Category: Risk Adjustment

Maximizing quality of care. Minimizing admin load.

By Vatica Health | July 12, 2024 | Risk Adjustment

Effective risk adjustment drives value-based care performance and promotes fairness and equity in the Medicare Advantage (MA) program by ensuring that payments to health insurance plans and providers reflect the health status and needs of the patients. 

The keyword here is effective. For risk adjustment to deliver on its purpose and its promise, all parties involved—patients, providers and payers—must be coordinated and aligned. The trouble is, legacy programs, such as Health Risk Assessments (HRAs) completed by in-home assessment vendors, remain disconnected from treating providers. While HRAs can be a helpful tool in identifying active conditions, diagnoses captured in HRAs are often not recorded in a subsequent medical visit. Detached programs and practices can undermine the purpose of risk adjustment, increase the risk of non-compliance with evolving regulatory requirements and fail to adequately support and incentivize providers in their transition to value-based care (VBC).

The modern healthcare ecosystem is increasingly complex. Risk adjustment programs that exclude the Primary Care Physician (PCP) are inefficient, create provider-patient friction and amplify risk. Physicians and their teams need a risk adjustment solution that makes coding and documentation easier and leads to high-quality outcomes for their practice and their patients.

Here’s how Vatica Health’s one-of-a-kind risk adjustment and quality of care solution can complement current coding and documentation processes and enhance risk adjustment without overextending staff or sacrificing precious time and resources. 

1. Prioritizes coding accuracy and completeness


Why it matters

Accurate coding is the backbone of effective risk adjustment, ensuring risk scores are calculated correctly and reflect the true health status of enrollees. HRAs, typically performed in-home by vendors on behalf of MA plans, can lead to inflated HCC scores and compromised care.


How Vatica delivers

  • Point-of-care integration: Vatica works at the point of care and proactively surfaces the most appropriate and up-to-date conditions for PCPs to validate. Physicians can focus on their patient interaction, knowing they have a complete and accurate picture of the patient’s conditions.
  • Holistic data collection: Unlike other solutions, Vatica collects and analyzes data from various sources, as well as unstructured data, including consult notes and medical images, offering a more comprehensive picture of a patient’s health. No need for PCPs to connect the dots between various systems and sources.
  • Clinical review: With Vatica, 100% of patient encounters are reviewed by clinicians, such as RNs with advanced coding certifications. This ensures accuracy, completeness and compliance—and offers peace of mind for PCPs.


2. Works with and for providers


Why it matters

Any risk adjustment solution that providers adopt needs to reduce friction, not add to the already taxing administrative load. A flexible and user-friendly solution that meets PCPs where they are ensures effective and robust use, promoting better outcomes for everyone.


How Vatica delivers

  • Provider-centric approach: Comprehensive pre-encounter work performed by Vatica clinicians arms providers with the most clinically relevant information to deliver the highest quality of care during patient visits. Providers remain at the center of care to diagnose, document and follow up.
  • Workflow compatibility: Vatica’s EMR-independent technology works within existing workflows, meeting providers where, how and when they work. 
  • Administrative support: The unique Vatica model includes expert clinician coding support, allowing PCPs more time to deliver high-quality care and assuring that coding and documentation will be accurate, complete and compliant.
  • Payer-agnostic: Vatica is payer-agnostic. Clients include most national health plans and many regional plans. 


3. Supports better outcomes for patients and PCPs


Why it matters

Accurate risk adjustment is a cornerstone of value-based care. Continuing to rely on legacy programs like HRAs and chart reviews that might not reflect the true status of health—and can lead to inflated HCC scores and inaccurate risk-adjusted payments—flies in the face of VBC principles and sets providers back in their journey.


How Vatica delivers

  • Help in identifying care gaps: Vatica flags open HCC coding and care gaps for PCPs to address during encounters. Real-time clinical data assists providers in addressing HEDIS measures during their interaction.
  • Accurate VBC benchmarking: Vatica empowers providers to make the PCP visit the foundation for VBC benchmark accuracy. PCPs can deliver continuous, more effective care and build stronger patient relationships. 
  • Revenue opportunities: Vatica helps PCPs earn additional revenue through reimbursable visits, health plan incentives and enhanced VBC performance.


Better risk adjustment benefits everyone

Vatica Health’s Best in KLAS® risk adjustment solution is designed to help health plans, providers and patients achieve better outcomes, together. By increasing patient engagement and wellness, improving coding accuracy and compliance, and helping identify and close gaps in care, Vatica helps ensure that everyone benefits.

What’s behind the move from retrospective to prospective risk adjustment?

By Vatica Health | July 10, 2024 | Provider, Risk Adjustment

Health plans across the country are recognizing the superior value of prospective risk adjustment programs, and rightfully so. These programs have impact at the point of care, as opposed to retrospective programs which are essentially chart reviews. Prospective risk adjustment programs permit timely, effective interventions. This includes presentation of suspected gaps in care and the opportunity to achieve thorough and accurate documentation, which supports coding to the highest degree of specificity.

Conversely, backward-looking retrospective risk adjustment programs limit effectiveness of code capture. A risk adjustment program consisting only of retrospective chart reviews is myopic and does not support the outcomes-driven, population health management focus inherent in most payment models today.

Which one is the optimal approach to risk adjustment? The answer: an effective mix of both. But most important is primary care physician (PCP) engagement. A winning risk adjustment strategy is heavily weighted towards prospective interventions but may need to include some retrospective elements to meet PCPs’ needs.

Prospective programs, while more operationally complex to deliver, are preferred because the ability to impact behavior at the point of care is powerful. It has significant cascading effects, including higher overall value, return on investment and reduced compliance risk. When coupled with PCP engagement, prospective risk adjustment can be the most effective method for obtaining comprehensive insight into the disease burden of a population. Prospective risk adjustment also enables forecasting the cost of care for your Medicare Advantage, Medicaid and commercial lines of business.

PCP engagement is the key to success across all risk adjustment strategies, especially prospective programs. PCP engagement improves care delivery and closes gaps in care by leveraging a proactive approach providing timely clinical and administrative support, education and performance management.

The challenge: Finding a prospective risk adjustment program that engages PCPs

Ideally, health plans and physicians would collaborate to reduce costs and improve health, quality and outcomes. Additionally, members would self-advocate and proactively schedule preventive and wellness visits. Unfortunately, true engagement among all stakeholders in the healthcare continuum is rare and difficult to attain. Physician engagement requires timely, ongoing support. It is essential to augment practices with dedicated clinical resources who curate information to save the physician time by streamlining coding and surfacing gaps in care that require consideration during the encounter.

Furthermore, support staff who provide insights on performance and drive physician engagement are critical. Successful programs supply expertly trained people, easy-to-use technology, turnkey processes and aligned financial incentives to achieve and maintain physician engagement.

Lastly, member engagement is an important piece of the puzzle. Physicians are more likely to engage in programs that drive material clinical improvements for their patients, such as improved outcomes and quality of life.

How Vatica Health can help: Aligning stakeholders around a common goal

Vatica Health is a compliance-first organization that enables a physician-centric approach to risk adjustment and clinical quality. We pair expert clinical teams with cutting-edge technology to work with physicians at the point of care. Vatica Health synthesizes EMR and health plan data to create the most comprehensive and complete view of each patient. We provide comprehensive PCP training as well as 100% clinical coding validation. All unsubstantiated codes are deleted prior to submission of the Vatica record to the health plan sponsor.

Advantages of partnering with Vatica Health

Our licensed registered nurses and administrative staff are dedicated to providing the best experience for PCPs and their office staff. Our attention to documentation and coding validation through Vatica’s quality improvement process improves accuracy and reduces compliance risk. Vatica’s clinical and administrative staff work closely with each practice to develop a custom workflow and process, achieving an ideal state that yields the best results with the least amount of effort for PCPs.

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

Another blow to detached health risk assessments

By Vatica Health | June 4, 2024 | Provider, Risk Adjustment, Value-Based Care

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

By Vatica Health | April 29, 2024 | Compliance, Provider, Risk Adjustment, Value-Based Care

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

By Vatica Health | January 25, 2024 | Compliance, Provider, Risk Adjustment

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 

Vatica covered the RADV Final Rule and the CMS Final Rate Notice in this piece highlighting practical strategies to consider. We delved into the RADV Final Rule in this blog, offering tips for both payers and providers. The potential financial impact of the RADV rule is explored in this piece.  

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/.

Partner with PCPs to maximize compliant risk adjustment yield

By Vatica Health | November 30, 2023 | Risk Adjustment, Value-Based Care

Payers are under a lot of pressure to optimize risk adjustment and compliant yield in light of the CMS Risk Adjustment Data Validation (RADV) Final Rule and Final Rate Notice issued earlier this year. A recent webinar for members of the RISE Association focused on how payers can partner with PCPs to accomplish both.  

Presenter Brian Williams, MD, is medical director of optimization at Northeast Medical Group in Mystic, Conn., part of the Yale New Haven health system. He is immersed in the system’s transition to value-based care (VBC), with 230,000 patients in shared savings or cost-sharing agreements.   

Dr. Williams was joined by Michael Rosenfeld, VP of business development for Vatica Health. Michael shared case studies from payers and providers who have benefited from collaboration to maximize compliant risk adjustment yield and close care gaps.  

You can read highlights of their discussion here or watch the webinar.

Legacy models for risk adjustment that work around PCPs, such as retrospective chart reviews and home assessments, are fraught with issues. Dr. Williams and Michael agreed that the ideal process is PCP-centric, providing dedicated resources, data and integration into the PCP’s existing workflow. Dr. Williams added that the most effective ways to engage providers are for payers to have a dedicated provider engagement staff and offer aligned incentives, provider education about clinical documentation and easy-to-use technology.

The role of provider-centric risk adjustment technology is to support the patient-PCP relationship by empowering compliant code capture, improved utilization management, patient adherence and holistic care. The technology should present high-confidence conditions from the EMR and claims data, deliver timely and actionable data and facilitate a complete and accurate coding exercise. It should not contribute to alert fatigue or require the provider to go back to the EMR to verify information. This approach improves provider and patient satisfaction and helps ensure better care coordination and the closure of care gaps.

Michael noted that working with community providers can mean multiple EMRs, limited staff and infrastructure, and competing priorities. To maximize their performance, payers can provide solutions that are easy to use and supported by clinical and administrative teams, while educating them on the importance of risk adjustment to drive optimal patient care.

Dr. Williams offered advice on how payers can assist busy PCPs on risk and quality initiatives. “It helps to have a lot of the work done before it’s presented to us. Make sure that we are working as a team. Then physicians can use their training and clinical decision making to do the assessment. Do the work that you can do as a payer,” he said. “You have to reimburse physicians for the time and effort they are spending on this work. Then make sure the clinicians have appropriate resources to help them learn to navigate whatever solutions it is.”

He cited actions that are not helpful to PCPs, including interruption to the clinical workflow, any interference of time spent with the patient, interruption of the practice’s revenue cycle or overburdening of staff.

Dr. Williams also noted that PCPs are taking on more administrative responsibilities unrelated to why they chose the profession. Payers can help make them feel valued by paying PCPs fairly and quickly and “staying in their lane,” that is, handling what is appropriate for payers to handle while not carving PCPs out of care decisions.

“A payer solution was our first real ‘toe in the water’ toward value-based care,” he noted. “Part of the success we’ve had comes from sharing the organization savings with the clinicians. They understand that the work is valuable. They take it seriously. We don’t have to force them. They’ve also become very skilled at it because they received good education and support to do this work.

“Our HCC recapture rates for fiscal year 2022 were over 95%,” Dr. Williams continued. “We have categorized our patients into seven categories of risk. We understand very clearly what patients’ risk for hospitalization and serious illness is based on which risk category they fall into. We have begun to use those risk categories to direct our resources. We’re seeing lower hospitalization rates for those patients that we’re using this algorithm for. That’s encouraging.”

Dr. Williams noted that NEMG has several payer programs in place; Vatica has the highest participation and highest user satisfaction. “It’s integrated with our EMR and that information becomes part of the patient’s care going forward.” Leveraging EMR data is critical, as many other solutions rely on claims data which can be stale and less accurate.

Vatica’s prospective solution pairs clinical staff and technology to assist physicians with coding and documentation. Clients have seen an average of 25%+ improvement in accuracy and specificity and 37% higher gap closure rate. “Our coding team reviews 100% of the information documented by providers to ensure it meets standards for clinical validation,” Michael added. “Nothing gets sent to our payer or provider partners that hasn’t been reviewed in a multi-step process to ensure that it meets compliance standards and protects our clients from audit risk.“

Michael reviewed a case study with a regional Blue Cross client that showed total incremental HCC revenue of over $100 million based on 44,600 annual encounters. It’s important to note that strong financial results are due to more accurate and complete coding and documentation.

He also shared data from a provider client who completed Vatica visits for 73% of 47,000 eligible patients in a year. During those visits, Vatica detected more than 73,000 open care gaps for physician review and helped physicians accurately identify and code diabetes with chronic complications, increasing the rate from a 4.74% baseline to 19.19% in one year.

For more information on how Vatica can help payers support PCPs to maximize compliant risk adjustment yield and quality of care, visit VaticaHealth.com.

Relieve providers’ admin burden to help combat burnout  

By Vatica Health | November 17, 2023 | Provider, Risk Adjustment

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. 

Five ways you can begin addressing SDOH to improve outcomes and lower costs

By Vatica Health | October 20, 2023 | Risk Adjustment, Value-Based Care

It’s an inescapable fact: The lower a person’s socioeconomic position, the worse their health. Research by the World Health Organization (WHO)  has shown that non-medical factors—such as education, employment, food insecurity and housing—have a significant impact on the health disparity between rich and poor. In fact, it is estimated that up to 89% of the factors that  influence health exist outside of medical care. These factors are known as Social Determinants of Health (SDOH).

Government agencies and healthcare providers alike understand the impact of SDOH and want to do something to close the gap. However, a 2022 survey showed that while 80% of care providers believe that addressing SDOH is essential to improving health outcomes and decreasing costs, 61% said they lacked the time and the ability to affect the SDOH of their patients.

If, like the care providers surveyed, you’re committed to addressing SDOH but feel ill-equipped to make a difference in the near term, read on to begin making progress against your SDOH goals.

Below are a few tactics to consider, which are more fully described in a recent white paper, “Five ways you can begin addressing SDOH to improve outcomes and lower costs.”

Identify people in need and collect the data

Social screening needs to be a component of every patient visit. Screening tools, available through some EMRs and other sources, can help identify people in need within your patient population.

Master the codes

To ensure your clinicians and coders are up to date on the new Z codes, consider designating one staff member as your in-house SDOH expert and charge that person with following, disseminating and training colleagues on that information as it is updated.

Leverage payer resources

Health plans are also offering more direct SDOH support. For example, Anthem’s Member Connect program guides Medicare Advantage members to community health workers who help them find the community resources they need. This has increased healthcare engagement for 74% of members, resulting in an 8% reduction in hospital admissions and a 43% reduction in ER visits.

Build relationships with community resources

To drive better outcomes, it’s vital to connect patients to governmental and community resources that can help address their SDOH issues.

While referring patients to the appropriate programs is a good start, it is not enough; you should follow up to ensure they’ve made those connections. For that reason, it’s to everyone’s benefit for you to get to know and partner with community-based organizations (CBOs) to share information, ideas and issues and ensure referrals are followed up.

Emulate the successful methods of other care providers

The experiences of other providers may offer valuable lessons on what works and what doesn’t. For example, the University of Pennsylvania Health System discovered that offering patients a complimentary ride to an appointment did not lower patients’ 36% no-show rate. However, NorthPoint Health & Wellness Center  of Minneapolis  has seen success over the past 15 years by providing patients with bus tokens and hosting lunches with religious leaders of underserved communities. These and other actions have enabled NorthPoint to more than double vaccination and health screening rates to nearly 80%.

Addressing SDOH makes an impact

Taking proactive measures as described here will inform better decision-making and drive policies that work to undo the inequities in healthcare and lower costs for everyone. And when you build on those findings, using analytics to identify at-risk or in-need individuals, you can take the next step with outreach efforts that refer patients to relevant professionals and community resources.

Vatica Health can help. Our PCP-centric risk adjustment and quality of care solution combines technology with clinical consultants who review and curate all relevant health plan and EMR data. This results in a pre-visit notification that can help your team efficiently perform the visit, document patients’ health status and assist with care gap closure.

Interested in a more in-depth look at SDOH resources? Click here.

Benefits of engaging PCPs in risk adjustment

By Vatica Health | September 14, 2023 | Provider, Risk Adjustment, Value-Based Care

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  

By Vatica Health | July 21, 2023 | Compliance, Provider, 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/.