As pent-up demand releases into the health care system, plans and providers need to quickly reassess patient populations. A well-run risk adjustment program can be a major asset in that effort.
As the United States battles COVID-19 outbreaks, the health system is bracing for another wave of health problems—the result of several months of cancelled primary care visits, disruptions to disease management, and gaps in preventive care.
The long pause in routine care leaves plans and providers with serious questions about the health of their members and patients. How many of those with type 2 diabetes have struggled to keep their blood glucose levels in range, exacerbating kidney problems? How have the stresses of the pandemic—job losses, food insecurity and social isolation—affected hypertension or other cardiovascular issues? What new physical and behavioral health issues have arisen that need treatment?
Analyses conducted by Evolent Health Services into the early weeks of the pandemic underscore these uncertainties. For one of our Medicaid partners, physician claims in April were 44% lower than what was observed a year earlier. Over a nine-week period starting in mid-March, the growth in documentation of risk adjustment conditions was little more than half that of the same period a year before. We see similar results across other lines of business and partner plans.
Facing so many unknowns, providers and health plans need to prepare for the challenge of reassessing the health of their patients and members, and doing so in a compressed timeline while patients may still be leery of stepping foot inside a clinic.
This is where a well-designed risk adjustment program can provide critical insights. Used by health plans, accountable care organizations and others working in value-based payment arrangements, risk adjustment programs seek to accurately and completely capture patients' diagnoses to ensure patients receive the appropriate care and health plans receive appropriate reimbursement to treat those patients. That remains an important aspect of risk adjustment, particularly for Medicare Advantage plans, whose payment levels next year will depend on diagnosis codes this year (unless the federal government intervenes.)
_q_tweetable:"Risk adjustment can help sift through the collateral damage of the COVID-19 response, by helping plans and providers identify and prioritize those members who are most likely to need to see a physician."_q_
Certainly, some high-risk, high-need individuals may already be engaged in care management programs. Still, there are others who have not yet been detected because their diagnoses have not been captured. A prospective risk adjustment program can help find these individuals. Using predictive algorithms that sift through a wide variety of data—medical and pharmacy claims, lab results and more—we can identify those plan members who are likely to have conditions that have not been documented. Guided by these coding gaps, a prospective RA solution can recommend which patients could be contacted to schedule an appointment. Providers can then confirm or deny those conditions at the patient encounter.
While a prospective-first approach will be most effective, retrospective risk adjustment also plays an important supporting role. As coders review the medical chart following the encounter, they can identify newly developed diagnoses that prospective approaches may not predict, given the potential for new conditions to worsen or develop in the early months of the pandemic.
Some providers and plans are anticipating a surge in utilization, as pent-up demand releases into in the health care system. There are concerns about backlogs and months-long waits to see specialists or proceduralists. Yet, many high-risk members may still be hesitant to see a provider in person.
A risk adjustment solution should be paired with tactics to outreach and engage these members. Telehealth is one solution, and CMS waivers for the pandemic allow providers to assess patients for risk-adjustable conditions via audio and video platforms that allow for two-way, real-time interactive communication, and for a limited set of codes, via audio only. For those Medicare and Medicaid members who are unable or unwilling to tap into technology for virtual visits, or for whom physical examinations are more important, plans may need to find creative engagement methods to incentivize office visits or in-home assessments.
The pandemic has created a huge blind spot for risk-bearing health plans and providers, unable to see how many of their patients are faring. Those who think proactively and plan well for the eventual return of new patients can potentially minimize the broader health impacts and the damage to plan financials.
About the AuthorMore Content by Brandon Barber