Category: Value-Based Care

Key metrics for value-based care

By Vatica Health | November 18, 2024 | Value-Based Care

Value-based care (VBC) is designed to incentivize providers to improve outcomes in a cost-efficient manner. In other words, payment and quality of care are inextricably linked. Understanding how VBC payments and penalties are calculated can help you better prepare and operationalize your VBC action plan—no matter where you are on the adoption timeline. In this article, we discuss how quality and cost intersect to help providers optimize practice performance in a VBC world.

Key metric 1: Quality

Two of the most critical components of any VBC arrangement are risk adjustment and quality reporting. This is because success in VBC depends on accurately assessing the clinical needs of your population and reporting these needs so that your payments will be sufficient to deliver appropriate care.

The challenge is that risk adjustment and quality reporting are labor-intensive and predicated on a complex set of rules, which frequently become a stumbling block for practices. Because of the complex payment methodology associated with risk adjustment, appropriate coding specificity is needed to accurately report chronic conditions. Without this specificity, plans and PCPs may end up with artificially low patient risk scores, resulting in insufficient funds to deliver adequate levels of care.

Similarly, PCPs must adhere to the reporting standards for quality gap closures. Deviation can result in sub-standard outcomes. For practices that lack specialized coding and quality technology, as well as properly trained staff, keeping up with these activities is a significant challenge.

Other measures relate to preventive health, such as ordering mammograms or colonoscopies. These routine activities are critical metrics for the health plan. Whether they’re process, outcome or preventive health metrics, it’s important that you understand all measures in your VBC programs and how they impact your financial performance.

Whether they’re process, outcome or preventive health metrics, it’s important that you understand all measures in your VBC programs and how they impact your financial performance.

Data for some measures come from standardized patient surveys such as the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) or the Health Outcomes Survey (HOS). Health plans use these surveys to understand how patients feel about access to care, their perception of the quality of care at their physician’s office, and how they feel about their overall health. The questions are not related to the patient’s health insurance benefits; instead, they correspond to the care they receive from their physicians. It’s obvious how physicians influence the responses and why health plans want to partner with physicians to improve scores.

How providers are compensated

Quality of care compensation typically will be paid on a per-patient basis. For example, every time a hemoglobin A1C is ordered or you get a patient’s LDL below 100, the health plan will make a certain payment, usually on a quarterly or monthly basis.

Other VBC models involve a unique set of quality measures. Five or 10 may be needed to achieve a minimum threshold. Or seven out of 10 quality measures are needed to earn a bonus. This is typically the way quality measures are used in a model. A minimum is needed to qualify for a bonus. The bonus dollars associated with achieving a result higher than the minimum can be paid out on a per-patient basis or on the population of patients attributed to a given provider.

Key metric 2: Costs

Costs can be measured in several different ways:

  • Medical loss ratio (MLR)
  • Medical expense ratio (MER)
  • Medical claims ratio (MCR)

All these methods involve taking medical expenses for your patients and dividing them by the premium that they’ve received for that patient. This is the risk-adjusted premium. Another way that it’s measured is by looking at the absolute cost per member—often expressed as per member per month (PMPM). Health plans take the claims expense for attributed patients and divide it by the number of patients you have. This produces a PMPM, regardless of what the measure is.

A common model uses hospital admissions, readmissions and ER visits. Those are big drivers of cost for a health plan. Sometimes, instead of using medical expense ratios or claims PMPM, plans will drive a penalty or bonus program from some of these key utilization metrics. Sometimes, those metrics will be expressed per 1,000 patients so plans can normalize that data. If your practice has 500 patients with a health plan, and there are 10 hospital admissions that month, you might see the metric described as “20 admits per 1,000.” The health plan is creating a standard across all practices so that they can compare results among practices and benchmark how each is doing. Note that some of these programs are purely based on quality, without any cost component.

A study by analysts at Harvard and Humana found Medicare Advantage members treated by doctors in advanced VBC models had 5.6% fewer hospitalizations and 13.4% fewer emergency department visits.

VBC cost vs. quality metrics

It’s important to understand both the quality and cost metrics and any relationship between them. In some cases, PCPs may need to achieve a minimum quality standard before earning any quality or cost bonus. In other cases, there are no minimum thresholds for quality; PCPs are paid as certain benchmarks are met. It matters because more and more of a PCP’s compensation is going to be tied to VBC. CMS expects all Medicare payments to go through value-based models by 2030. Those payments or penalties are calculated by using these metrics. It’s critical to understand what each of the metrics is, how the penalties or bonuses are calculated, and how you are doing today relative to the program’s maximum penalties or bonuses.

Operationalize your VBC plan

Download the full VBC white paper to learn the key action items to develop and implement a VBC program and the steps needed to improve an existing one.

Benefits of payer-sponsored risk adjustment and quality programs 

By Vatica Health | August 14, 2024 | Provider, Risk Adjustment, Value-Based Care

As provider groups struggle with increasing demands and staffing challenges, two physician leaders presented solutions to both. During a webinar sponsored by the RISE Association, Richard Charles, MD, chief medical officer of General Physician, PC, and Jagraj Rai, MD, president of Guthrie Lourdes Medical Group, spoke about payer-sponsored programs that have helped both their patients and their practice.  

You can watch the webinar here or read on for highlights. 

Dr. Charles noted that he and his colleagues had criteria for an in-office program to support risk adjustment and quality requests from payers. It had to be quick and easy for physicians and integrate with their current workflow. It needed to help the physician before and after the visit, with incentives for the treating PCP. 

According to Dr. Charles, a payer-sponsored solution from Vatica helped his group identify the true burden of illness for their patients to accurately stratify them and deliver appropriate care. Vatica’s pre-visit notification identified gaps in care to help the practice improve HEDIS scores as shown in the graph. General Physician also increased risk score accuracy by about 10% per patient. 

Vatica gap closure rate
Compared to 4-star rating; claims paid through 1/31/23

More accurate coding and documentation, along with the incentive offered by the payer, allowed the practice to add support services such as care management and enhanced pharmacy programs. Both are valuable resources to help PCPs address conditions and close care gaps, resulting in increased patient satisfaction, improved outcomes and additional practice revenue.  

Dr. Charles shared tips for the webinar’s payer audience. He recommended sharing data with PCPs so they can understand how coding and documentation affects the practice’s financial performance. Provide a payer-agnostic solution that’s easy and efficient. General Physician’s average time to complete a review is only 2 minutes/patient.  

Dr. Rai’s practice has similar requirements for a risk adjustment program. He stressed the importance of sharing incentives with treating PCPs. While it took six months of work with several departments in the practice, he found that passing along the incentive to PCPs has a major impact. In the first five months of 2024, the practice has more than doubled the number of completed visits during the same period in 2023. 

Dr. Rai lauded the pre-visit summary that lists conditions to address, open care caps and prescriptions to reconcile. The ideal time to address those issues is when the PCP is face to face with the patient. The summary saves the PCP significant time, requiring less chart review. 

“I continue to marvel about our team at Vatica because they are there at every step,” he adds. “They provide education. Sometimes our clinicians may forget to complete the chart. The Vatica team reminds them. We may need a little more education, and they’re always there.”  

Moderator Whitney Chernoff, senior VP of client engagement at Vatica Health, summarized the key takeaways. She noted that tech-only solutions often create more work for the PCP. Having trained clinicians in the process helps ensure that PCPs are looking at the most accurate data. All three speakers highlighted the importance of sharing incentives with treating providers and hiring needed staff with the funds. In the end, addressing chronic conditions and closing care gaps makes patients healthier and supports lower overall healthcare spend, which is everyone’s goal.

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/.   

Four observations from the frontlines regarding our recent VBC survey 

By Vatica Health | March 1, 2024 | Value-Based Care

By Whitney Chernoff, senior vice president for client engagement and growth operations, Vatica Health

Vatica Health recently conducted an independent survey of over 100 managers and executives of primary care practices and health systems to learn what’s working for them and what still needs to be addressed to facilitate a smooth transition to value-based care. 

As senior vice president for client engagement and growth operations at Vatica, I routinely meet with physicians and provider group leaders working through this transition. I would like to share some observations based on my experience working with those on the front lines of this exciting and challenging industry-wide transformation. 

1. Champions wanted 

While the survey revealed that the majority of respondents believe that VBC will lead to improved patient outcomes, many practices lag behind in implementation. The number one reason? Lack of staff. 

I can’t disagree with that; adding staff is certainly important. But a more important first step is finding a champion. Someone you can rely on to make sense of everything, keep up with changes and government regulations, identify the right initiatives to focus on, push your VBC initiatives forward, help you navigate around roadblocks, assess the financial impact and measure success. 

Ideally, this person should come from within your organization. Their knowledge of your people and processes will be invaluable when determining how best to navigate moving along the VBC continuum. Also, in today’s healthcare labor market, it can be difficult to find and hire outside experts. Once you find your champion, resources such as Vatica can provide them with expert support at no cost to your organization. 

2. The time is now 

CMS has a goal for 100% of Original Medicare beneficiaries to be in a care relationship with a VBC payment model by 2030. In addition, CMS recently announced the gradual transition to version 28 (V28) of the CMS-HCC model, which will be phased in and fully implemented by 2025. The changes from transitioning to the V28 model will make it more challenging to produce highly compliant revenue via risk adjustment. This could lead to a negative impact on your financial performance in the absence of a comprehensive, well-managed solution. While these new regulatory changes take hold, it is important for health plans to offer the right solutions to allow PCPs to continue or begin their transition to VBC. The sooner you begin, the sooner you can gain the advantages of VBC: improved patient care, reduced cost of care and better care coordination. 

3. Turnovers: bad for football, worse for your practice 

Caregiver turnover is a very real problem across the industry. And that’s especially the case with PCPs. Losing physicians means losing expertise and—potentially—patients. It can also mean losing continuity and creating greater strain for the PCPs who remain in place. Success in a VBC world means practices should do whatever they can to retain their most important and experienced staff. Like what? 

  • Implement strategies, policies or technologies that can improve everyone’s work-life balance. Carving out time for administrative tasks, which are often a necessary evil, can help ensure everyone works more efficiently and gets home at a reasonable hour. 
  • Explore ways to improve compensation models and incentive programs so more staff have a stake in the overall success of the organization. 
  • Provide pathways for continuing education. This not only engages employees; it also ensures your organization can grow and keep up with changes. 

By preventing brain drain, you reduce the cost of recruitment, onboarding and lost productivity and help ensure any VBC initiatives you implement will survive, evolve and thrive. 

4. Inertia is enemy #1 

One of the most common things I hear from providers is, “I’m too overwhelmed to think about how to not be overwhelmed.” But transitioning to VBC payment models can result in so many dividends for you and your patients; you HAVE to find the time. I understand how busy we all are. But if you can find a little time each week to meet with staff and outline a plan to move forward, you’ll find it gets easier—and more profitable. Consider outside resources to help. A vendor such as Vatica can reduce the administrative burden of coding and documentation for your providers while identifying open care gaps and ensuring accuracy and compliance. If you select the right resources, you can speed your time to adoption and get some time back in your day for yourself and everyone else at your practice.  

Read full survey here.

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.

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/. 

Understanding the financial impact of the RADV final rule

By Vatica Health | June 27, 2023 | Compliance, Risk Adjustment, Value-Based Care

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

On January 30, 2023, the Centers for Medicare and Medicaid Services (CMS) released the final rule on Risk Adjustment Data Validation (Final Rule). The rule includes several changes. The most consequential is the new RADV audit methodology used by CMS to address overpayments to Medicare Advantage plans based on the submission of unsupported risk-adjusting diagnosis codes. The final rule authorizes CMS to extrapolate RADV audit findings beginning with payment year 2018 (not 2011-2017 as originally proposed). The industry views the use of extrapolation as especially punitive because in the Final Rule, CMS also rejected the application of the FFS Adjuster to account for an allowable threshold of errors related to provider medical record documentation. 

The financial implications of the Final Rule are significant. Prior to the Final Rule, repayment obligations were limited to errors found in a sample of a few hundred records. Under the Final Rule, that error would be applied across a broader population of the Medicare Advantage Organization’s contract. Recently, the Office of Inspector General (OIG) audited diagnosis codes submitted by a health plan for approximately 200 members. The OIG found a high percentage of codes were not supported in the medical record. This resulted in $480,000 in overpayments, though the health plan disputes the findings. The new extrapolation methodology would not apply in this instance because the alleged overpayments occurred in 2015 and 2016. If extrapolation did apply – instead of approximately $480,000 – the overpayments would result in an exponentially higher repayment amount of approximately $27 million.  

What can we tell about the extrapolation method if we consider these figures with membership data of the MAO contract in question? Straight-line math indicates that for each dollar of overpayment identified in the RADV sample, there’s an additional $55 of overpayment under extrapolation.   

We should be careful applying these assumptions to other populations, especially considering the highly targeted nature of this audit in question. The OIG targeted HCCs representing $695,000 in payments. Based on their review, 69% of those dollars could not be supported by documentation. However, what seems to be apparent is that an extrapolation methodology has been determined and, when applied, material payment modifications can result.  

Conclusion 

The financial implications for RADV error rates will no longer be limited in materiality to small sample populations. Extrapolated penalties will be significant and potentially catastrophic to payers as well as at-risk providers. CMS estimates that from 2023 through 2032, the agency will recover an extra $4.7 billion from insurers via the new audit methodology. Given this, at-risk entities should evaluate their current risk adjustment programs and focus on solutions that produce accurate and compliant yield. Programs should include a robust quality improvement process to validate coding and documentation prior to submission. Legacy programs, such as retrospective chart reviews and in-home assessments, should be augmented with a provider-centric approach. Leading plans recognize PCPs as partners in coding accuracy and complete documentation to mitigate the risks associated with the Final Rule and the overall increased scrutiny on risk adjustment compliance. 

How Vatica Health can help 

Vatica Health is the #1 ranked provider-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 facilitates the closure of care gaps, 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. Vatica Health is trusted by many of the leading health plans and thousands of providers nationwide. For more information, visit vaticahealth.com. 

Advancing health equity with an index

By Vatica Health | May 17, 2023 | Compliance, Risk Adjustment, Value-Based Care

By Jamie Jenkins, PhD, MBA, CPHQ, quality of care director, Vatica Health

Advancing health equity is the first pillar of Centers of the Medicare and Medicaid Services’ (CMS) strategic plan. The Biden-Harris administration has committed to promoting racial equity through government programs focused on underserved communities. To that end, CMS’ 2023 Medicare Advantage Quality Rule released in April 2023 finalized the new Health Equity Index (HEI) for measuring how well Medicare Advantage and Part D plans manage at-risk populations.

What is the index?

The HEI will drive health plans to fully engage and take steps to address the social determinants of health (SDOH) which negatively impact health quality and outcomes.

CMS has defined HEI as an index or single score that encapsulates contract performance for plans whose enrollees face specific social risk factors. The index will use existing data to limit the number of members who are identified as vulnerable. Stratified plan members who receive a low-income subsidy, those with a disability and those who are dual eligible will be in the scoring pool. Health plans should begin analyzing their data and designing programs to support these members.

What are the goals?

The initial goal of HEI is to increase transparency and understanding of plan performance in addressing the needs of members facing social risks. First, the index will be used to identify populations with the greatest needs so that targeted assistance may be granted to communities and providers serving those communities.

Second, the HEI will allow beneficiaries to select plans based on performance on health equity measures. Third, the index would become part of the Star Ratings program which is used to incentivize health plans with bonuses to improve performance. Prior to this new approach, there were no targeted incentives to address disparities among a plan’s enrollees. The HEI would be an added layer encouraging investment in health equity initiatives for Part C and Part D Star Ratings.

Call to action

Health plans have time to begin examining their approaches. The baseline data for the initial calculation of the HEI will be based on calendar years 2024 and 2025. The performance reward will be included in the 2027 Star ratings year.

Health plans can start their data analysis by comparing contracts to one another. For example, plans may consider the variances between those populations receiving a low-income subsidy versus those who are not. Comparing groups will allow plans to determine where support is most needed.

Data collection is key

One of the five priorities outlined by CMS in the framework is expanding the collection and analysis of standardized reporting. The agency seeks comprehensive, interoperable and standardized individual-level demographic and SDOH data. With an increased understanding of members’ needs, CMS plans to leverage quality improvement and other tools to ensure all members have access to equitable care and coverage.  

CMS notes that developments in health information technology have improved the ability to collect health data and measure disparities at the provider level. Vatica Health, for example, provides technology and dedicated clinicians to enable providers to efficiently capture more accurate and complete diagnostic coding and documentation both for risk adjustment and improving quality of care. Vatica’s team of nurses curates relevant clinical data from various sources and creates a pre-encounter provider notification to enable more comprehensive encounters. The notification lists medical conditions, unreconciled medications and targeted quality measures to help the provider efficiently address the patient’s needs during the visit. As part of this process, Vatica can collect race and ethnicity information as well, using CDC specifications.

In summary, this framework is the first step in CMS’ drive toward improving health equity. “Our goals for Medicare Advantage mirror our vision for CMS’ programs as a whole, which is to advance health equity; drive comprehensive, person-centered care; and promote affordability and the sustainability of the Medicare program,” said CMS Administrator Chiquita Brooks-LaSure.

How Vatica Health can help

If you are considering a partner to help improve your Star quality measure performance, consider Vatica Health. We are the #1 rated 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 facilitates the closure of care gaps 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.