Before I joined Informatica I worked for a health plan in Boston. I managed several programs including CMS Five Start Quality Rating System and Risk Adjustment Redesign. We recognized the need for a robust diagnostic profile of our members in support of risk adjustment. However, because the information resides in multiple sources, gathering and connecting the data presented many challenges. I see the opportunity for health plans to transform risk adjustment.
As risk adjustment becomes an integral component in healthcare, I encourage health plans to create a core competency around the development of diagnostic profiles. This should be the case for health plans and ACO’s. This profile is the source of reimbursement for an individual. This profile is also the basis for clinical care management. Augmented with social and demographic data, the profile can create a roadmap for successfully engaging each member.
Why is risk adjustment important?
Risk Adjustment is increasingly entrenched in the healthcare ecosystem. Originating in Medicare Advantage, it is now applicable to other areas. Risk adjustment is mission critical to protect financial viability and identify a clinical baseline for members.
What are a few examples of the increasing importance of risk adjustment?
1) Centers for Medicare and Medicaid (CMS) continues to increase the focus on Risk Adjustment. They are evaluating the value provided to the Federal government and beneficiaries. CMS has questioned the efficacy of home assessments and challenged health plans to provide a value statement beyond the harvesting of diagnoses codes which result solely in revenue enhancement. Illustrating additional value has been a challenge. Integrating data across the health plan will help address this challenge and derive value.
2) Marketplace members will also require risk adjustment calculations. After the first three years, the three “R’s” will dwindle down to one ‘R”. When Reinsurance and Risk Corridors end, we will be left with Risk Adjustment. To succeed with this new population, health plans need a clear strategy to obtain, analyze and process data. CMS processing delays make risk adjustment even more difficult. A Health Plan’s ability to manage this information will be critical to success.
3) Dual Eligibles, Medicaid members and ACO’s also rely on risk management for profitability and improved quality.
With an enhanced diagnostic profile — one that is accurate, complete and shared — I believe it is possible to enhance care, deliver appropriate reimbursements and provide coordinated care.
How can payers better enable risk adjustment?
- Facilitate timely analysis of accurate data from a variety of sources, in any format.
- Integrate and reconcile data from initial receipt through adjudication and submission.
- Deliver clean and normalized data to business users.
- Provide an aggregated view of master data about members, providers and the relationships between them to reveal insights and enable a differentiated level of service.
- Apply natural language processing to capture insights otherwise trapped in text based notes.
With clean, safe and connected data, health plans can profile members and identify undocumented diagnoses. With this data, health plans will also be able to create reports identifying providers who would benefit from additional training and support (about coding accuracy and completeness).
What will clean, safe and connected data allow?
- Allow risk adjustment to become a core competency and source of differentiation. Revenue impacts are expanding to lines of business representing larger and increasingly complex populations.
- Educate, motivate and engage providers with accurate reporting. Obtaining and acting on diagnostic data is best done when the member/patient is meeting with the caregiver. Clear and trusted feedback to physicians will contribute to a strong partnership.
- Improve patient care, reduce medical cost, increase quality ratings and engage members.