Category: Value-Based Care

Bridging the Quality Gap through Race and Ethnicity Reporting

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

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

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

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

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

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

National Committee for Quality Assurance Strategies  

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

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

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

Improving Data Collection 

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

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

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

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

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

Conclusion 

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

About Vatica Health  

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

Closing the Gap on Missed Medical Care

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

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

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

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

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

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

How Vatica Health can help

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

Why a “Technology-Only” Approach Will Not Drive Value-Based Care Performance

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

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

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

Value-based care requires a comprehensive solution

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

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

Evaluating possible solutions

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

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

How Vatica Health can help

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

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

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

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

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

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

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

The added challenge of physician burnout

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

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

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

Consequences of physician burnout

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

How to foster physician engagement in capturing risk

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Healthcare organizations should assist physicians in this effort by providing a framework and support for capturing SDoH. Successful SDoH-focused programs include training clinical staff, providing access to local resources, developing workflows and promoting standard practices that help simplify the risk-adjustment process, including allocating time during patient encounters for these critical conversations.

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

A necessary charge

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

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

Why providers face an increased challenge in understanding patient risk

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

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

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

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

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

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

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

The Evolution of Risk Adjustment

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

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

The Challenge Around RADV Audits

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

The Problem with Retrospective Chart Reviews

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

What I Learned Firsthand

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

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

What Comes Next

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

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

How to Close Care Gaps for Patients With SDOH

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

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

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

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

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

How health plan-sponsored programs can help

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

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

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

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

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

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

10 Year-End Activities to Optimize Performance in Value-Based Care

2021 has been a challenging year for primary care physicians nationwide. They’ve risen to the challenge by remaining committed to providing value-based patient care during times of intense operational transformation and financial uncertainty. However, it hasn’t been without sacrifice. Sixty-six percent of primary care physicians say they often experience feelings of burnout. This isn’t surprising given the risks associated with COVID-19 exposure as well as the significant burden of non-clinical work that requires their time and attention. Internists, for example, spend nearly 20 hours per week on paperwork and administrative tasks. Nearly a quarter of physicians (23%) say the most challenging part of their job is navigating ever-changing managed care and regulatory compliance requirements. The silver lining is that COVID-19 cases are declining and there are solutions to help you improve clinical and financial performance.

With only a couple of months remaining in 2021, there are several steps you can take to ensure that your practice meets all performance targets and that your patients receive the highest quality of care. The good news is that most of these actions are often supported by payer-sponsored risk adjustment and quality programs that provide vital clinical and administrative support to practices. This support helps providers close care gaps, enhance coding and documentation, identify and assess social determinants, and perform patient outreach. To enhance performance under value-based care contracts, consider these 10 tips:

1. Review 2021 performance reports from payers. These reports are a treasure trove of information and identify opportunities for improvement. Common examples include patients without primary care office visits, patients for whom chronic conditions were coded in 2020 but not recaptured in 2021, patients with incomplete preventive screenings, and patients with open gaps in care. Gather internal resources and put action plans in place.

Keep in mind that data latency may result in delayed reporting. Consequently, best practice is to compare external reports with your patients’ medical records for confirmation. Your practice’s EMR may include information that has not yet been reported to managed care plans. This information may impact your performance in value-based care programs. Perform a thorough reconciliation of all data sources to ensure consistency, alignment, and accurate performance reporting for all patients.

2. Ensure all eligible patients have completed an annual preventive care office visit. Schedule annual wellness visits (AWV) and other preventive care visit types for eligible patients. These visits provide opportunities for each patient to complete their personal prevention plan and Health Risk Assessment. Annual physical exams allow physicians to address care gaps as well as proactively identify potential chronic conditions. Check patients’ records when they present for a sick visit and schedule applicable preventive visits. For patients who have not visited the office, proactive patient outreach signals that you care about their well-being and that your office is there to help. Remind them they’re due for a visit and assist with scheduling. These actions foster trust and build stronger patient-physician relationships.

3. Follow up with patients who miss scheduled appointments. Consider whether any of your patients are missing appointments or not accessing routine care due to socioeconomic barriers?

Social determinants have a significant impact on health outcomes. As such, it is important to proactively reach out to vulnerable patients and address those barriers? The American Academy of Family Physicians provides some helpful advice.

4. Follow up with patients who were referred for preventive screening but did not comply. Patients’ needs and challenges vary. While some may have forgotten about the recommended screening, others may be experiencing difficulty scheduling the appointment due to long call wait times or limited appointment availability. Others may have unanswered questions that prevent them from taking action. The best practice is to call patients directly, assess the barrier, and determine what the practice can do to help. Oftentimes, a reminder call is all that’s needed.

5. ‘Close the loop’ with specialists. Communication between primary care physicians and specialists is important to avoid fragmented care delivery and ensure patient satisfaction. Ensure care continuity by following up with any specialists to whom patients are referred. Request findings and recommended treatment plans, as applicable, an update your EMR with relevant clinical information.

6. Keep close tabs on patients with multiple chronic conditions or who are on multiple medications. Do patients take medications as prescribed? Are their chronic conditions controlled, or are they at risk of acute exacerbations? The goal is to keep patients healthy and out of the hospital. If your practice hasn’t yet started a chronic care management program, now is the time to do it. For elderly patients who are on high-risk medication regimens, conduct a thorough evaluation, and consider lower-risk alternatives.

7. Conduct patient outreach after an acute event or hospitalization. Schedule appointments to review aftercare plans and make sure patients understand and can implement these plans. Do patients understand the specialists with whom they must follow up? Do they know what medications they must take? Do they know who to contact if they have questions? Can they recognize signs and symptoms that would warrant a phone call to their doctor? These are important questions to review with your patients.

8. Evaluate office workflows. Focus on preventive care, prioritization of high-risk patients, coordination of care, and strong communication with other members of each patient’s care team. Where are the deficiencies and how can the team improve processes? Research and evaluate technology solutions that can seamlessly integrate with your office’s existing systems and improve workflows while reducing operating costs.

9. Improve documentation and coding accuracy. Schedule dedicated time for role-specific training and education that includes front office staff, medical coders, and providers. Individuals serving in each of these roles must understand how their actions (or inactions) impact the accuracy and specificity of medical record documentation and coding. This information directly impacts performance calculations, care delivery, and potential payments.

10. Leverage free external resources. External resources such as local community programs can often provide support for patients and serve as an extension of your practice through their focus on improving quality of life. For example, there are programs that can help address social determinants of health. Additionally, health plans sponsor risk adjustment and quality programs that provide clinical and administrative resources to support primary care practices. Leveraging these programs improves quality of care and patient satisfaction while reducing the burden on physicians. This, in turn, reduces the risk of burnout and attrition.

How Vatica Health can help

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 on-site or virtual licensed, clinical nurses that serve as extensions of your team at no cost to the practice. 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/.

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

How to Succeed in Value-based Care with Service-Enabled Technology

More and more primary care providers (PCPs) are entering value-based care arrangements, whether by choice or mandate. In fact, CMS hopes to have 100% of Medicare Advantage payments linked to alternative payment models by 2025.

With this new approach to care, it’s important for PCPs to understand the impact that risk adjustment and quality of care has on value-based care performance and assess whether their organization has the building blocks in place to ensure success. Unfortunately, PCPs are frequently impeded by insufficient time, data, and staffing resources, which prevents them from reaching their clinical and financial goals under these emerging payment systems. However, PCPs who address these gaps by evaluating their practices’ strengths, opportunities, and partnership needs are well-positioned to thrive in value-based care.


Risk Adjustment and Quality of Care

As we move to value-based care, providers will be compensated based on efficiently delivering better results—not more procedures. Value-based care is designed to incentivize providers to improve outcomes in a cost-efficient manner. In other words, payment and quality of care are inextricably linked.

Two critical components to any value-based care arrangement are risk adjustment and quality reporting. This is because success in value-based care 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 is labor intensive and is predicated on a complex set of rules, which frequently becomes 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, and 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.


What to Look for in Service-Enabled Technology

More often than not, PCPs attempt to solve these challenges with the aid of technology. However, as many PCPs know, the implementation of new software can create more problems than it was intended to solve. With office staff burnout at an all-time high, it is important to make sure that any new tools being utilized are supporting, not hindering, the team’s success.
What should PCPs be looking for when selecting the right partner? Let us look at some common quality reporting and risk adjustment challenges and how your technology should address them.

Provider Documentation Support
Challenge: Due to lack of coding expertise and ineffective technology, provider documentation is often not specific enough to support the ICD-10 coding necessary to accurately risk adjust a patient. Many common chronic conditions, such as major depressive disorder, specified arrhythmias, staged chronic kidney disease, and others, can only be risk adjusted when specified in physician documentation.
Solution: This level of detail can be achieved with a combination of clinical decision support, computer-assisted diagnostic coding technology, and supplemental clinical staff. Because technology alone cannot eliminate these challenges, augmenting existing staff with clinical resources to supplement these technology solutions, commonly known as service-enabled technology, is emerging as a gold standard.

Coding Expertise
Challenge: Risk adjustment payment methodology is highly complex. While PCPs may have medical coders on staff, they often lack the specialized skills needed to code to appropriate specificity. To bridge this gap, health plans deploy vendors to perform either home assessments or retrospective chart reviews, which can cause patient and provider abrasion.
Solution: PCPs can avoid these pitfalls with EMR-integrated technology that is powered by algorithms that do the heavy lifting by surfacing the most specific and relevant codes. Because an accurate and complete data set for each patient is critical, providers should consider supplemental clinical staff to support provider documentation with the EMR to synthesize it with health plan data.

Seamless Quality Reporting
Challenge: Quality of care programs can be challenging for providers in value-based care arrangements. Providers often lack the data and tools to support the reporting and activities associated with these measures.
Solution: Providers should consider solutions that specialize in quality reporting to foster greater communication and collaboration with health plans. New service-enabled technology solutions change the way health plans and providers are working together to improve financial and clinical results.
In a nutshell, technology alone is insufficient. Providers need both powerful EMR-integrated technology wrapped with clinical and administrative support to drive superior value-based care performance. PCPs do not need another application to log into—they need a team of experts behind the screen helping the technology work for them.


To learn more about Vatica’s PCP-centric solution for Risk Adjustment Coding and Quality of Care, click here.

Improving Quality of Care and Coding: The Road Less Traveled to Value-Based Care

Q&A with Vatica Health Co-Founder, Dr. Averel Snyder

At Vatica, we pride ourselves on being a company founded by physicians for physicians. Dr. Averel Snyder, a cardiothoracic surgeon, cofounded Vatica in 2011 after becoming frustrated with the mounting challenges physicians were facing. He set out to create a unique PCP-centric model that places providers in the driver’s seat of improving both quality of care documentation and practice revenue. We recently spoke with Dr. Snyder to discuss why he started Vatica and how risk adjustment and quality initiatives fit into broader, and timelier, industry issues including value-based care, the role of the PCP, and the COVID-19 pandemic.

There are not a lot of companies that solely focus on enabling physicians to perform risk adjustment coding and quality of care initiatives. What inspired that for Vatica?

It’s a funny story. Steve, my co-founder, and I initially started Vatica nearly a decade ago to enable physicians to more efficiently deliver the newly created Medicare Annual Wellness Visit. We knew that once we helped providers improve care and practice revenue, we could offer more comprehensive solutions. A couple of years later, I was attending a healthcare conference, listening to the CEO of a home assessment company boast about the benefits of his organization versus alternative methods of capturing diagnostic codes for the purpose of risk adjustment. He stated emphatically that their model was the best method for optimizing risk adjustment coding and stratifying patient risk, which enabled their health plan clients to accurately predict the costs on which their capitated payments are based. As he spoke, I felt myself becoming more frustrated by the minute because his claims seemed unfounded.

Immediately, I thought, this isn’t fair or accurate for a few reasons. First, PCPs are inappropriately being cut out of the financial and care loop. Second, it’s not in the patients’ best interest to be seen by a clinician with whom they have no relationship with and who does not have access to their complete medical record. Third, I wondered how non-PCP affiliated nurses were closing clinical and quality care gaps.

I went home and began to research the Medicare Advantage industry and quickly found that my concerns were justified—CMS also began to scrutinize the value of home assessments that failed to improve care and outcomes due to the lack of integration with the PCP.  

I had the proverbial light bulb moment. It struck me that we should empower physicians to use a simple interface to perform risk adjustment coding and capture quality of care data in a way that also improves their practice’s financial performance. I knew this could address an important pain point that most physicians feel—being overworked and underpaid. Plus, I knew that the treating physicians could do this work with greater efficiency and quality, leading to improved patient outcomes.

Fortunately, this insight, unlike many of my other entrepreneurial ideas, proved accurate, and nearly a decade later we have empowered thousands of PCPs to “take back” risk adjustment assessments. In doing so, we’ve helped improve outcomes and generated tens of millions of dollars for our provider network.

What makes Vatica’s solution different?

As a busy practicing physician for over two decades, I think I have a good sense of what frustrates providers—too many administrative burdens, not enough time, and declining income. We designed our solution with these frustrations in mind. We provide dedicated clinical support services to reduce administrative burdens, we negotiate health plan incentives to enhance PCP revenue, and improve quality by increasing the use of preventive services and helping to close care gaps. It’s a win-win-win—providers, health plans, and patients all benefit.

Why is it important to put PCPs at the center of risk adjustment?

I feel strongly that the PCP should be at the center of care. The treating PCP and their staff—not some randomly assigned clinician—is best suited to have the most efficient and effective face-to-face encounter with the patient. 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 better outcomes.

Talk to us about how Vatica helps PCPs succeed in value-based care.

Value-based care is about efficiently providing the highest quality of care to improve outcomes. There are a number of studies that demonstrate physicians in value-based care programs provide higher quality of care. Unfortunately, many PCPs lack the technology, expertise, staff, time, and other resources to thrive in value-based care. Vatica addresses this issue head-on. Unlike a lot of other solutions, Vatica is not here to make more work—we actually do 90% of the work for PCPs.

Vatica’s solution not only facilitates risk adjustment documentation and coding—but also enables PCPs to close gaps in care and increase the utilization of preventive services which are critical to improving outcomes. Powered by our technology platform, PCPs accurately capture all the active medical conditions with the associated documentation for clinical validation in the medical record. Vatica’s clinical consultants leverage all available data to create an accurate and complete view of the patient—the key to improving outcomes and performance in value-based care.

Why are risk adjustment and quality of care initiatives important to primary care providers?

Value-based care is designed to incentivize providers to improve outcomes in a cost-efficient manner.  Finances and quality of care are inextricably linked. 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. And for PCPs, this should be an urgent initiative since each year alternative payment models shift more risk to providers. I’ve heard providers say, “When value-based care comes, then I will pay attention to risk adjustment.” But, then it’s too late. The CMS data collection lags approximately three years, so your allocated resources for patient care in 2021 may be dependent on your coding and documentation in 2018. The time to focus on it is now.

What are the compliance risks for PCPs and health plans with other risk adjustment and quality of care solutions?  

In a standard risk adjustment data validation audit for a health plan, a meaningful percentage of the submitted diagnosis codes will be unsubstantiated in the medical record. Most of the approaches to risk adjustment are not meeting the new standard, which requires clinical validation. As a physician, it was important for me to design a solution that improved efficiency and mitigated compliance risk for providers. To accomplish this goal, we aggregate all available clinical data from the EMR and present all active medical conditions and their associated documentation for clinical validation to the treating provider. The provider is then responsible for selecting an appropriate ICD-10 code and completing “TAMPER” documentation. Then, as a fail-safe, after the provider e-signs the visit, we ensure that 100% of the codes are reviewed for completeness and accuracy by our team of AAPC CRC™ certified nurses, prior to submitting the codes to the health plan. We also deliver comprehensive provider ICD-10 coding and documentation training, which I personally provide and oversee.

What keeps you up at night in the current situation, with all the changes and disruptions in care during the pandemic?

PCP practices, particularly those who serve seniors, have endured some serious challenges. Reimbursement models are changing, and the new models demand vigilant documentation, accurate coding, additional practice resources, and subject matter expertise lacking by most physicians. At the same time, health plans are struggling to maximize risk adjusted revenue to ensure that seniors, who are the most vulnerable and costly patients, are receiving quality care and improved outcomes. Fortunately, CMS approved telehealth for a variety of encounters, including risk adjustment, and in-office patient volume has also started to bounce back from the post-pandemic decline. I think CMS will have to continue to adapt and make changes to the Medicare Advantage HCC model to account for the missed outpatient care during the pandemic. I am concerned about the increasing demands and worries of the PCPs, but I am optimistic about our ability to be a true partner, and subject matter expert, to help them succeed in this everchanging environment.

To learn more about how Vatica helps providers, watch our quick overview video.