As a provider-sponsored health plan or provider organization with payer-delegated risk, you are fully aware that successful execution of a risk adjustment strategy is more complicated than it seems. Not only does success differ based on which population you are risk adjusting, organizations must also take into account the methods to document diagnoses – are they pulling in the best data sources and scrubbing them for accuracy? Consider your physician education and training programs – are you sending a message that resonates, or only adding to their already overburdened day?
Upon reflection of our experiences transforming health care across over 30 markets, we have realized that regardless of location, population or years running a risk adjustment program, there are many common misconceptions about what it takes to be successful in risk adjustment.
We highlighted these myths – and the realities we’ve come to understand – in our April webinar that featured two risk adjustment experts: Mike Lee, Evolent’s risk adjustment Regional General Manager who works with key stakeholders at partner organizations to implement risk adjustment strategies; and Deaconess Health System market medical director and practicing family medicine physician Dr. David Koehler, who has spent the past few years visiting Deaconess provider offices across the network, discussing risk adjustment best practices with a specific focus on physician engagement.
After the webinar, we received requests from attendees for additional information that would be beneficial in putting these strategies into practice, so we’ll be going into even more detail in this three-part blog series.
Feel free to check out the webinar recording here , or read on for a recap of the first risk adjustment myth and the reality we’ve uncovered. More on the four other myths coming soon!
Myth #1: Your EMR’s problem list is the best source for risk adjustable conditions.
But the reality is… the problem list is just one source of data. It’s helpful to use as a frame of reference, but actually keeping the problem list updated varies greatly depending on numerous hard-to-control factors. Keep in mind that the reliability of the problem list is highly dependent on the hygiene of the health systems and physicians properly maintaining the list. As Dr. Koehler shared, while he once felt that the problem list at his practice could serve as their source of truth, he realized over time that it was often a hodge-podge of conditions that were difficult to parse and not always relevant for risk adjustment.
In addition, it is highly likely that there are instances of care delivered by specialists and other providers outside the four walls of the practice, which won’t be reflected in your EMR either. Due to the inherent lack of connectivity of your native EMR, integration with other data sources is a key component to overall success. Consider the advantages of having a holistic view of your patients.
Having an accurate view of each patient via EMR data in addition to medical claims, pharmacy data and self-reported information goes a long way to fleshing out the true burden of illness and identifying the full spectrum of risk adjustable conditions. To accomplish this, it’s helpful to have technology or infrastructure that can pull together these various sources of data in a way that paints the whole picture, making those conditions easier to identify. Ideally, the same information that you are using to drive care management will actually be used to drive your HCC coding (and vice versa) – the data has already been aggregated, so why not repurpose the investment that you’ve already made?
Consider the alternative: executing risk adjustment with incomplete data means you’ll be playing catch up with retrospective reviews which introduce a different set of challenges. The optimal process should leverage the resources at your disposal to enable a data-driven physician/patient encounter which drives a more complete view of each patient, and thus a more well-informed care plan -- better for the patient experience and better for your bottom line.
Next up in the series, we’ll cover why organizations should invest in prospective risk adjustment solutions that integrate into the physician’s workflow, instead of relying solely on retrospective risk adjustment to sustain your program. If you can’t wait, check out the full webinar recording here.