Tag: Risk Adjustment

Telling the patient’s story during COVID-19: Primary care challenges and long-term solutions

By Vatica Health | February 1, 2021 | Provider, Risk Adjustment, Telehealth

When the COVID-19 pandemic first struck, small independent primary care physicians were among the first providers to feel the impact. Patients cancelled appointments out of fear or necessity. Practices shut down temporarily to comply with shelter-at-home orders. As with many businesses, some practices eventually closed their doors for good because they simply couldn’t weather the storm financially. As the pandemic raged on, even larger, system-owned practices began to feel the wrath of COVID-19. Today—nearly a year later—entire health systems both large and small are feeling the strain.

Despite these unprecedented challenges, providers have tried not to lose sight of the most important goal: to provide high-quality patient care that drives optimal health outcomes and supports the transition to value-based care.

How can they do that?

Ensure accurate and complete documentation that reflects each patient’s clinical story. Document all current and emerging chronic conditions to the highest degree of specificity. Administer all age-based or seasonal screenings and vaccines that affect health and functioning, or refer patients for these services. Encourage preventive care and behavior modification to support a healthy lifestyle.

As we look ahead, organizations must confront an ongoing shortage of primary care physicians and nurses, as well as a virus-fearful patient population that may be difficult to engage in preventive health. The ‘old way’ of addressing gaps in patient care (like during an in-person visit with a physician) probably isn’t realistic anymore. It’s time to rethink strategies and address ongoing challenges.

Following are four challenges every healthcare organization must address, along with potential solutions to ensure high-quality patient care and revenue integrity.

Challenge #1: There aren’t enough physicians working in the practice setting.

An increase in hospital admissions—including admissions for patients with COVID-19—has forced health systems in rural and urban areas to re-deploy employed physicians and their nursing staff into acute care units. With fewer providers working in the office setting comes diminished appointment availability, including appointments for preventive health. This comprehensive annual visit is a critical opportunity to identify conditions that warrant ongoing monitoring. Without this touchpoint, care gaps can easily occur. The patient’s clinical story remains largely untold, and performance in value-based care arrangements may be jeopardized.

Solution: Think outside the box.

It’s understandable that physicians are distracted by other responsibilities; however, it’s also critical that they not lose sight of reviewing patients’ chronic conditions annually. That’s where they may need help. Some have contemplated hiring a physician assistant, for example, but are hesitant to make the financial investment out of fear that patient volume won’t cover the person’s salary and benefits. The good news is that there may be other options. For example, the practice could consider participating in a health-plan sponsored program that provides clinical and administrative staff for support. Going this route prevents care gaps, reduces overhead costs, and slows the spread of COVID-19. As an added benefit, there is often a financial incentive offered for completing patient encounters.

Challenge #2: Some patients still fear coming into the office.

Even despite stringent COVID-19 protocols, many patients continue to feel that the risk of coming into the office for preventive and routine care isn’t worth it. Four out of every 10 U.S. adults say they’ve avoided medical care because of concerns related to COVID-19.

Solution: Telehealth (with patient tutorials).

Telehealth helps practices keep patients happy and safe. However, there’s one caveat: it might take a little effort to help older adults learn to use this technology. More than a third of adults over age 65 face potential difficulties seeing their doctor via telemedicine. Proactively educating patients on how to use the telehealth solution and supporting their utilization can go a long way in terms of engagement. Administrative support often includes the use of Patient Engagement Representatives to contact patients to schedule appointments, deliver appointment reminders, and educate them on telehealth tools.

Challenge #3: Patients may no longer prioritize preventive health.

During COVID-19, many patients have deferred routine and preventive care. Perhaps they lost their insurance or faced another type of financial hardship—or the physician they always saw is no longer available. Some may have even gravitated toward the idea that they don’t need a doctor because they’re able to self-diagnose using the internet. Routine and preventive health falls to the bottom of the priority list, which is especially critical for patients diagnosed with chronic conditions.

Solution: Educate patients.

Practices must be able to convey the value of preventive and routine health services. Preventive care helps physicians diagnose diseases earlier, which often results in better outcomes and lower cost of care. Routine care prevents exacerbations, reduces symptoms, and improves quality of life. Practices must be able to engage patients on a personal level while also explaining that many of these services may be covered at 100%. This education empowers patients to make the best decisions for their health.

Challenge #4: Physicians are burned out, and revenue is declining.

Forty-seven percent of family medicine physicians and 46% of internal medicine physicians say they’re burned out, and it isn’t surprising why: long and busy workdays, time pressures, and ever-increasing administrative demands. COVID-19 has exacerbated this dynamic and led to a sharp decline in patient volume that has threatened the financial viability of many PCP practices.

Solution: A comprehensive Risk Adjustment and Quality solution.

Participating in health-plan sponsored risk adjustment and quality of care initiatives can help PCPs who are struggling to close revenue and care gaps. PCPs are already overworked and dealing with the cascading effects of COVID-19. It’s critical to find a partner that provides dedicated clinical and administrative support services to reduce administrative burdens, engage patients, and improve health outcomes. The result? Increased utilization of preventive health encounters and improved financial and clinical performance in value-based care arrangements.

How Vatica Supports Health Systems

As practices continue to seek point-of-care solutions to better tell each patient’s story, they need look no further than Vatica Health. We’re accelerating the transformation to value-based care by helping providers, health plans, and patients work together to achieve better outcomes. Our team deploys on-site or virtual clinical consultants with backgrounds as RNs, LPNs, or PAs that serve as extensions of your team at no cost to the practice. Practices retain all fee-for-service payments generated from patient encounters and also receive incentives for coding visits.

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

Improving quality of care and coding: The road less traveled to value-based care

By Vatica Health | September 8, 2020 | Provider, Risk Adjustment, 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.

The impact of telehealth on risk adjustment

By Vatica Health | April 22, 2020 | Risk Adjustment, Telehealth

In our recently published whitepaper, and in an article by our CEO, Hassan Rifaat, MD, published in FierceHealthcare, we discussed the current challenges health plans face to meet the requirements for risk adjustment during the COVID-19 pandemic. In the early innings of the coronavirus crisis, CMS implemented many helpful initiatives in response to the national emergency declaration, but none addressed risk adjustment. This created a lot of anxiety among health plans and other at-risk entities, given the importance of accurately risk adjusting your membership. Our hope, at the time, was that CMS would build on its series of telehealth waivers from March to allow health plans to gather risk adjustment data through telehealth visits.

Well, our dream has become a reality. Late last Friday, April 10, we all exhaled a collective sigh of relief when CMS officially approved telehealth as a means for health plans to gather risk adjustment data.

We applaud CMS for making this move, as it allows Medicare Advantage plans—which insure many of the oldest and sickest patients—to stay on track with risk adjustment. In addition, to the extent that the risk adjustment solution is provider-centric, it also enables primary care physicians (PCPs) to uphold care quality and address care gaps through preventive and routine care.

And while that’s good news for health plans, rolling out telehealth isn’t as simple as flipping a switch. PCPs and seniors may face obstacles in adopting and integrating what is a new technology for many of them.

During this period of transition, health plans should recognize the new challenges PCPs face and support them in continuing to provide care to their patients.

Challenge: Disjointed Telehealth Strategies

Telehealth usage is increasing but may be disjointed between audio and video methods and external telehealth solutions. In order to capitalize on the telehealth risk adjustment waiver, visits via telephone alone will not be enough. CMS has stated that PCPs can only gather encounter data for risk adjustment via real-time, interactive audio-video telecommunication systems.

Additionally, many outsourced telehealth solutions use clinicians with no relationship to patients or connectivity to a PCP’s EMR. While such solutions may be effective to treat acute needs when a patient’s PCP is unavailable, they should not be a substitute for a PCP-centric telehealth solution for risk adjustment and care coordination. Outsourced telehealth solutions will likely be ineffective and cause significant provider abrasion at a time when PCPs are struggling to keep their practices open.

Solution: Centralized, PCP-Centric Approaches

During this time, PCPs need solutions that keep them productive and engaged with their patients, rather than creating more work by picking up the pieces of an outsourced telehealth solution. PCPs also need support implementing this new care delivery model into their workflow.

Challenge: Strained and Under-staffed PCPs

As coronavirus care impacts all aspects of our business and personal lives, PCPs are under considerable stress, and their financial viability is being threatened. A survey of physicians in mid-April revealed that patient volumes are down 65% compared to pre-pandemic volumes, and the effects are beginning to catch up to the PCP practices. Shockingly, due to coronavirus effects, only one-third of PCPs feel confident that their practice has enough cash to continue operating through the end of April. Some practices have already decreased their workforce, and others think they’ll have to temporarily shutter their doors.

Solution: Member Engagement

Even though telehealth is now an option, practices still need help getting patients to participate. PCPs need easy-to-use member engagement tools with administrative and clinical support to secure patient participation. To optimize participation, health plans should promote PCP-centric telehealth to the members. Not only can this help maintain risk adjustment programs, but it also helps PCPs generate reimbursable revenue at a time when it’s needed most.

What’s Next?

While it’s hard to imagine that telehealth will ever fully replace in-person care, we expect that it will be our “new normal” for quite some time. This is especially true for seniors who are at the greatest risk of complications from COVID-19. We are cautiously optimistic that telehealth will remain in place for routine and preventive care and, if it does, we would expect CMS’ new guidance on risk adjustment via telehealth to also be extended. In the meantime, health plans should lean into PCP-centric telehealth programs to take full advantage of the new rules and flexibility relating to telehealth and risk adjustment during COVID-19.

Learn more about Vatica Health’s new PCP-centric telehealth and risk adjustment solution.

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