Category: Risk Adjustment

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/.

Why Medicaid Risk Adjustment Can’t Be Ignored During COVID-19 and Beyond

Given the number of people who experienced income and job loss during the COVID-19 pandemic, it’s not surprising that Medicaid enrollment increased by 7.7 million or nearly 11% between February and November 2020, according to recent data from the Kaiser Family Foundation. However, what may come as a surprise—at least for some Medicaid plans—is the effect of this growing population on their revenue. Spoiler alert: It isn’t good news.

The challenge: Medicaid risk adjustment is a moving target.

Most health plans acknowledge the value of risk adjustment for the Medicaid population.  However,  implementing a successful program is a difficult process. Why? Medicaid risk adjustment programs are complex and vary by state. For example, while most states use the Chronic Illness and Disability Payment System (CDPS), there are several others including DxCG, CRG and more. Furthermore, states’ risk adjustment regulations, incentives, and penalties all tend to vary widely.  This variability poses challenges and increased costs particularly for multi-state health plans when trying to devise and implement a comprehensive risk adjustment strategy.

Other challenges include the frequency with which Medicaid eligibility changes, volatility among sub-populations, as well as the difficulty associated with obtaining encounter data from an often-transient population. Despite these obstacles, risk adjustment is incredibly important because Medicaid managed care is often high-risk with low margins and reimbursement for care of this population depends on the specificity and accuracy of encounter data.  

The complication: A growing Medicaid population could dilute risk.

Here’s where it gets even more complicated. Most states aggregate risk scores and then compare the performance of health plans in a region to each other. Failure to ensure Medicaid members receive appropriate care, including comprehensive annual exams by a primary care physician, can lead to severely diluted risk scores. New Medicaid beneficiaries are most likely to be individuals for whom health plans have no prior encounter data. This means there is no baseline for understanding how much it will cost to care for these members. Imagine an individual with multiple complications due to uncontrolled diabetes. If the health plan does not receive this data from care providers, it can’t accurately report this information to the state, which can result in sub-optimal funding to provide the care necessary for that beneficiary.

The same is true for members with previously diagnosed chronic conditions. Recapture of these conditions is critical to developing accurate population risk scores. If the diagnosis was reported in the prior year, but not the next, they will be omitted from the risk score calculation. Lastly, failure to accurately capture social determinants of health leads to systemic under-compensation, which disproportionately affects physicians and health plans serving these patients.  This was true before COVID-19, but it is even more critical now as the number of Medicaid beneficiaries has risen and continues to grow.

Ultimately, Medicaid plans must ensure their encounter data accurately reflects severity of illness and risk of mortality, of their covered population. Otherwise, they could find themselves spending far more than they actually receive in payments.

The solution: A PCP-centric, health-plan sponsored program.

The sooner Medicaid plans can accurately capture all chronic conditions and social determinants of health, the better. The most effective and streamlined way to do this is by leveraging primary care physicians (PCP) who have the ability to quickly establish long-lasting  relationships with these patients. PCPs are the providers with whom patients develop trust and, therefore, are likely to  see most frequently. Through frequent interactions and encounters with their PCPs, it is possible to address health problems in real-time and document social determinants which may be impacting their health and quality of life.  

When health plans sponsor PCP-centric risk adjustment programs, they are creating a win-win dynamic – ensuring that their members will receive high quality care in the most appropriate setting, and making sure they receive the correct amount to manage the patient.  Unlike other programs that work around physicians and cause abrasion, PCP-centric programs support physicians and their staff with the clinical support and technology to efficiently document all chronic conditions and code to the highest degree of specificity.  In addition, PCP-centric, health-plan sponsored programs often include services to assist with member engagement,  appointment scheduling and confirmation, patient education on the use of telehealth, and more. These wrap-around services are particularly helpful with transient populations for whom outreach requires more persistence. The more touch points patients have with their provider, the more likely that provider can capture data that leads to accurate risk adjustment and appropriate reimbursement. The best part? There’s no additional burden placed on physicians and staff. For the health plan, the benefits of these programs include higher quality data capture, improved outcomes, and lower costs due to greater patient engagement. Additionally, an enhanced bond between a PCP and his or her patients helps reduce the likelihood that a patient will switch health plans.    

Why PCP-Centric Risk Adjustment and Quality Programs Help Identify and Address Social Determinants of Health

The data might surprise you. Medical care accounts for only 10%-20% of the modifiable contributors to healthy outcomes. The other 80%-90% are referred to as social determinants of health (SDOH)—the conditions in the environments where people are born, grow, live, learn, work, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.  Examples of social determinants include housing and economic stability, literacy skills, access to nutritious food and physical activity opportunities, and more.

By identifying and addressing SDOH, physicians—especially primary care physicians (PCP)—can aid in removing the barriers and challenges that impede a person’s healthy lifestyle, wellbeing, and ability to achieve positive health outcomes. Identifying and documenting SDOH not only helps drive actions to improve these conditions, but also positively impacts performance in value-based payment models such as accountable care organizations, patient-centered medical homes, and Medicare Shared Savings programs that reward providers based on health outcomes—not volume.

In addition, PCPs’ efforts to address social determinants counts toward medical-decision making under fee-for-service payment models. As these payment models continue to evolve, it becomes easier to justify whole-person, patient-centered care.

Taking a PCP-centric approach

PCPs are uniquely positioned to capture and address social determinants because they already have trusted relationships with their patients and can engage them on a personal level. They are also at the center of clinical care, public health, behavioral health, and community-based resources.

Every touchpoint with a patient presents an opportunity to identify, capture, and address these critical factors that impact health outcomes.  Annual wellness visits, for example, are a perfect time to address SDOH.  Seizing these opportunities is paramount because a patient’s social or economic status can change over time. For example, opportunities for good health can be constrained after a recent job loss; or a patient may move into an area that is considered a food desert, making healthy food options highly impractical.

The challenge: Operational limitations

Most PCPs know that social determinants play an important role in health outcomes, yet finding ways to identify and impact these determinants is a challenge. Most patients aren’t necessarily forthcoming with information. Even once identified, carving out time to engage patients in meaningful conversations can be daunting. Another challenge is identifying and addressing implicit bias that can thwart efforts to address SDOH. In addition, physicians must be able to connect patients  community resources.

Given these obstacles, it’s not surprising that there are countless missed opportunities to address social determinants. This dynamic is exacerbated by PCP burnout and PCPs lacking the tools and resources to effectively address SDOH.

The solution: A health plan-sponsored, PCP-centric risk adjustment and quality programs

Over the last several years, health plans have shifted resources toward PCP-centric solutions, especially in the case of coding and quality programs. This represents an important trend for physicians, as legacy risk adjustment programs work around PCPs and prevent them from closing care gaps and addressing SDOH. Because PCPs have an existing and trusted relationship with their patients, such programs have much higher engagement than in-home risk assessments.

Another important development has centered around the recognition that technology alone doesn’t solve these problems. Infrastructure augmentation, especially support from licensed clinical consultants, is critical to helping busy PCPs develop a comprehensive view of the patient. This serves as a catalyst for an open discussion about possible social determinants of health that may be impacting their health and quality of life.

In addition, PCP-centric programs can offer guidance and support on establishing  a team-based approach to screen for social determinants. For example, onsite RNs, LPNs, or PAs can ask patients about their social determinants while checking vital signs and alert PCPs when a deeper conversation about social determinants is warranted. Receptionists can distribute SDOH screenings tools upon check-in. Everyone within the practice plays a role of driving engagement and results.

Training is also critical. PCPs who undergo training to address implicit bias will be better equipped to have conversations about SDOH. PCPs must also be able to deliver strong, personalized messages about preferred community resources and follow up with patients to ensure they are getting the help they need. Training the entire team on implicit bias, health equity, and cultural proficiency is also a good idea.

Conclusion

A health plan-sponsored program that supports physicians with tools, clinical resources and financial incentives enables PCPs to identify and address SDOH without adding operational burden. PCPs are empowered to treat each patient holistically to improve outcomes in a cost efficient manner. To learn more, visit https://vaticahealth.com/provider/.

Unlocking Value Based Care Performance With Improved Coding and Documentation

The transition to value-based care is underway, but many PCPs lack the tools, resources, and expertise to thrive in these new arrangements. For physicians, an essential element of success is being able to accurately assess and report a patient’s clinical needs so that value-based payments will align with the necessary care delivered to that individual. Unfortunately, diagnostic coding with appropriate specificity and quality reporting is labor-intensive and is predicated on a complex set of rules, which frequently become a stumbling block for practices.  This dynamic creates a powerful inertia, which can be overcome by understanding the ramifications of inaction and the availability of effective solutions.

Why is documentation so important?

Provider organizations—through their documentation—tell their patients’ stories using the ‘language’ of ICD-10-CM diagnosis codes. Robust documentation and coding provide a comprehensive view of the patient, driving better and more cost-effective care. If documentation is incomplete, patients may not get the necessary care and practices can incur significant shortfalls in revenue.  As a result, high quality coding and documentation is no longer just a good practice, but an indispensable element of value-based care success.  

 The Financial Impact of Accurate Documentation & Code Capture

The example below illustrates how no or partial coding by a physician can result in $15,000 difference in payment under the CMS-HCC model based on whether the provider captures these four diagnoses with maximum specificity: Type 2 diabetes mellitus with a manifestation of stage IV chronic kidney disease, long-term insulin use, and chronic obstructive pulmonary disease.

Improving Coding and Documentation Without Burdening Physicians

According to a 2021 national survey conducted by Medscape that included more than 12,000 physicians across 29 different specialties, 42% of physicians report feeling burned out.

Interestingly, 79% of physicians said this burnout started before the current COVID-19 pandemic with the majority (58%) citing ‘too many bureaucratic tasks’ as the number one reason.  This presents a challenging dilemma as business leaders for health systems and physician practices have to balance the reality of physician burnout with the necessity of improved documentation and coding.

Fortunately, there are solutions that drive improved financial and clinical performance without burdening physicians and their staff. Vatica Health is one example. Vatica takes a physician-centric perspective, focusing on minimizing the amount of time and effort required of physicians. Vatica uses a combination of powerful technology along with clinical and administrative resources dedicated to practices.  Organizations participating in Vatica’s program realize incremental revenue, better outcomes, increases in the utilization of preventive health encounters (e.g., Annual Wellness Visits), and improvement in overall performance in value-based care arrangements.

Learn how to maximize revenue and results for your organization

A New Paradigm In Risk Adjustment – A Shift From Collecting Codes to Impacting Care

Development of risk adjustment strategies is often complex and involves input from stakeholders across multiple cross-functional teams. Quality, finance, compliance, operations, and other teams are all stakeholders in the decision-making process. Managed care organizations strive to deploy effective, comprehensive risk adjustment solutions which requires taking into account a number of considerations: effectiveness, regulatory compliance, and patient and provider satisfaction.

When considering the various options available to health plans, there is an emerging trend to shift from retrospective and home assessments to PCP-centric prospective programs. There are a few reasons for this change. Given the established relationships patients have with their PCPs, prospective programs are often the most effective method for addressing gaps in care and ensuring alignment between medical record documentation and coding to the highest degree of specificity. Prospective programs permit real-time alerts of previously diagnosed conditions as well as those that are suspected. The ability to impact outcomes, at the point of care, is powerful.

In contrast, legacy models have very little impact on care and outcomes.  Retrospective review programs deploy teams of coders to review charts and capture codes after the patient encounter has occurred. This backward-looking approach is not only abrasive and disruptive to providers, it is also ineffective in terms of impact on quality of care and patient outcomes.

Home assessments, while prospective in nature, are abrasive and invasive to patients. They are performed by clinicians that typically do not have an existing relationship with patients and do not have access to the EMR where the most valuable clinical information is stored. Furthermore, continuity and coordination of care is often non-existent in that follow-up care is not guaranteed. In fact, a September 2020 report from the Office of Inspector General (OIG) expressed this key takeaway: “Billions in estimated risk-adjusted payments supported solely through HRAs [health risk assessments] raise concerns about the completeness of the payment data, validity of diagnoses on HRAs, and quality of care coordination for beneficiaries.”

The shift from antiquated programs that simply center around collecting codes to PCP-centric initiatives has been accelerated by certain actions and comments made by the Centers for Medicare and Medicaid Services (CMS). Beginning in 2017, CMS began to gradually revise its methodology for calculating beneficiary risk scores to increasingly rely on encounter data. By 2022, the expectation is that the Part C risk score would rely entirely on encounter data. The benefit of encounter data is that it validates the source of the data to ensure that it appropriately meets program requirements. Said differently, validation of treating providers, type, and place of service. These requirements are best addressed through the use of prospective risk adjustment programs.

CMS officials have also been critical of home assessments, previously stating the following: “There appears to be little evidence that beneficiaries’ primary care providers actually use the information collected in these assessments or that the care subsequently provided to beneficiaries is substantially changed or improved as a result of the assessments. Therefore, we continue to be concerned that in-home enrollee risk assessments primarily serve as a vehicle for collecting diagnoses for payment rather than serve as an effective vehicle to improve follow-up care and treatment for beneficiaries.”

In limited circumstances retrospective chart review and in-home assessment programs may be considered as part of an overall risk adjustment portfolio. However, such programs must be carefully and thoroughly evaluated and should only be utilized to address situations where an in-office prospective program is not a viable option.

A well-designed health plan-sponsored risk adjustment program should be easy to implement and very beneficial to PCPs. To do so requires a combination of powerful technology and comprehensive in-office support that seamlessly integrates with physician workflows. It also requires documentation and coding validation and provider education. When health plans and providers partner on risk adjustment and quality programs, great things happen: superior RAF yield, enhanced provider satisfaction that drives revenue and VBC performance, and better clinical outcomes.

Shifting from retrospective to prospective risk adjustment: Why health plans need to partner directly with primary care physicians

Health plans across the country have begun to realize the superior value of prospective risk adjustment programs, and rightfully so. These programs permit impact at the point of care as opposed to retrospective programs which are essentially chart reviews. Prospective risk adjustment programs permit timely, effective interventions including the presentation of suspected gaps in care and the opportunity to achieve thorough and accurate documentation, which supports conditions coded to the highest degree of specificity. Conversely, backward looking retrospective risk adjustment programs limit effectiveness to code capture. A risk adjustment program which only consists of retrospective chart reviews is myopic in that it does not support the outcomes-driven, population health management focus which is now inherent in most payment models.

You may be asking yourself which one is the optimal approach to risk adjustment?  The answer: an effective mix of all of the above, but most importantly, primary care physician (PCP) engagement. A winning risk adjustment strategy is heavily weighted towards prospective interventions and programs but may need to include some retrospective elements to meet physicians’ needs. Prospective programs, while more operationally complex to deliver, are preferred because the ability to impact behavior, at the point of care, is powerful and 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 your member 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 which provides clinical and administrative support, education, and performance management in a timely manner.

The challenge: Finding a prospective risk adjustment program that actually 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 at the time of the encounter. Furthermore, support staff who provide insights on performance and drive physician engagement, are critical to success. 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 also 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 all 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. It also provides 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:

  1. Our licensed registered nurses and administrative staff are dedicated to providing the absolutely best experience for PCPs and their office staff.
  2.  Our attention to documentation and coding validation (Vatica’s Quality Improvement process) improves accuracy and reduces compliance risk.
  3. Vatica’s clinical and administrative staff work closely with each practice to develop a custom workflow and process until we achieve the ideal state that yields the most results with the least amount of effort for the physicians.

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 https://vaticahealth.com/.

Documentation, coding, and revenue: What every physician needs to know about HCCs and risk adjustment

Every patient has a story. The question is, are you—as the provider—telling the most important aspects of it, or are you missing critical details? We’re talking about the details that affect the patient’s health status and predict the resources required to care for them—two pieces of information that play a critical role in risk-adjusted payment models. Here are five questions and answers to consider.

Why does provider documentation matter for risk adjustment?

The provider—through their documentation—tells the patient’s story using the ‘language’ of ICD-10-CM diagnosis codes. Together, these codes create a narrative that includes important diagnostic information. When combined with demographic data and other details, the patient’s health status becomes clearer. Without this narrative, the story is disjointed, confusing, or lost completely. Health plans, CMS, and other treating providers can’t connect the dots when there are only a few dots to connect, or worse yet, a blank page.

If your documentation doesn’t support the ICD-10-CM codes you’ve assigned—or you omit certain codes because no documentation exists—your revenue under value-based contracts could suffer. 

Why does coding matter for risk adjustment?

If your coded data indicates subpar performance or that you haven’t met certain performance thresholds, you could be missing out on revenue. Inadequate coding (i.e., missing codes or lack of specificity) also often leads to time-consuming onerous retrospective chart retrieval and reviews as well as compliance risks.

For patients, lack of appropriate ICD-10-CM diagnosis codes can result in poor coordination of care. This is true under all payment models—not just risk-adjusted ones. That’s because documentation and coding are the primary means of communication between care teams. In addition, patients may be omitted from beneficial care management, disease intervention, and other wellness programs if the coded data associated with their records is inaccurate or incomplete. Strong documentation, combined with appropriate ICD-10-CM coding, provides a comprehensive view of the patient. This ultimately helps control the cost of care.

For the purposes of this article, we’ll focus on the Centers for Medicare & Medicaid Services’ (CMS) risk adjustment model.

Not every ICD-10-CM diagnosis code affects risk adjustment under the CMS model. That’s because this payment model excludes diagnoses that are vague/nonspecific (e.g., symptoms), discretionary in medical treatment or coding (e.g., osteoarthritis), not medically significant (e.g., muscle strain), or transitory/definitively treated (e.g., appendicitis).

In the CMS model, those conditions that do affect risk adjustment (which are roughly 10,000 out of 70,000+ diagnoses) are grouped into approximately 1,300 diagnostic groups (DXG) that are then aggregated into condition categories (CC). CCs are related clinically and with respect to cost. Hierarchies are imposed among related condition categories. This mean that a patient is coded for only the most severe manifestation among related diseases. Hence the term ‘hierarchical condition categories’ or HCC. HCCs accumulate among unrelated diseases, and the model accounts for interactions between certain conditions for which costs can be exacerbated, (e.g., diabetes and congestive heart failure).

HCCs paint a complete picture of each beneficiary’s acuity to ensure appropriate and accurate reimbursements, effectively managing costs for high-risk members and delivering high-quality care.

Check out the example below that illustrates a $15,000 difference in payment under the CMS-HCC model based on whether the provider captures these four diagnoses with maximum specificity: Type 2 diabetes mellitus with a manifestation of stage IV chronic kidney disease, long-term insulin use, and chronic obstructive pulmonary disease.

Impact of Accurate Documentation & Code Capture

What are some documentation and coding best practices for busy physicians?

Consider these tips:

  1. Perform a valid face-to-face encounter. As a result of the ongoing impact of the COVID-19 pandemic, synchronous audio and video appointments are, for the time being, acceptable for the purposes of risk adjustment.  
  2. Use the ‘MEAT’ acronym as a best practice guide for documentation:
    • Monitor: Document signs and symptoms as well as any disease progression or regression. Don’t forget to evaluate chronic conditions at least once annually. Also, avoid use of ‘history of’ if the condition remains active.
    • Evaluate: For example, document test results, medication effectiveness, and response to treatment.
    • Assess: For example document any of the following, when relevant: Ordering of tests, discussion, reviewing records, and counseling. Copying and pasting the entire problem list into the assessment and plan is unacceptable.
    • Treat: For example, document any medications ordered, therapies, or other modalities.
  3. Link diagnoses with manifestations using a linking statement or other document.
  4. Add all diagnosed conditions to both the chronic problem list and assessment.
  5. Submit all relevant ICD-10 diagnosis codes, including Z codes.
  6. Ensure the medical record includes a legible signature with name, date, and credentials.
  7. Ensure the diagnoses being billed match the actual medical record documentation.
  8. Always remember the golden rule of medical record documentation: If it’s not documented, it didn’t happen.

How can physicians minimize compliance risk and benefit from risk-adjustment programs?

One way to minimize risk and to actually increase revenue is to participate in a health plan-sponsored risk adjustment program that helps providers tell the patient’s story as accurately and completely as possible—all while minimizing the impact on staff and internal processes.

Leverage health plan-sponsored programs to combat physician burnout

The statistic is striking: 42% of physicians report feeling burned out. That’s according to a 2021 national survey conducted by Medscape that included more than 12,000 physicians across 29 different specialties. Interestingly, 79% of physicians said this burnout started before the current COVID-19 pandemic with the majority (58%) citing ‘too many bureaucratic tasks’ as the number one reason. While it is too early to measure directly, we anticipate that the COVID-19 pandemic will exacerbate this critical problem, further amplifying the mental, physical, emotional, and financial strain physicians were previously experiencing.

Why is physician burnout dangerous?

First, physician burnout is associated with higher rates of major medical errors. Physicians who are burned out may be less likely to identify and address all of a patient’s chronic conditions, thereby missing out on opportunities to improve outcomes. In addition, it can potentially lead to access challenges as physicians who experience burnout ultimately reduce time spent on direct patient care. The personal effects of physician burnout are also concerning: Increased risk for cardiovascular disease and shorter life expectancy, problematic alcohol use, broken relationships, depression, and suicide. Finally, it can negatively affect patient satisfaction.

The challenge: Increasing administrative burden, inadequate support

There’s no denying the fact that bureaucratic tasks, such as increasing documentation requirements, fuel physician burnout. According to a recent survey, clinical process design and the clinical structure, both of which are highly impacted by EHRs, contribute to approximately 40% of clinician stress. EHR complexity driven by increasingly detailed and nuanced data requirements, creates stress and distracts from patient care.

Healthcare policy makers and regulators continue to mandate even more documentation to demonstrate compliance with laws and standards. The advent of value-based payment models necessitates incremental documentation and workflows to achieve performance goals. Additionally, significant administrative efforts are often required to obtain prior approvals for certain treatments and prescription medications. These tasks are time-consuming contribute to physician burnout. According to a physician survey conducted by the National Institutes of Health (NIH), on average, 24% of working hours were spent on administrative duties.

The solution: Simplicity, support, value, and flexibility

For an immediate impact, health systems and individual physicians can turn to health plan-sponsored programs that improve both clinical and financial performance. Some of these programs supply free clinical and administrative resources and assist with performance in value-based arrangements to yield financial incentives.

Vatica Health is one example. Vatica takes a physician-centric perspective, meaning the physician and clinical workflow are the central focal point of the program. With a keen focus on process simplification and efficiency, Vatica Health focuses on minimizing the amount of time and effort required of physicians. All aspects of the physician experience are designed to yield maximum value with the least amount of effort.

Vatica assigns licensed clinical nurses 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. The result is that the physician is presented with a streamlined and prioritized list of conditions for review that they can complete at their convenience. Organizations participating in Vatica’s program realize incremental revenue, increases in the utilization of preventive health encounters (e.g., Annual Wellness Visits), and improvement in overall performance in value-based care arrangements.

There are also other ways to address the troubling dynamic of physician burnout and there are many resources currently available online. For example, the Well-Being Playbook 2.0—provided by the American Hospital Association (AHA) and AHA Physician Alliance, includes links to various webinars, podcasts, and case studies. The American Medical Association also provides a variety of articles that can help physicians experiencing burnout.

Taking the first step toward addressing physician burnout can have a long-lasting impact that benefits the entire healthcare ecosystem. Vatica will continue to do its part to raise awareness of this problem and lends its support to the collective, coordinated actions being taken across the industry to address the underlying causes of burnout.

About Vatica Health

Founded in 2011 as the first preventive services technology solution designed specifically for physicians, by physicians, Vatica Health remains a pioneer in physician-centric technology and support solutions that directly improve clinical outcomes, efficiency, and financial performance. Vatica Health deploys licensed, clinical nurses (on-site and virtually) that serve as extensions of your team at no cost to the practice. Practices retain all fee-for-service payments generated from the encounters, and they also receive incremental incentives for completion of the signed Vatica encounter.

The best part?

It’s a health-plan sponsored initiative. That means it’s completely free for practices to participate.

As practices continue to seek point-of-care solutions to better tell each patient’s story and improve outcomes, 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/.

Don’t Let Chronic Conditions Be An Afterthought When Using Telehealth

If there’s one silver lining to COVID-19, it’s the rapid adoption of telehealth that enables physicians to take care of patients while also limiting the spread of the virus. The Centers for Medicare & Medicaid Services (CMS) even expanded its list of telehealth-covered services during the public health emergency, allowing physicians to render certain preventive care, evaluation and management of conditions, and other services without requiring patients to come into the office.

One unintended consequence?

When using telehealth, physicians may be less likely to capture chronic conditions that affect risk-adjusted payments. Why? Lack of time, new workflows, and a variety of other causes.

This is detrimental to risk adjustment for two reasons. First, it can affect the quality of patient care—particularly during care transition when documentation becomes critical. Patients who benefit the most from remote care during the pandemic are often those that tend to have multiple chronic conditions. However, it is still critically important to capture patient complexity through appropriate documentation and coding.

Second, it negatively affects physician reimbursement under capitated or risk-based payment models. When documentation and medical codes don’t paint an accurate picture of patient severity, physicians receive fewer resources for those patients who are inappropriately perceived to be less clinically complex. The same is true for government-sponsored payers.

The good news is that a comprehensive risk adjustment and quality solution can help by taking some of the administrative burden off physicians so they can concentrate on providing high-quality patient care. The first step, though, is to address common myths about telehealth in a value-based care environment.

Below, we address three myths about telehealth as well as strategies to help physicians depict a more accurate picture of patient severity, acuity, or complexity when using this technology.

Myth: ‘I only have time to focus on the acute problem during a telehealth visit. I can’t possibly capture chronic conditions as well.’

Truth: Although physicians are often pressed for time during an encounter, it only takes a few seconds to check in with the patient about the status of their chronic conditions. It can be as simple as asking the patient whether they are taking their medications as prescribed for each chronic condition.

Physicians can also participate in health-plan sponsored risk adjustment and quality of care initiatives that can help them report the quality of care they normally provide. These initiatives provide clinical and administrative support to ensure accurate and comprehensive documentation and coding so physicians can spend more time on direct patient care.

Myth: ‘It’s too difficult to provide an Annual Wellness Visit (AWV) via telehealth. Care quality will suffer.’

Truth: In a recent survey, 49% of physicians cite ‘diminished quality of care’ as a top reason why they haven’t provided a virtual consultation. However, decreased care quality with telehealth isn’t yet proven, and for some patients, it may be the only way to get them in the door—albeit a virtual one. The AWV is an opportune time to capture and manage chronic conditions. During COVID-19, this is more important than ever as these diagnoses may place patients at higher risk for developing complications if they were to contract the virus.

Deferred care during COVID-19 has become all too common. Four in 10 U.S. adults reported avoiding medical care because of concerns related to COVID-19. One recent survey found that patients with chronic conditions are less engaged and that fewer patients are seeking preventive care. This means chronic conditions could go undetected and unmanaged for months at a time. There may also be missed opportunities for routine vaccinations or early detection of new conditions, both of which could result in poor patient outcomes.

Health-plan sponsored risk adjustment and quality of care initiatives help physicians efficiently provide critical preventive care services without jeopardizing the time spent on patient care.

Myth: ‘Telehealth won’t help me succeed under value-based payment models. It’s too risky to embrace this new technology knowing that my revenue could suffer.’

Truth: Telehealth is in no way a barrier to value-based care. In fact, it enhances value by increasing patient access and providing physicians the platform to capture and address chronic conditions.

In fact, more than 75% of clinicians responding to a recent survey said telehealth enabled them to provide quality care for an array of conditions and situations: COVID-19, acute care, chronic disease management, hospital follow-up, care coordination, preventative care, and mental/behavioral health. Additionally 60% reported that telehealth has improved the health of their patients, and the majority would like to continue to offer telehealth visits following the pandemic.

With the help of health-plan sponsored clinical and administrative support, physicians can use telehealth to improve quality care reporting while also supporting revenue integrity through accurate and complete data capture.

How Vatica Supports Providers

Physicians providing care via telehealth need extra support. Our team deploys on-site or virtual clinical consultants with backgrounds as RNs, LPNs, or PAs that serve as extensions of your team at no cost to the practice to help surface important items to address with paitents in a virtual or in-office setting, such as chronic condition management. Practices retain all fee-for-service payments generated from patient encounters and also receive incentives for coding visits.

The best part? It’s a health-plan sponsored initiative. That means it’s completely free for practices to participate. Learn more about how Vatica can help your practice.