Category: Risk Adjustment

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.

6 Ways to Ease Physicians’ Burden From Coding, Documentation and Risk Adjustment

By Shannon Lukez, Senior Vice President, Clinical Solutions, Vatica Health | This article first appeared on HFMA

The COVID-19 pandemic has heightened the need for the nation’s hospitals and health systems to gain physician cooperation in documenting and coding patient risk.

The reason is that many patients, and particularly the elderly, stopped visiting their care providers during the pandemic, often resulting in an undocumented deterioration of their health status.

Consider, for example, a 76-year-old patient with Type 2 diabetes and stage 3 chronic kidney disease, whose conditions were fully documented in the patient’s medical record and coded to the highest degree of specificity on all claims submitted in 2019. Let’s assume the patient not only refrained from visiting a physician’s office in 2020 due to COVID-19, but also was not comfortable enough with technology to receive telehealth services. Facing isolation, with severely reduced family and community support, the patient experienced growing depression and anxiety — and uncontrolled diabetes. The patient also began experiencing symptoms of high blood pressure and severely reduced access to healthy food as result of the increased financial strain brought on by the pandemic. Because the patient did not see a physician in 2020, none of this information was documented in their medical record or coded.

Undocumented deterioration in a patient’s health status impacts a healthcare organization’s revenue considerably. The absence of preventive care significantly increases the possibility for patient illness and premature death, while also depriving healthcare providers the opportunity to positively impact the patient’s life. Failure to recapture previously documented conditions, as well as new ones, leads to poor patient outcomes and lower levels of reimbursement.

The added challenge of physician burnout

Unfortunately, this heightened need for physician engagement comes at a time when many physicians are struggling with burnout exacerbated by the challenging work conditions created by the pandemic amid the ever-present risk of contracting the virus.

According to a 2021 national survey conducted by Medscape, 42% of physicians reported feeling burned out. Interestingly, 79% said the burnout started before the pandemic, with a majority (58%) citing “too many bureaucratic tasks” as the number-one cause.

These circumstances may cause many healthcare finance leaders to feel hesitant to add to physicians’ plates any kind of operational burden, particularly tasks related to enhanced coding, documentation and risk adjustment. It’s not easy to ask physicians — especially those who are salaried — to spend more time documenting conditions and reporting data for value-based payment programs while also increasing daily patient volume. Yet the financial future of a healthcare organization depends on its ability to delicately balance and accurately perform both tasks. As the industry shifts from volume-based to value-based payment models, healthcare organizations and physicians must cooperate to achieve long-term financial viability.

Consequences of physician burnout

Physician burnout is problematic because it leads to unsatisfied physicians and high turnover, which significantly affects patients. For example, burnout is associated with higher rates of major medical errors. It can also negatively affect patients’ access to and continuity of care as well as their care experience. All of these issues can harm a healthcare organization’s reputation and, in turn, its bottom line. For these reasons, physician burnout is an important ongoing concern for healthcare finance leaders.

How to foster physician engagement in capturing risk

Addressing these challenges requires a strategic approach to making coding and risk adjustment practices more physician friendly. Following are six strategies that CFOs should consider as they strive to support physicians in more accurately and documenting the risk profile of their patients.

1 Provide physicians with training on standard coding and documenting practices. One of the challenges associated with creating a risk-adjustment strategy is getting all physicians on the same page in terms of process and workflows. All too often, each practice — particularly one that’s newly acquired — will either have its own way of capturing risk or have no formal process at all. Consistency is important because it reduces the cost to operationalize the program, permits standardization of training and other key elements, and facilitates the establishment of expectations. Both the healthcare organization and the physicians will know exactly what is expected.

2 Align physician compensation with value-based care initiatives. Compensating physicians for their efforts is of paramount importance to obtaining physician buy-in and ongoing participation. Yet some healthcare executives contend that coding and documentation are simply part of the physicians’ role, so extra compensation is unnecessary.

This perspective does not consider newer models of care that focus on population health and outcomes, where revenue is largely determined by value, affordability and outcomes. And outcomes and value will be determined through analyses of claims and encounter data, which must be supported by accurate and thorough medical records documentation.

Aligning physician performance and compensation with overall organizational goals ensures shared accountability. Just as important, by thoughtfully designing compensation programs for both clinical and support staff, a health system can proactively counter the problems of physician burnout, declining retention and a growing shortage of talented physicians.

Paying physicians a base salary plus a gain-share bonus based on value-based care performance, for example, gives them an incentive to go the extra mile documenting for risk adjustment. It also sends the message to physicians that executive leaders are aware of the extra time and effort improved coding and documentation requires.

3 Optimize the electronic health record (EHR). EHRs, on their own, do not sufficiently support coding and documentation to optimize value-based care performance. However, solutions are available that optimize EHR performance to help identify care gaps and facilitate accurate coding.

Physicians need help with this process as risk adjustment coding is complex and cumbersome. In the CMS risk adjustment model alone, roughly 10,000 diagnoses are assembled into about 1,300 diagnostic groups that are then aggreged into condition categories (CCs). CCs are related clinically and with respect to cost. Hierarchies are imposed among related CCs, hence the term hierarchical condition categories or HCCs. HCCs paint a complete picture of each beneficiary’s acuity to effectively manage costs for high-risk members while ensuring they receive high-quality care and the organization receives appropriate and accurate payment.

Efficiently distilling this information for physicians reduces the burden on them and improves performance in value-based care, quality and risk adjustment initiatives. Healthcare organizations should work with their EHR vendors on ways to improve EHR performance to optimize the provider experience and patient outcomes.

4 Advocate for programs that remove operational burden associated with risk adjustment. For example, health systems could consider working with a health plan on a plan-sponsored program for primary care physicians (PCPs) that is easy to use and provides support to physicians. Such programs can combine powerful technology with clinical and administrative resources dedicated to medical practices.

These programs can help the participating health systems realize incremental revenue, improved outcomes, increased numbers of preventive health encounters (e.g., annual wellness visits) and improved overall performance in value-based care arrangements. The senior financial executive can initiate this strategy by reaching out to the organization’s managed care partners to see whether they provide this type of program and, if so, what type of performance reporting is included. Ideally, the health plan would provide real-time data so the physicians could understand care gaps for each patient and how well they are addressing those gaps.

If health plans don’t offer this option, the health system could consider developing a program internally, depend on its goals, available resources and competing priorities. In deciding whether to pursue such an approach without outside help, the organization would need to perform an in-depth assessment of the potential benefits weighed against the costs associated with the required  upfront investment and ongoing resources for program management, analytics and reporting.

Armed with the results of such an analysis, the senior finance executive can champion the effort by communicating to the health system’s C-suite the potential financial impact of a PCP-focused program to the health system, and how it could help the organization not only survive, but thrive, in the years ahead. In this way, the senior finance leader also can help demonstrate to the physicians that there is uniform buy-in at the leadership level for a program designed to help them manage the risk-adjustment process.

5 Provide support to help physicians capture and address social determinants of health. Medical care accounts for only 10% to 20% of the modifiable contributors to healthy outcomes. The other 80% to 90% are referred to as social determinants of health (SDoH) — the conditions in the environments where people grow, live, work and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks. Examples of SDoH include the lack of essential resources necessary to maintaining health, including housing and economic stability, literacy skills and access to nutritious food and physical activity opportunities. Because SDoH often can affect risk adjustment and, consequently, revenue, it is important for physicians to capture this information.

Healthcare organizations should assist physicians in this effort by providing a framework and support for capturing SDoH. Successful SDoH-focused 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.

6 Be transparent about the financial impact of physician performance in value-based care. Given the significant impact physicians have on a health system’s performance under value-based payment arrangements, executive leaders should share financial performance data with physicians (and potentially other staff as well). For some healthcare organizations, incremental revenue earned through participation in such programs can help them end the year in a financially positive position. Transparently communicating to physicians the financial impact of performance in value-based-payment contracts, including positive results attributed to quality and risk adjustment programs, builds awareness, trust and engagement.

A necessary charge

Value-based care is a strategic imperative for U.S. hospitals health systems, and it requires, first and foremost, physician engagement. Thus, although finance executives may be wary of asking physicians to take on the additional administrative tasks such contracts require, they must do so because success will depend on physicians’ absolute commitment to accurately documenting care and adjusting for risk. Although physicians may initially object to the additional work, they will likely become more receptive if they can be shown how better coding and documentation directly improves the organization’s financial performance — and how that translates into reduced pressures placed on physicians.

It is here where the finance leader can make a difference. By examining and implementing  creative and effective solutions aimed at easing the administrative burden on physicians, the senior finance executive can help them better meet the challenge of performing documentation and coding. The result is a win-win in the form of improved value-based payments and alleviated physician burnout.

Why providers face an increased challenge in understanding patient risk

During the first six months of 2020, an estimated four out of 10 adults in the United States avoided medical care because of concerns related to COVD-19. With these delays in care came missed opportunities for hospitals and health systems to capture risk and predict costs accurately.

With the rollout of the COVID-19 vaccine, some patients are slowly resuming preventive services, which is good news. Yet this trend means providers may be overwhelmed with patients whose chronic conditions have worsened or who are newly diagnosed with a chronic condition. It is of paramount importance that the provider organizations capture these diagnoses to ensure their payment is appropriately adjusted for risk.

For patients who are still not returning to their provider, it also will be important for providers to address care gaps. Telehealth may be a great way to engage these patients so that physicians can capture risk without necessitating the need for an in-person visit.

In addition, in 2020, about 8.3 million people signed up for Affordable Care Act plans that rely on risk-adjusted payment models. This is a new population of patients for whom risk adjustment suddenly matters. Many of these patients don’t have a baseline risk adjustment factor score, making it critical to capture any and all diagnoses that affect risk-adjusted payments as soon as possible.

A Solution for Medicare Advantage Overpayments: Taking a Provider-Centric Approach—Not Suspect Analytics

By Averel B. Snyder MD, CMO, CRC, CPC, CDEO, Vatica Co-Founder and Chief Medical Officer

Driven by a flurry of lawsuits and Office of Inspector General (OIG) reports alleging billions in overpayments, government pressure is mounting for Medicare Advantage Organizations (MAOs) to improve risk adjustment practices. Before we delve into how MAOs can effectively address the increased compliance scrutiny, it’s instructive to consider how we got here.

The Evolution of Risk Adjustment

The beginnings of Medicare Advantage (also known as Medicare Part C) go back to the 1970s. At that time, beneficiaries could receive managed care through private insurance companies. It was not until 1997 that the program, then called “Medicare Choice,” became official with the passing of the Balanced Budget Act. In 2003, Medicare Part D was created, and Medicare Choice plans were renamed “Medicare Advantage” plans. A major change in the program addressed favorable selection in Medicare Advantage and was phased in from 2004 to 2007. This introduced a new system for adjusting plan payments based to a large extent on severity of illness for each beneficiary. The system requires the health plans to submit to CMS the diagnosis data annually as each member is assumed to have no diagnostic conditions at the start of a new calendar year.

The new system created an industrywide frenzy to capture all diagnoses to optimize risk adjusted revenue.   This spurred new business models to help MAOs document members’ active medical conditions. These businesses include companies providing home health assessments, suspect analytics, gap closure programs, natural language processing, and machine learning to name a few. Many of these businesses focused more on increasing revenue at all costs without an equal, or greater, focus on improving the accuracy and completeness of coding and documentation.  Likewise, some health plans have developed internal coding programs that lack adequate safeguards to ensure the accuracy of conditions submitted to CMS.

The Challenge Around RADV Audits

As the government increases RADV audits, warning signs indicate that industry practices may need an overhaul. For example, a recent RADV audit of Plan A revealed that only 40% of 203 sampled enrollee-years had medical records supporting the diagnosis codes submitted to CMS. For the remaining 123 enrollee-years, the diagnosis codes were not supported in the medical records.  A RADV audit of Plan B found 43% of beneficiary risk scores invalid due to not supporting one or more diagnoses for the following reasons: the documentation did not support the associated diagnosis, or the diagnosis was unconfirmed. Similar reasons were responsible for the results of Plan C’s audit with only 54% of risk scores being valid.

The Problem with Retrospective Chart Reviews

The OIG released findings in a report dated December 2019 relating to supplemental diagnosis codes that were not linked to an encounter. This practice is used when submitting retrospective codes via a CMS submission in either Risk-Adjusted Processing System (RAPS) or an unlinked chart review through Encounter Data Processing System (EDPS). Of the submissions, it was found that $1.7 billion of the total $6.7 billion risk-adjusted payments were retrospective chart reviews. The OIG also found that within all chart review submissions, only 1% accounted for deletions for previous erroneous codes submitted. Regarding the supplemental unlinked chart reviews submitted, half were linked to only 10 hierarchical condition categories.

What I Learned Firsthand

I was a practicing clinical physician for 30 years before my 10-year involvement with Medicare Advantage. For 30 years, I would review the patient’s medical record prior to a face-to-face visit so that I could address those active medical conditions during the visit. I may have been more efficient, had a trained nurse or mid-level reviewed the record and presented me with all the active medical conditions, along with the documentation and clinical validation found within the medical record.

I strongly believe that had I been presented ‘lists’ composed of ‘suspect conditions’ or ‘other’ provider claims history, or lists generated by natural language processing, and machine learning, the abundance of false positive diagnoses generated by these techniques would have made me much more prone to err in documenting and coding inaccurate and non-compliant active medical conditions. On the other hand, a physician or mid-level provider responsible for patient care with access to mined data from that patient’s medical record prior to a face-to-face visit is the ideal process for Medicare risk adjustment.

What Comes Next

Due to a confluence of factors, including increased lawsuits, OIG reports claiming billions in overpayments, and negative RADV audit results. A strategy based on claims data and suspect analytics increases negative RADV exposure similar to the 40% to 50% unsupported conditions in recent RADV audits. MAOs should consider a physician-centric approach to risk adjustment, which should provide physicians with technology and expertly trained mid-level or nurse support. As a result, this will drive more accurate and complete coding and documentation to improve overall compliance and results.  

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Dr. Averel Snyder is a cardiothoracic surgeon and is board certified in general surgery, critical care medicine and cardiothoracic surgery. He practiced heart surgery for over 25 years. He also has an AMA certification in age management, and several medical coding certifications (CRC, CDEO and CPC). Dr. Snyder is co-founder of Vatica Health, the leading PCP-Centric solution for risk adjustment and quality of care. To learn more about Vatica Health, please visit vaticahealth.com  

How to Close Care Gaps for Patients With SDOH

By Shannon Lukez, Senior Vice President, Clinical Operations Vatica Health

Even before COVID-19, providers struggled to close care gaps. The pandemic has only worsened the problem as some patients continue to delay or forgo care out of fear of contracting the coronavirus. In addition, there’s a significant number of patients who struggle with non-medical factors such as lack of transportation, economic stability, literacy, housing, and food insecurity which contribute to untreated care gaps and poor outcomes. Unaddressed social determinants of health (SDOH) not only leads to disparate care, it also prevent providers from optimizing performance under value-based care (VBC) programs. Why is it so hard to close gaps in care – especially for patients with SDOH?

Provider burnout. For starters, addressing SDOH is one more thing—albeit a critically important one—on an already daunting to-do list. Many providers are on the verge of significant burnout, which is being exacerbated by a shortage of resources caused by Covid-19. When faced with the patient in front of them, they’re frequently only able to address the condition prompting the reason for the visit. They don’t have the time or staff necessary to dig more deeply into the non-medical factors that could be contributing to the patient’s overall health status.

Lack of SDOH data. Many providers don’t have the data necessary to identify at-risk patients. If they don’t collect this data themselves or have access to it in some other way, they won’t know which patients are facing SDOH-related challenges. It’s impossible to effectively address these barriers without having a targeted, analytics-driven approach.

Lack of clinical and administrative support. Providers don’t have the clinical and administrative staff necessary to perform patient outreach and engagement. Many practices are still struggling to retain staff needed to perform the most basic duties necessary to keep the business afloat. Recent Covid-19 vaccine mandates for healthcare workers have only worsened the resource constraints. Tackling SDOH is an added responsibility for which many providers feel their staff simply don’t have the bandwidth.

How health plan-sponsored programs can help

The good news is that some health plans are starting to step in and partner directly with primary care physicians to help them close care gaps and address SDOH. That’s because these payers realize providers can’t do it alone.

Consider BlueCross Blue Shield of Massachusetts (BCBS-MA) that has begun to incentivize providers to address gaps in care specifically for people of color. The payer is using existing HEDIS data to identify racial and ethnic disparities and then link solutions to its current value-based purchasing model.

As part of this initiative that will begin in 2023, BCBS-MA will work with providers and employers to collect data and continue to ask members to self-identify. BCBS-MA is also using imputed data (i.e., data that assumes a member’s race based on multiple factors). It will focus on colorectal screenings, adolescent well care, severe maternal morbidity, and antidepressant medication management for Asian, Black, and Hispanic members of its commercial plans that are already attributed to its primary care-focused Alternative Quality Contracts.

The BCBS-MA initiative is a step in the right direction because it acknowledges the importance of these two elements: Comprehensive SDOH data and aligning VBC care with financial incentives. However, health plans cannot overlook a third factor that’s equally as important: Infrastructure augmentation—specifically, clinical and administrative support.

A health-plan sponsored program can help incentivize physicians to identify and address SDOH without adding operational burden. However, this type of program must not only supply data, technology, and aligned financial incentives—it must also provide expertly-trained people and clinical resources to achieve and maintain physician engagement.

To learn more about Vatica’s PCP-centric solution to improve clinical and financial performance, visit https://vaticahealth.com/.

Customer Centricity: Building Your Business One Relationship at a Time

By Josh Stern, Chief Revenue Officer at Vatica Health

How you treat your customers matters. Every successful business knows this and is intentional about consistently adding value and exceeding their expectations.

It’s why Starbucks, for example, created a mobile ordering and personalized rewards program that makes it simple for customers to order exactly what they want and pick it up with a minimal wait. It’s why the meditation app Calm gave away content and meditation exercises for free during COVID-19. It’s why Target expanded its drive-up option with more spots at stores and provided customers with the ability to scan self-checkout items with their phones instead of a communal scanner.

It’s all about customer centricity and not just for the employees that have direct interactions with customers. It’s about ensuring and committing to have the entire organization think this way, customer-centricity is a cultural mindset.  That is, building your business from the ground up with customers in mind—to let customer satisfaction drive strategic decisions. It’s about clear communication, trust, and accountability. It’s about asking this critical question: What can we do to deliver value, build partnerships, and contribute to customer success? Simply put, it is about being able to answer, “our business and relationship matter” through the lens of the client.

Achieving the Holy Grail: Partnership

In many industries, services are commoditized with very little collaboration between vendors and their customers. Vendor products and/or services meet basic specifications, and that’s about it. The decision to partner with a particular vendor is usually based on price or availability, and customers aren’t necessarily loyal when better opportunities present themselves.

However, thriving customer-centric companies know that this transactional level of engagement isn’t enough. For both organizations to thrive, they must become allies and partners. Organizations must strive to meet each customer’s deeper needs and help them solve business problems. They must invest in relationships and provide close personal attention.

How do you know if you are at or working with an organization that is truly customer centric, as opposed to one just saying the right words? The following are five attributes you will be able to consistently observe:

1. Transparent communication. Customer-centric companies communicate directly and truthfully. They give customers all the information, both good and bad, they need to make informed decisions. They keep customers abreast of changes industry-wide or within the organization that affect them directly or indirectly. No secrets. Nothing withheld. They communicate in a way that says: I value you and want to be as open and honest as possible. They provide invaluable context, roadmaps to the “who,” “what,” “why,” “where,” and “how” so you as business leaders can make informed decisions for you and your company with all the relevant information at your disposal.

2. Belief that trust is earned, not freely given. Customer-centric companies know that trust is personal and that it develops over time. Customer-centric companies work hard to build that trust with each and every customer through each interaction, and they don’t ever take it for granted. They do this through consistency, openness, and dedication.

3. Alignment. Customer-centric companies take the time to understand how each customer defines and measures success. Alignment is about collaboration and truly listening to what customers have to say. It’s not about thinking you know what’s best for the customer or assuming they measure success in the same way you do. It’s about understanding their unique challenges and goals and trying to figure out how you can truly offer value.

With that said, customers themselves may not be aware of or be able to articulate the best solutions to address their needs. Customer-centric companies help them figure it out by asking questions for clarification. What will this product or service provide to the customer? Is it what the customer really wants and needs? Does it solve their problem or help them reach their goal? If they can’t define a direct or indirect customer benefit, a customer-centric company won’t recommend the product or service – even if it’s to their financial detriment.

4. Accountability. Customer-centric companies consistently strive to follow through with commitments. When they commit to things – they do them, no babysitting necessary. When they fail, they own it. They admit mistakes and oversights, and they identify a clear plan to do better in the future.

5. Agility. Customer-centric companies are nimble and able to quickly adapt to customers’ needs. They’re also willing to implement novel strategies to improve the customer experience. For example, they might use cultural index surveys to match employees and customers based on behavioral attributes to increase the effectiveness of communication. They provide leadership training and commit to ongoing professional development. They’re constantly brainstorming ways to be better and do better both for their own employees and the customers they serve.

Conclusion

In any industry, selecting a vendor/partner can be daunting. Every candidate has a value proposition and some will say whatever it takes to get your business. If you are having trouble sorting through the noise, consider asking these questions:

  • How do you build trust with clients?
  • How do you approach client partnership and collaboration?
  • How will you help us meet our short- and long-term goals?
  • What is your process to ensure accountability?

Their answers may surprise you, and they’ll bring you one step closer to making an informed decision. And don’t forget to ask for specific examples and references to validate their answers.

How Vatica can help

When health plans partner with Vatica Health, they ensure a comprehensive, collaborative, and results-oriented prospective risk adjustment program that’s a win-win for everyone – health plans, physicians, and  patients. To learn more, visit https://vaticahealth.com/.

Aligning incentives in healthcare to improve physician documentation

By Burke Burnett, Senior Director of Product Strategy

When you put effort into a task, it feels good to get rewarded for it. It’s the idea behind incentive theory. People are frequently motivated by a desire for positive reinforcement and gravitate toward behaviors that lead to incentives and away from those that might lead to negative consequences.

Sounds simple. It’s why we study to get good grades or work hard to get a promotion. However, in healthcare, it’s a bit more complex. Why? Payers and providers are paid differently, and when incentives aren’t aligned, that can lead to different priorities. While everyone in the healthcare ecosystem generally has the same goal-  to keep patients healthy and living a high quality of life – the way payments flow through the system can create misalignment.

For example, Medicare Advantage plans are paid based on predicted costs derived from patients’ severity of illness and risk of mortality. If the documentation and coding doesn’t accurately reflect risk, the health plan may not receive enough sufficient capitation to manage the patient’s active medical conditions. Physicians, on the other hand, are often paid based on the volume of services they provide. There’s no financial incentive to painstakingly capture and code a patient’s risk because it doesn’t directly impact revenue in fee-for-service payment models.

The irony is that treating PCPs and their staff—are best suited to conduct a comprehensive risk assessment. Given their relationship with the patient and access to all clinical information in their EMR, they are the most appropriate clinician to accurately document and code clinical conditions and close care gaps leading to more accurate HCCs and better outcomes which benefits both health plans and providers.

To help promote better collaboration and alignment between health plans and physicians, consider the following talk tracks.

1. The Inevitable Transition to Value-Based Care. One third of all U.S. healthcare payments already flow through alternative payment models. 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.

How will we get there and make the seismic shift from fee-for-service to value based care payment models? One recent roadmap from the University of Pennsylvania’s Leonard Davis Institute of Health Economics says the Centers for Medicare & Medicaid Services (CMS) must take these steps:

  • Articulate a clear vision for the future of value-based payment that aligns across all publicly-financed healthcare, Medicare, and Medicaid.
  • Dramatically simplify the current value-based payment landscape and engage late-adopting providers.
  • Accelerate the movement from upside-only shared savings to risk-bearing, population-based alternative payment models while curtailing the ability of providers to opt out of value-based payment altogether.
  • Pull providers toward advanced alternative payment models while also structuring incentives to push providers away from fee-for-service payment.
  • Achieve health equity to promote value-based care.

What’s the takeaway here?  Financial performance and quality of care are inextricably linked, and success in value-based care depends on accurately assessing the needs of your population so that your payments will be sufficient to deliver appropriate care. Physicians can’t afford to wait until 2025 for value-based care arrangements to be forced upon them, it will be too late. The key is to strike a balance so that physicians and their staff are not inundated with more administrative tasks and receive appropriate compensation for any additional work which is performed.

2. Annual comprehensive risk assessments pay off. Many payers offer providers a financial incentive for each comprehensive risk assessment they complete. This means direct revenue for the practice. The annual wellness visit (AWV) is a perfect time to conduct this assessment and be paid separately for it. A payer-sponsored risk adjustment program even helps physicians conduct these assessments with ease as they supply physicians with turnkey solutions that include free clinical and administrative resources, and easy to use technology.

3. Physicians earn more money when they help payers improve quality measures. When physicians document more thoroughly and close clinical care gaps, health plans benefit by being rated more favorably. Thus, many plans provide financial incentives for physicians to improve quality measures and close gaps in care.

4. Driving the utilization of preventive services can generate additional revenue for the practice. Engaging patients in an AWV or comprehensive annual physical not only helps keep patients healthy, it also can lead to additional revenue opportunities for the practice. For example, a patient who presents for an AWV might also need immunizations, colorectal cancer screening or advanced care planning. A payer-sponsored risk adjustment program provides physicians with easy-to-use software and services that surface clinically appropriate preventive services and better address all chronic conditions.

5. Comprehensive documentation is the right thing to do. All financial incentives aside, comprehensive documentation is what promotes high-quality patient care. An overwhelming majority of physicians go into medicine to help patients, and that’s exactly what comprehensive documentation does. It captures severity and risk and tells the patient’s entire story. That story is the foundation for the clinical care they receive. Without it, patient care could be compromised.  In the end, better alignment not only leads to better financial performance for health plans and providers – but the efficient delivery of the highest quality of care.  

How Vatica Health can help

Founded in 2011, Vatica Health is the leading provider-centric risk adjustment and quality of care solution for health plans and health systems. By pairing expert clinical teams with cutting-edge technology at the point of care, 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. Vatica Health is trusted by many of the leading health plans and thousands of providers nationwide

The best part?

It’s a health-plan sponsored initiative. That means there are no direct costs for practices to participate.

As practices continue to seek point-of-care solutions to better tell each patient’s story, they need look no further than Vatica Health. 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/.

How an end-to-end risk adjustment strategy helps direct contracting entities grow with confidence

By Brian Flower, Vice President of Client Solutions

Value-based care (VBC) is truly a team sport—especially when it comes to direct contracting entities (DCE) that include healthcare providers and suppliers sharing the common goal of improving healthcare delivery. DCEs operate under the Global and Professional Direct Contracting Model (GPDC), one of the Centers for Medicare & Medicaid’s (CMS) latest innovations to right-size costs and improve outcomes for patients with traditional fee-for-service Medicare coverage.

According to CMS, the goal of the GPDC is to transform risk-sharing arrangements in Medicare fee-for-service, empower beneficiaries to personally engage in their own care delivery, and reduce provider burden to meet healthcare needs effectively. There are 53 DCEs participating in the first Performance Year (PY2021) running from April 1, 2021 through December 31, 2021.

Here’s how it works. DCEs contract directly with Medicare under a risk-adjusted payment model similar to that of other alternative payment models. This means they accept financial accountability for the overall quality and cost of medical care furnished to Medicare fee-for-service beneficiaries aligned to them. While CMS has provided various participation options, all options are aligned the same. They measure DCE performance against annual medical cost benchmarks while ensuring quality metrics are met and reported.

DCEs represent a big win for CMS in the drive to expand value-based care and the vertical alignment of incentives in healthcare. However, for DCEs to be successful, these entities must educate and promote the shift to from FFS to VBC at the provider level, employing strategies to manage patient populations for whom preventive care and risk adjustment accuracy weren’t necessarily a priority in the past. While CMS has structured the financial equation to mitigate increases in RAF scores overall, targeted patient engagement, risk adjustment, and quality capture interventions are critical to ensuring predictable and reasonable benchmarks for each DCE. DCEs need each PCP’s help and buy-in to accomplish this. PCPs who don’t accurately capture hierarchical condition categories (HCC) can drag down a DCE’s benchmarks, negatively impact revenue, and stall overall growth. Again, VBC is a team sport.

The challenge: Achieving controlled growth without compromising data integrity

DCEs want—and need—to grow quickly. However, growth without a strategic plan can easily backfire. They can’t afford to onboard PCPs who have little or no experience in value-based care if they don’t have an onboarding process in place to drive documentation and coding compliance. This process shouldn’t put the onus on PCPs to take on more work. There simply aren’t enough hours in the day, and many PCPs are already facing burnout. Adding another task to their to-do list would cause unnecessary friction.

In GPDC, CMS has set up a financial structure to recognize the importance of quality care and allocating resources based on the needs of specific populations. For the majority, RAF growth will be capped at +/- 3% to ensure that risk adjustment accuracy is a priority instead of the priority. However, those with VBC experience know that the potential 6% window in med-expense benchmark is no small thing—potentially $3M+ on a population of 5,000 beneficiaries in Atlanta, Georgia.

DCEs need a risk adjustment strategy that promotes patient engagement, improves quality reporting, and prioritizes accuracy and compliance.

The solution: An end-to-end prospective approach to risk adjustment

Leveraging an end-to-end, prospective risk adjustment partner helps DCEs ensure risk and quality accuracy without having to worry about each PCP’s experience with HCC capture and risk adjustment. Even practices that are new to the world of value-based care can quickly be brought up to speed with custom workflows and education as well as clinical and administrative support. The goal is to yield maximum accuracy with minimum physician effort. Mitigating burnout is key. And promoting early detection and effective management of chronic conditions are cornerstones of effective prospective risk adjustment.

Following are five priorities for DCEs as they continue to expand:

  1. Understand current state of documentation and coding accuracy, patient engagement, and quality performance on provider panels.
  2. Understand options for ensuring risk adjustment accuracy and quality performance to drive better patient outcomes.
  3. Empower providers with the right tools to improve the accuracy of population-specific medical expense benchmarks.
  4. Identify and measure key indicators at the PCP level to align organization value-based outcomes with provider performance and incentives.
  5. Maintain compliance and focus on the quadruple aim.

Each of these priorities is equally as important, and collectively, they lay the foundation for a DCE’s long-term success.

How Vatica Health can help

Vatica takes the pressure off DCEs by supporting the VBC onboarding process for all PCPs regardless of their experience with risk adjustment and quality capture. It does this by pairing expert clinical teams, including licensed registered nurses, with cutting-edge technology to work with physicians at the point of care. By synthesizing EMR and health plan data to create the most complete view of each patient and applying a rigorous clinical documentation improvement process, Vatica improves data accuracy and reduces compliance risk. It also provides comprehensive PCP training as well as 100% clinical coding validation. When coupled with PCP engagement, prospective risk adjustment enables comprehensive insight into the disease burden of a member population. In addition, prospective programs actually drive higher return on investment due more accurate and complete coding and documentation. It’s about engaging patients when they’re directly in front of their provider. This is where real change can occur. This is how to move the needle on value-based care. To learn more, visit https://vaticahealth.com/.