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Fostering Payer-Provider Collaboration to Improve Risk Adjustment & Quality Programs

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This presentation throws light on how to:
• Develop sustainable risk adjustment and quality programs
• Prioritize score improvements based on your specific populations to optimize results
• Streamline tactics to reduce provider abrasion
• Share data to drive behavior changes.

For more information on our Risk Adjustment solutions, please visit: http://www.sciohealthanalytics.com/offerings/solutions/risk-adjustment-quality-measurement

Published in: Healthcare
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Fostering Payer-Provider Collaboration to Improve Risk Adjustment & Quality Programs

  1. 1. |1©2017 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved.©2017 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. ROWING TOGETHER Fostering Payer-Provider Collaboration to Improve Risk Adjustment & Quality Programs April 13, 2017 | 1:00 - 2:00 PM ET
  2. 2. |2©2017 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. START BY UNDERSTANDING THE PARTNER YOU WORK WITH Use of Technology Human Capital Risk Adjustment Sophistication
  3. 3. |3©2017 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. ASSESSING THE CURRENT STATE VIA DATA TRANSPARENCY Members with Gaps Provider-Specific Concerns Global Process Issues
  4. 4. |4©2017 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. EXAMPLE GLOBAL ISSUE: RAPS/EDPS PROCESSING DIFFERENCES 48.8% Discrepancy Between Members with HCCs Captured by RAPS vs. EDPS Health Plans and Providers Should Strive for a Discrepancy of < 5%
  5. 5. |5©2017 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. RISK ADJUSTMENT RED FLAG WARNINGS Signs You May Not Be Receiving Correct Reimbursements Missing Reimbursement Forecasts Submitting EDPS and RAPS Data to an EDI Vendor Without Sufficient Oversight Lack of Transparency • Understanding Filter Logic • Joint Meetings • Data Sharing Multiple Risk Adjustment Software Solutions
  6. 6. |6©2017 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. COMMON RISK ADJUSTMENT CHALLENGES Clinical Care Gaps Year End Crunch Tactics Incorrect Coding Missing HCCs Insufficient Staffing Measuring Impact of Programs Lack of Data Transparency Data Drop Off Collecting Data Risk Adjustment Factor Scores HEDIS, Stars & P4P Quality Scores
  7. 7. |7©2017 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. BALANCING RETROSPECTIVE AND PROSPECTIVE TACTICS Retrospective Prospective
  8. 8. |8©2017 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. SETTING ACHIEVABLE GOALS • Develop goals alongside provider group leadership • Be “SMART”: Specific, Measurable, Assignable, Realistic, Time-Bound • Use two comparisons: year-over-year and against a benchmark • Mix quantitative-leaning goals (eg, RAF score increase) with qualitative-leaning goals (eg, attend risk adjustment education sessions) • Member Visits: Reduce percentage of members without an office visit to <20% in the next payment year. Led by patient engagement. • Recapture Rate: Over the next year, 5% improvement in documenting previously reported HCCs for Dr. Smith. Beginner: • Prevalence: 10% increase in members documented in 2 key HCCs (CHF and COPD). Led by risk adjustment department at the health plan. Intermediate: • RAPS & EDPS: Attain RAPS/EDPS HCC capture discrepancy of within 5% by the final EDPS submission date. Led by the IT department Advanced: “Start where you are. Use what you have. Do what you can.” - Arthur Ashe
  9. 9. |9©2017 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. DEVELOPING A PHYSICIAN CHAMPION ROLE • Liaison between the health plan and provider group who promotes and implements changes to achieve jointly developed goals. • Oftentimes they interface with multiple departments (e.g., care management and risk adjustment) WHO TO TARGET? • Clinical Provider Group Leaders (preference towards those with a financial background/interest) • Medical Directors are a good place to start SIGNING THEM UP • Aim for representation from all in network groups • Consider contractual language requesting a good faith effort of participation
  10. 10. |10©2017 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. KEEPING PHYSICIAN CHAMPIONS ENGAGED MONTHLY MEETINGS AT THE HEALTH PLAN • Includes a presentation on emerging topics (e.g., ICD-10) – Offer CME credits for some presentations • Opportunity to voice satisfaction/concerns with programs/solutions/EMRs • Opportunity to network, share best practices, and build relationships INDIVIDUAL MEETINGS AS NEEDED
  11. 11. |11©2017 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. ENSURING YOUR PHYSICIAN CHAMPIONS SUCCEED Five Common Reasons Physician Champions Fail (Becker’s Hospital Review) 1. Champion lacks a formal job title or description 2. Champion doesn't have the proper support and mentorship 3. Failure to address the conflict between clinical workload and physician champion duties 4. Champions don't have a say in decision-making 5. Poorly selected physician champion Source: http://www.beckershospitalreview.com/hospital-management-administration/5-reasons-your-physician-champion-will-fail.html
  12. 12. |12©2017 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. THE THREE “RIGHTS” Engaging the RIGHT PERSON (member or provider) with the RIGHT INFORMATION at the RIGHT TIME(S) Before Visit During Visit After Visit Challenges Member Not Visiting PCP PCP Does Not Diagnose and Document Member Conditions Coding / Billing Process Failures Documentation Not Submitted to CMS Solutions Member Suspect Lists Patient Engagement In Home Visits Provider Education Sessions Incentivization Visit Support Tools Chart Review Data Flow Analysis and Quality Initiatives
  13. 13. |13©2017 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. TAKING STOCK OF NEW MEMBERS/PATIENTS Before Visit
  14. 14. |14©2017 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. PROSPECTIVELY CLOSING DOCUMENTATION GAPS During Visit Chronic Conditions Previously Documented Now Missing For This Member
  15. 15. |15©2017 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. QUANTIFYING DOCUMENTATION GAPS After Visit Chronic Condition Documentation Gaps and Their Financial Impact
  16. 16. |16©2017 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. QUANTIFYING DOCUMENTATION GAPS After Visit
  17. 17. |17©2017 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. CASE STUDY Rapidly Growing Medicare Advantage Health Plan in California Background + Goal Solution • The health plan was unsure whether they were receiving all of the risk adjustable diagnosis codes for their members • Many members were not visiting their PCPs for preventative services – utilizing hospitals when acute conditions arose. • Needed a way to capture diagnosis codes from inpatient setting • Developed a program whereby they engaged their in-network hospitals for 100% of member inpatient stays. • Conducted concurrent pursuits to ensure timely reimbursement from CMS Results • 90% response rate • Annual Value of Additional Risk Adjustable Codes = $1.54 Million • More complete HCC data set to share with PCPs − Helps PCPs prioritize patient engagement, guides prospective data collection, and lessens health plan’s reliance on acute stay data USING INPATIENT DATA TO CLOSE GAPS
  18. 18. |18©2017 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. SUPPORTING A RANGE OF PLANS & PROVIDERS Sophisticated processes in place to optimize outcomes Newer to risk bearing contracts EHR Integration and real-time integration Sharing reports and suspect lists in the right format Outsourced patient and provider engagement for gap closure Risk Adjustment 101 – Provider in-service and education Portal for CMS and claims data transparency Flexibility to Engage Providers in Various Stages of the Risk-Bearing Readiness Continuum Contract 1 Contract 2 Contract 3 One Platform to Manage Medicare Risk Adjustment
  19. 19. |19©2017 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. CASE STUDY 65,000+ Member Medicare Advantage Health Plan Goal Solution • Optimize revenue and quality by collaborating with providers to: − Identify members with chronic gaps in care − Identify low performing providers who may need additional risk adjustment support and education − Deliver actionable information to provider groups in a consistent format • Developed a three- pronged approach based on the provider sophistication/ volume: − High volume providers: Full access to risk adjustment analytics − Low volume providers: Share health assessment tool reports − Outlier providers: Risk Adjustment 101 education Results • Annual revenue potential of $24 million per month • Successfully closed 38% of gaps for members with chronic conditions in the first year. PARTNERING WITH PROVIDERS ACROSS A SPECTRUM
  20. 20. |20©2017 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. GAIN EFFICIENCIES BY COMBINING RISK ADJUSTMENT & QUALITY Accurate Medicare Advantage Risk Scores Ensure That CMS Reimbursement is Commensurate With the Expected Costs Improved Quality Measures Ensure that Conditions are Identified and Treated Each Year Revenue Quality of Care
  21. 21. |21©2017 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. ANALYTICS DRIVING PROACTIVE ENGAGEMENT
  22. 22. |22©2017 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. ADDING QUALITY DATA POST-ENCOUNTER
  23. 23. |23©2017 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. MEASURING PROGRESS An important part of a well-run risk adjustment program is measuring results. SET YEAR-END AND INTERIM GOALS Set a year end goal and break it into monthly/quarterly milestones. CREATE A BALANCED SCORECARD Your risk adjustment dashboard should reflect all aspects of the program - RAF results, initiative return on investment, provider engagement/satisfaction, and auditing results. WATCH MONTHLY RESULTS AND TRENDS OVER TIME Important trends might include quarterly RAF scores, RAF trends by provider group/PCP/geography, year over year adjustments and program costs.
  24. 24. |24©2017 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. MEASURING PROGRESS An important part of a well-run risk adjustment program is measuring results. MEASURE ROI Be sure to note the impact of initiatives on year over year trends. COMMUNICATE TOP TO BOTTOM Share progress/results with all levels of the organization to ensure data transparency and increase engagement CELEBRATE SUCCESS A successful risk adjustment program takes a village! Recognize key contributors to the initiatives. SPECIAL RECOGNITION Recognize providers that have demonstrated the most significant improvement in care gap closures.
  25. 25. |25©2017 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. EXAMPLE: PROVIDER RAF SCORE LEADERBOARD
  26. 26. |26©2017 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. BUILDING EFFECTIVE FEEDBACK LOOPS EXAMPLES: • Standing meetings • Formal Post-Program Debrief – Share Results & ROI – Discuss Improvements for Next Year • Provider Forums • Newsletters BEST PRACTICES: • Nothing beats face-to-face meetings • Put it on the calendar! • Know Your Audience (Decision Makers vs. Staff) – Make sure audience matches agenda – Anticipate topics that may arise

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