in US history—were caused in part by acute staffing shortages that drive provider burnout. 

To combat burnout, healthcare organizations are raising wages. Most are strengthening hiring and retention efforts, along with a variety of other tactics. Some states are pursuing safe staffing legislation. The situation is dire and creating an impediment to achieving the CMS Triple Aim: improving patient care, reducing healthcare costs and improving population health. More recently, recognizing the importance of provider engagement and wellness, healthcare leaders have considered expanding to a Quadruple Aim to include the clinician experience. 

Ramifications of burnout 

Less common solutions to a common problem 

Aside from obvious solutions—staff recruitment and wage increases—what else can be done? 

One area of focus should be administrative burden, with physicians spending nearly 2 hours a day on EMR tasks outside work. While EMRs bring needed automation and better data, they’ve become more complex, driven by increasingly detailed and nuanced data requirements that create stress and distract from patient care. Alert fatigue is one result of this stress and distraction, which is exacerbated by vendors that send unvalidated conditions and codes directly into the EMR and physician workflow. 

Additionally, healthcare policymakers and regulators continue to mandate more documentation to demonstrate compliance with laws and standards, resulting in lengthier documentation. Value-based care (VBC) payment models, which are becoming more common, require even more clinical support, coding and documentation  to achieve performance goals. 

At Vatica Health, clients appreciate our unique model of supporting providers with clinical and admin resources. We’ve found these strategies reduce the admin burden for our provider clients and support their transition to VBC payment models as well:

  • Offer physician training on standard coding and documentation practices: get all providers on the same page in terms of process and workflows. 
  • Align physician compensation with VBC initiatives: ensuring that physicians are compensated and incentivized is paramount to obtaining physician buy-in and ongoing participation. By thoughtfully designing compensation programs for both clinical and support staff, provider groups can counter the problems of physician burnout, declining retention and shortage of physicians.  
  • Optimize the EMR and pre-encounter prep to drive efficiency and comprehensive visits: EMRs on their own do not sufficiently support coding and documentation to optimize VBC performance. Solutions are available that optimize EMR performance to help identify care gaps and facilitate accurate coding. 
  • Create better alignment with payers and advocate for programs that remove operational burden associated with risk adjustment and quality initiatives: these programs can help provider groups realize incremental revenue, improved outcomes, increased numbers of preventive health encounters and improved performance in VBC arrangements.   
  • Provide support to help physicians capture and address SDOH: successful programs include training clinical staff, providing access to local resources, developing workflows and promoting standard practices that help simplify the risk-adjustment process, including allocating time during patient encounters for these critical conversations.  
  • Be transparent about the financial impact of physician performance in VBC: executive leaders should share financial performance data with physicians and potentially other staff as well. Incremental revenue earned through participation in such programs can support a financially positive outcome for the group. 

A select few health plan-sponsored solutions relieve administrative burden and help improve clinical and financial performance. One example is Vatica Health, where licensed clinical nurses are assigned to each contracted practice. The nurses create a comprehensive, curated Vatica medical record for each patient encounter, presenting only conditions that are fully supported by clinical documentation. PCPs receive a streamlined, prioritized list of conditions that they can review at their convenience.  

Conclusion 

Provider group leadership should consider all viable options to address provider burnout – especially as VBC transformation creates more demands. Recruiting additional providers gets tougher as competition for fewer physicians, mid-level practitioners and nurses escalates. Finite financial resources limit never-ending wage increases. Leaders should consider out-of-the box solutions, such as payer-sponsored programs that include additional clinical and administrative resources to support providers.  

Vatica’s clinical and admin resources can reduce PCPs’ burden from coding and documentation. That not only improves provider experience but keeps the PCP central to patient care, supporting the patient experience as well. Vatica helps PCPs address chronic conditions, identify care gaps to more easily resolve them and present the most accurate picture of the patient’s condition. An accurate picture results in appropriate reimbursement, avoiding over- and under-coding that impacts overall healthcare costs. This moves us in the right direction to achieve the Quadruple Aim and gives provider group leaders concrete resources to address physician burnout. 

Benefits of engaging PCPs in risk adjustment

As regulatory pressure mounts, health plans face challenges that impact the operations, compliance and results of their risk adjustment and quality programs. It’s become evident that PCPs should be at the center of risk adjustment efforts, but for payers and ACOs, that is easier said than done.

In a recent webinar hosted by Vatica Health for members of the RISE Association, Margaret Paroski, MD, CEO of Catholic Medical Partners, and Brian Flower, vice president of client solutions at Vatica, discussed this topic. You can view the webinar or read on for highlights of the presentation.

Dr. Paroski and Brian agreed that the risk adjustment landscape changed more in the past six months than the past six years. The Office of the Inspector General (OIG) has made clear its focus related to risk adjustment is on single submissions made by someone other than the patient’s care team. Under the RADV Final Rule, coding accuracy and specificity is even more important due to increased fines and penalties. The implementation of V28 under the 2024 Final Rate Notice introduced significant changes to the risk adjustment model including a reduction in the number of diagnosis codes that risk adjust and a shift in coefficient weight for many conditions.

The need to document all active conditions annually has remained constant. Dr. Paroski noted that, for most conditions, the PCP is the best source for that information. Often, the PCP has been caring for that patient for many years and has access to critical clinical data in the EHR. “We ask that you give us resources to help us, don’t try to replace us,” she advised payers.

Benefit #1: maximize compliant coding capture

Dr. Paroski offered several suggestions for payers to help providers code accurately and compliantly. Timely, patient-specific data presented within the provider’s clinical workflow is critical. In contrast, Dr. Paroski noted that surfacing low-probability suspected conditions overwhelms and frustrates providers.  In addition, provider education and training is very helpful.  Brian agreed, noting that highly focused and practical training, instead of broad and general education, is often more effective.

Benefit #2: improved outcomes

Supporting the patient/PCP relationship with enhanced payer collaboration empowers compliant code capture, improved utilization management, patient adherence and holistic care. This model enables more comprehensive and targeted data accuracy at the point of care with the opportunity for PCPs to close gaps in care by enabling a provider-centric model for value-based reimbursement activity. Payers can support this approach by offering PCPs a clear strategy and sponsored solutions to progress in value-based care (VBC) payment models.

Dr. Paroski suggests health plans find programs that work and build them into VBC contracts. Give providers data that goes beyond risk and HEDIS/Stars data. For example, information on patients’ social determinants of health is extremely helpful to PCPs. Equally helpful are community resources to address these issues, which many payers now offer but PCPs may not be aware of. Conversely, when payers auto-assign members that the PCP has no record of, this wastes the provider’s time and causes frustration. Likewise, when payers offer poor visibility into the provider’s VBC performance, it does not help improve outcomes. More collaboration, communication and transparency between payers and providers drives more accurate and compliant results.

Challenge #1: PCPs are busy

Dr. Paroski used the analogy of an online meal prep and delivery service to describe how payers can help busy PCPs. Blue Apron assembles, preps and premeasures the ingredients so the recipient just needs to follow the directions and cook the meal. Payers should do everything they can to make coding and documentation simple and efficient for PCPS. Allow providers to work at the top of their license, reimburse the staff for additional time, effort and expertise, and support providers with clinical and administrative resources. For maximum efficiency, don’t interrupt the PCP’s day or revenue cycle, interfere with time spent seeing patients, or overburden the clinical staff.

Challenge #2: PCPs do not feel valued

The healthcare system is asking PCPs to take on administrative responsibilities unrelated to why physicians chose the profession. Physicians did not go to medical school to become super-coders. Dr. Paroski noted that payers can help by paying fairly and quickly, and sponsoring programs that support physicians. In addition, payers should examine leveling the playing field for house-call visits so that PCPs get paid a fair amount for their time completing a house call. Given the OIG scrutiny on coding submissions from outside of the patient’s clinical care team, involving the PCP in a home or virtual visit designed to capture HCC codes is preferred. Brian noted home visits initiated by the PCP have a higher success rate in terms of acceptance by the patient and continuity of care.

“Stay in your lane,” Dr. Paroski added. “Don’t carve us out of care decisions or support risk adjustment programs that work around us. We can help fill the potential erosion of HCC RAF scores in the shift from V24 to V28 given our strong relationships with patients and access to all relevant clinical data.”

Dr. Paroski and Brian highlighted these key takeaways for the payers attending the webinar:

  • Provide timely, accurate and useful data
  • Provide viable VBC contracts and a clear path for evolution of VBC
  • Do the work you can do to support PCPs and don’t interrupt providers’ workflows
  • Pay providers fairly and quickly for the work they do

How Vatica Health can help 

Vatica Health is the #1 ranked PCP-centric risk adjustment and quality-of-care solution for health plans and health systems. By pairing expert clinical teams with cutting-edge technology, Vatica increases patient engagement and wellness, improves coding accuracy and completeness, identifies and closes gaps in care, and enhances communication and collaboration between providers and health plans. The company’s unique solution helps providers, health plans and patients achieve better outcomes, together. With the Vatica team providing the extra resources needed for complete, compliant coding and documentation, physician participation is easier to enlist and sustain. To learn more, visit https://vaticahealth.com/. 

Boosting plan performance and compliance with provider-centric risk adjustment  

With the CMS RADV Final Rule and Final Rate Notice issued earlier this year, health plans are adjusting to the new coding guidelines and increased regulatory scrutiny over their risk adjustment activities. How can plans adhere to the new guidelines and maximize plan performance?  

One way is through provider-centric risk adjustment practices. Putting providers at the center of the process and giving them the right resources helps optimize risk adjustment and quality performance. Provider centricity increases both provider and patient satisfaction because care can be better coordinated and care gap closure increased.  

Bright Spots in Healthcare, moderated by host Eric Glazer, assembled an all-star panel well versed in risk adjustment to share best practices to drive strong performance in this changing environment:

  • Colleen Gianatasio, director, clinical documentation integrity and coding compliance, CDPHP 
  • Michelle Illitch, vice president of network solutions and value-based programming, Priority Health  
  • Gregg Kimmer, president and CEO, ATRIO Health Plans 
  • Hassan Rifaat, MD, CEO, Vatica Health 
  • Frank Shipp, executive director, Johns Hopkins Clinical Alliance 

Watch the webinar to get the full story, but in the meantime, here are key pieces of advice from the panel: 

Develop workflows to minimize impact on provider productivity 

Risk adjustment can be a heavy lift for provider groups of any size according to Frank Shipp, who offered the provider’s point of view on the panel. Physician buy-in is the first step. Instill confidence by ensuring a seamless workflow, decreasing administrative burden, and reducing  compliance exposure via education and regular feedback on the appropriateness and accuracy of their coding documentation. For minimal impact on workflows and provider productivity, assess your EMR capabilities and load as much data into the EMR as possible. Payer data is also helpful. At Johns Hopkins, payer data is loaded into the EMR. Credentialled coders conduct pre-chart reviews to “set the table” for the visit. This helps build trust and credibility. Shipp recommends identifying physician champions to support your program. These are often early adopters with an interest in risk adjustment.  

View risk adjustment as a clinical function, not a revenue function 

ATRIO’s Gregg Kimmer sees risk adjustment as a clinical function, rather than a revenue function. Because Medicare Advantage has no medical underwriting, knowing the acuity of your members early is important. That requires support from providers who maintain a treasure trove of invaluable clinical information. Develop a framework so your providers can document to the highest level of specificity and give payers the most accurate picture possible. Create a partnership where both parties win. Support providers before, during and after the encounter. Offer resources and solutions that allow physicians to work at the top of their license.  

The best place for complete and accurate coding is with the PCP 

Make sure the process fits into the provider’s workflow and minimizes time required and abrasion, advised Hass Rifaat. The media has alerted providers to the heightened liability associated with faulty risk adjustment initiatives. Therefore, payers need to educate and reassure providers about how risk adjustment works and how to mitigate fines and penalties. “A combination of technology, people and data works best to help PCPs improve accurate and compliant risk adjustment coding,” Rifaat noted. Provider organizations vary; you’ll need to offer different workflows and flexible options to accommodate provider preferences. One vital component that’s often overlooked is compensation. Share incentives with treating providers and their staff. Leverage the entire PCP staff to complete coding and documentation, including mid-level providers. 

Take advantage of the EMR  

Michelle Illitch represented Priority Health, the third largest provider-owned plan in the country. Illitch noted that while technology is key, how the technology is implemented and utilized is critical. She pointed out that although the EMR is not ideal for documentation, payers who access the EMR directly can avoid asking for charts and obtain the info they need. The payer can also handle much of the pre-visit work for the provider and act as a planning resource, but it’s critical that the data is accurate. “If you give providers inaccurate info for a patient, the damage is irreparable,” she noted. 

Ensure integrity of the data for the PCP 

CDPHP has built their own clinical documentation integrity program that benefits the health plan and its providers with timely, actionable and trustworthy data. “Our program unites people, process and technology,” Colleen Gianatasio noted. CDPHP gives providers a curated list of information to review after the visit, with a full circle clinical data integrity process, including chart review after the visit. The plan continues to improve the data and analytics. For example, the plan has separate HEDIS and risk adjustment teams. The teams have been cross trained for better coordination and collaboration with providers.  

The role of member retention in risk adjustment  

Too often, plans don’t consider the importance of member retention in their risk adjustment programs, according to Gregg Kimmer. If plans can’t retain their members, they won’t reap the benefits from the risk adjustment and gap closure work they are doing today. The industry standard for voluntary disenrollment is 5 – 8%. ATRIO keeps disenrollment rates below the industry average with a constant focus on member experience and satisfaction.  

Does it really work? 

Hass Rifaat has seen from experience that a provider-friendly solution that compensates providers for their time and reduces their burden with dedicated resources can be successful. Offer a payer-agnostic solution that providers can use at the end of the appointment, during lunch or after office hours. Vatica Health has found that approximately 50% of PCPs want the solution in their EMR. The other half prefer a separate solution they can do in batches after the patient encounter. Rifaat called out a common misperception that risk adjustment is all about making money for the payer. It’s helpful to educate providers about the Affordable Care Act guardrails for medical loss ratios. At least 85 cents of every premium dollar must be used for members’ medical care. 

 He offered a case study with a regional plan in the Northeast which made its RA solution mandatory for participating providers. After three years, 70% of eligible members had an annual visit to gather info for risk adjustment. The plan increased its premium revenue by 15%, resulting in more market-competitive products. That drove more payers to adopt the risk adjustment solution; 80% of MA lives are covered by the solution with 70% of all PCPs participating. Importantly, the plan saw six Star measures move from less than 4 stars to more than 4 stars in one year, which are associated with better patient outcomes. 

Bring back the joy 

Priority Health Plan strives to be a catalyst for pre-visit planning, according to Michelle Illitch. This includes rich claims feeds provided via technology in a smooth, consistent process. Priority recognizes that providers don’t think about “lines of business” like payers do. They scrub data so the provider’s workflow reflects patients who need care the most, regardless of line of business. 

Illitch noted that providers “feel beaten up by health plans.” She recommended keeping the Quadruple Aim at the forefront of what you do. Don’t forget about the provider experience. Payers can help bring back the joy of medicine for providers.  

How Vatica Health can help 

The Vatica Health solution directly supports many of the recommendations made by the experts on the webinar. Vatica Health is the #1 ranked PCP-centric risk adjustment and quality-of-care solution for health plans and health systems. By pairing expert clinical teams with cutting-edge technology, Vatica increases patient engagement and wellness, improves coding accuracy and completeness, identifies and closes gaps in care, and enhances communication and collaboration between providers and health plans. The company’s unique solution helps providers, health plans and patients achieve better outcomes, together. With the Vatica team providing the extra resources needed for complete, compliant coding and documentation, physician participation is easier to enlist and sustain. To learn more, visit https://vaticahealth.com/

Physicians want resources to address SDOH: Here’s where to find them

Physicians are well aware of the impact created by social determinants of health (SDOH) and want to address these needs, as indicated in a recent survey. But many believe they can’t help their patients, due to:

  • Limited time to discuss SDOH during patient visits
  • Insufficient staff to direct patients to the appropriate resources
  • Existing payer requirements that take time
  • Lack of reimbursement for screening for SDOH
  • Unavailable, inadequate or difficult-to-access resources

The good news is that as the focus on SDOH grows, more resources than ever are available to help physicians, from community resources to health plan-sponsored programs to time-saving solutions.

Primary care physicians (PCPs) can take advantage of multiple resources from their health plans. In particular, Medicare Advantage plans are rapidly transitioning to value-based care, at the direction of CMS. As CMS moves to pay for quality rather quantity, the depth and breadth of payer-sponsored programs grows.

SDOH programs show measurable improvements

Anthem, for example, offers the Members Connect program to its Medicare Advantage members. The program addresses social isolation and loneliness to improve members’ overall health. It connects members to a community health worker who helps them find specific community resources they need. Volunteers act as social care partners or “phone pals” who call members weekly to check on them and provide a social connection.

The program gets accolades from members: 74 percent said they increased engagement in their health. Anthem’s claims data shows that participants reduced hospital admissions by 8 percent and ER visits by 43 percent.

Superior HealthPlan, based in Texas, offers a multitude of programs: housing assistance, an in-house network of community health workers to guide members, and a unique program that helps provide funding for hygiene closets. The plan partners with community organizations across the state to offer these hygiene closets with products needed to maintain a healthy, active life. At nearly all of the hygiene closets, specific dates are designated as “Superior Days,” where plan representatives join with other community partners to host events and provide direct resources for those who need them.

To learn about programs available to their patients, physicians and office managers can contact their health plans’ provider representatives or quality teams.

Time-saving solutions

Lack of time and insufficient staff to address SDOH were cited by survey respondents as well. Here, too, PCPs can look to their health plans. With the transition to value-based care, plans offer resources such as care managers who support patients with SDOH-related needs. PCPs should be aware of which health plans offer these services and refer patients for additional support.

Note that ICD-10-CM Z codes are available to report patients’ SDOH but are generally underutilized by PCPs. When PCPs use these codes to report SDOH, that information is passed to health plans through claims. Plans can use that information to enroll patients into their various SDOH programs, alleviating the burden for PCPs.

Likewise, as plans ask PCPs to document and code Medicare Advantage patients’ health status for accurate risk adjustment, they may offer additional resources to assist patients with identified needs. A number of national and regional plans partner with outside resources, such as Vatica Health. Vatica offers a PCP-centric risk adjustment and quality of care solution, which combines technology and clinical consultants at no cost to the practice. These specially trained clinicians serve as an extension of the practice. They review and curate all relevant health plan and EMR data. This information is used to create a pre-visit notification to help the PCP efficiently perform the visit, document patients’ health status and assist with care gap closure.

Vatica’s time-saving solution enables PCPs to increase use of preventive services and improve patient satisfaction with Vatica’s combination of technology and clinical support teams. When patients’ conditions are accurately reported to health plans, that ensures adequate financial resources are available through CMS. This can also result in the patient receiving additional services from the health plan to address chronic care needs, complex conditions and SDOH.

More resources benefit PCPs and patients

SDOH continues to get more visibility, and rightfully so. This is good news for PCPs. More resources from health plans, government-funded programs and community organizations can help PCPs address SDOH. Outcomes include healthier, more satisfied patients and easy-to-access resources that can help to address lack of clinical staffing and staff burnout.

Bridging the quality gap through race and ethnicity reporting

As efforts continue to improve quality and reduce healthcare costs in the U.S., evidence shows that racial and ethnic health disparities have a significant negative impact. According to a report from the Commonwealth Fund, “Black and American Indian/Alaska Native (AIAN) people live fewer years, on average, than white people.” They are more likely to die from treatable conditions, to die during or after pregnancy and suffer serious pregnancy-related complications, and to lose children in infancy. Black and AIAN populations are also at higher risk for many chronic health conditions, ranging from diabetes to hypertension.  

The harsh reality of these health disparities was revealed by the COVID-19 pandemic and its disproportionate impact on people of color. Black, Hispanic and Asian populations in the U.S. have significantly higher infection rates, hospitalization, and death compared to white populations.  

The effect on the cost of healthcare is substantial. A recent Texas study showed that over the last six years, racial and ethnic health disparities in the state have resulted in $2.7 billion in excess medical spending and $5 billion in lost productivity.  

An important step to reducing disparities is efficiently collecting race and ethnicity data. This has proven to be a difficult task due to: 

  • The lack of standardized race and ethnicity categories 
  • Incomplete forms used to collect the data 
  • Electronic health records built without the ability to collect the information 
  • Discomfort of healthcare staff asking for information 
  • Few detailed descriptions for patients to accurately self-identify 
  • Patients may be reluctant to share this kind of information  

Additionally, social determinants of health (SDOH) have proven to be a significant source of disparity among racial and ethnic minorities. Using quality tools as a method for collecting data and advancing health equity has great potential to address the deeply rooted issues of SDOH. While some improvement has occurred, more work is needed.  

National Committee for Quality Assurance Strategies  

The National Committee for Quality Assurance (NCQA) compiles the Healthcare Effectiveness Data and Information Set (HEDIS). This provides quality results annually for more than 203 million people and 60 percent of the U.S. population. 

NCQA introduced a racial/diversity measure in 2015. But health plans struggled to obtain the needed data through member self-reporting, disease registries and other traditional means. NCQA’s 2019 records showed that approximately 76 percent of racial data and 94 percent of ethnicity data were incomplete for the commercial product line. Medicare plans demonstrated higher collection rates: 26 percent of racial data and 60 percent of ethnicity data is incomplete.  

The lack of completeness raised concerns about relying on traditional sources to accurately measure disparities in care. Without reliable data, identifying those with unmet needs is difficult. 

Improving Data Collection 

To increase collection of data from health plans, NCQA began requiring stratifications by race and ethnicity in 2021.  

NCQA started with five measures across key known disparities: colorectal cancer screening, controlling blood pressure, hemoglobin A1c control for patients with diabetes, prenatal and postpartum care, and child and adolescent well care visits.  

Race and ethnicity data on these measures help plans better understand member needs and provide services to address those needs. Plans can measure and track performance on disparities and implement data-driven approaches to close care gaps and improve outcomes in vulnerable communities, especially related to SDOH.  

Some plans are already working to close equity gaps. Centene Corporation was recently awarded the Innovation Award for Health Equity by NCQA. They implemented a data-driven approach focused on community disparities within markets. Improvements were seen in colorectal cancer screening rates for American Indian/Alaska Native members, increased rates of immunizations for Latino children and better maternal outcomes among Black mothers. 

Help is available to health plans seeking ways to reduce disparities of care among their membership. Vatica Health, for example, provides technology and dedicated clinicians to enable providers to efficiently capture more accurate and complete diagnostic coding and documentation for risk adjustment and improving quality of care. As part of this process, Vatica can collect race and ethnicity information using CDC specifications for the measures designated by NCQA. This helps Vatica clients meet NCQA requirements and collect the data needed to identify and reduce disparity gaps in care. 

Conclusion 

High quality, affordable healthcare for all isn’t possible without addressing disparities in our current system. Collecting race and ethnicity data is the first step toward developing effective solutions to address this complex challenge. While this is not a simple task, actions by NCQA and other stakeholders show potential. Collecting and using race and ethnicity data to identify disparities and factors that drive them is critical to achieving better healthcare for everyone. 

About Vatica Health  

Vatica Health deploys clinical nurses at the point of care, armed with powerful technology. Vatica’s solution accelerates the transformation to value-based care by helping providers, health plans, and patients work together to achieve better outcomes. Visit https://vaticahealth.com/ to learn more. 

Closing the gap on missed medical care

The COVID-19 pandemic has had a ripple effect, impacting not only those people who have contracted the virus, but the tens of millions of others who have managed to avoid it.  Many have foregone recommended preventive and well care since March 2020. Studies confirm this trend, including a recent report from Avalere on routine vaccinations missed.  From January 2020 – July 2021, monthly vaccine claims (for routine vaccinations excluding COVID) decreased an average of 32 percent for adults and 36 percent for adolescents, compared to the same months in 2019.  A poll conducted in January 2022 found that 30 percent of adults aged 50 and older missed a scheduled appointment for a medical test, procedure or operation.

Israel Cordero, M.D., medical director of primary care for Middlesex Health in Connecticut, attested to this troubling trend during a recent interview with WFSB TV. “We have seen many patients delay routine and preventive care, as well as ongoing chronic disease management,” said Dr. Cordero, a long-time Vatica client. “We are seeing some of those aftereffects of delaying care during the pandemic.”

While all age groups are affected, seniors are among those most at risk from delayed or avoided care. Whether it’s a colorectal cancer screening, a flu vaccine or an eye exam for a person with diabetes, missing a recommended test or procedure could have significant long-term effects. To help keep seniors healthy and reduce the enormous amount of money spent on treating preventable illnesses, Medicare covers a number of preventive services. For example, the Annual Wellness Visit (AWV), which is informed by a comprehensive health risk assessment, focuses on early detection, positive lifestyle choices, and utilization of preventive services.

Only one in four beneficiaries receives an AWV, despite this service being 100 percent free. Unfortunately, many other preventive services are also underutilized. This problem has been exacerbated by COVID, demonstrated by the studies cited here. As we start to return to our pre-COVID lives, we must ensure that the most vulnerable among us–including seniors–get the routine and preventive care they need. This requires communication, creativity and collaboration.

Partnerships between payers and providers are one way to tackle this problem. Payers and providers are using a variety of outreach and incentive programs to get patients in the door, from multi-model outbound messaging and mailers to gift cards and greeting cards.  Another effective approach is leveraging health plan initiatives that provide physicians with clinical and administrative support as well easy-to-use technology.  Finally, marrying preventive services with payer-sponsored programs designed to capture and close risk and quality gaps benefits the entire healthcare ecosystem: plans, providers, and patients.

Given their vulnerabilities and higher prevalence of chronic conditions, older Americans were prioritized when the COVID vaccine was initially rolled out. Likewise, a similar focus is needed to reengage seniors in preventive and routine care. As the nation emerges from the acute phase of COVID, it’s critical to refocus on mitigating the development and exacerbation of chronic and preventable diseases. There are effective steps providers and payers can take together to ensure that seniors—some of our most vulnerable population—catch-up on preventive care and reduce their likelihood of developing serious illnesses.

How Vatica Health can help

Vatica Health is a pioneer in physician-centric technology that supports improvements in clinical outcomes, efficiency, and financial performance. The Vatica solution deploys clinical nurses at the point of care, armed with powerful technology. The nurses use Vatica’s solution to identify, document, and report gaps in care, helping physicians increase the utilization of preventive services such as colonoscopies, mammograms and diabetes screenings. Vatica Health is accelerating the transformation to value-based care by helping providers, health plans, and patients work together to achieve better outcomes. To learn more, visit https://vaticahealth.com/.

Why a “technology-only” approach will not drive value-based care performance

Over the last few years, we’ve witnessed significant advancements in medical technology including the proliferation of telehealth, remote patient monitoring, and artificial intelligence. These offer the potential to dramatically improve insights and shape healthcare delivery. While technology development is essential, it must properly interface with clinical services to drive the maximum benefit—for providers and for patients.

Recent technology developments that provide coding and care gap notifications in electronic medical records (EMRs) offer increased potential for value-based care. These solutions address an important problem—but are incomplete as they don’t ensure conditions are coded correctly. Patients must have their conditions accurately coded to ensure health plans and providers receive appropriate compensation. Accurate coding can lead to cost-effective clinical services with the goal of improving patient outcomes.

In reality, these “technology-only” solutions may compound the problem. Providers are inundated with competing priorities and lack resources to add additional uncompensated services—a situation exacerbated by COVID-19. Current solutions cause alert fatigue and have little impact on care. They also suggest insights based on unsubstantiated data and therefore create compliance risk.

Value-based care requires a comprehensive solution

The transition to value-based care is inevitable. By 2025, it is anticipated that all Medicare Advantage and traditional Medicare plans will adopt two-sided risk alternative payment models. Fifty percent of Medicaid and commercial plans will adopt these models. This move requires providers to accurately code services for appropriate risk-adjusted reimbursement, connecting financial performance and quality of care. Success in value-based care depends on accurately assessing patient needs so that provider paymentsbased on the reported health conditions for that patient—will be sufficient to deliver appropriate care.

Technology cannot replace providers and clinical judgement. To drive optimal performance in value-based care, consider leveraging powerful, clinically validated technology coupled with clinical experts. By using technology combined with clinical experts, care gaps and relevant diagnostic codes can be identified. Such comprehensive services lead to more accurate coding and better performance in value-based care for both providers and health plans.

Evaluating possible solutions

There are a growing number of solutions that promise to drive value-based care performance, but very few that provide a comprehensive approach to improving risk adjustment coding and quality of care. Here are three questions to consider when evaluating various solutions:

  1. Is the risk adjustment and quality solution provider-centric? Providers need intuitive, easy-to-learn, and simple-to-use technology that seamlessly fits into their workflow, uses their EMR and intelligently mines data to optimize efficiency.
  2. Does the solution provide comprehensive in-office support? In addition to data and technology, providers need access to onsite clinicians who understand the technology and serve as an extension of their team at no cost to the practice. These clinicians can perform various tasks to reduce the burden on providers and their staff.
  3. Does the solution ensure coding accuracy and compliance? While there are “technology-only” solutions that surface codes in providers’ EMRs, they are often derived from unreliable data sources and not validated by certified clinical coders. This creates audit and compliance risk.  

How Vatica Health can help

Vatica Health is a pioneer in provider-centric technology and support solutions that directly improve clinical outcomes, efficiency, and financial performance. Vatica Health deploys clinical nurses at the point of care, armed with powerful technology. Vatica Health is accelerating the transformation to value-based care by helping providers, health plans, and patients work together to achieve better outcomes. Visit https://vaticahealth.com/ to learn more.