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Key levers to manage the risk in your risk based contracts

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This webinar discussed key levers providers can use to mitigate and effectively manage the risk facing their organizations. Attendees heard Scripps Health Plan Services discuss their strategy to mitigate risk across their organization by focusing on key documentation and coding best practices. The Scripps strategy is highly focused around quality outcomes for the patients and members they serve and incorporate quality-focused initiatives that improve health outcomes and ultimately, financial success.

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http://www.sciohealthanalytics.com/offerings/solutions/SCIOClarity

Published in: Healthcare
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Key levers to manage the risk in your risk based contracts

  1. 1. |1©2018 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved.©2018 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. SCIO HEALTH ANALYTICS® Key Levers to Manage The “Risk” in Risk-based Contracts February 15, 2018
  2. 2. |2©2018 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. GROWING FOCUS ON VALUE-BASED CARE & PAYMENT Driving providers to assume greater financial risk via alternative payment models Growth in new and participating MSSP ACOs Heightened focus and increased growth across Medicare Advantage 1 2
  3. 3. |3©2018 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. EVOLVING CMS MEDICARE ADVANTAGE REGULATIONS Key Highlights For 2019, CMS is proposing important changes to the Part C risk adjustment model CMS-HCC Risk Adjustment Model Proposal - Additional HCCs April 2, 2018: CMS Announce 2019 MA Capitation Rates and Final Payment Polices (including final HCC Risk Adjustment Model) 21st Century Cures Act: In response requirements, CMS propose the following:
  4. 4. |4©2018 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. LEVERS TO MANAGE YOUR RISK-BASED ARRANGEMENTS IDENTIFY WHERE GAPS EXIST Closing both documentation and quality gaps across your population will enable you to improve revenue accuracy as well as quality compliance. OPTIMIZE NETWORK PERFORMANCE Your providers are some of your best assets. Work across your network to manage provider performance related to utilization, costs and leakage. IMPLEMENT SHORT & LONG TERM POPULATION PROGRAMS Design and implement care programs that leverage advanced insights into opportunities for short term and long term clinical and financial return.
  5. 5. |5©2018 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. LEVERS TO MANAGE YOUR RISK-BASED ARRANGEMENTS IDENTIFY WHERE GAPS EXIST Closing both documentation and quality gaps across your population will enable you to improve revenue accuracy as well as quality compliance. OPTIMIZE NETWORK PERFORMANCE Your providers are some of your best assets. Work across your network to manage provider performance related to utilization, costs and leakage. IMPLEMENT SHORT & LONG TERM POPULATION PROGRAMS Design and implement care programs that leverage advanced insights into opportunities for short term and long term clinical and financial return.
  6. 6. |6©2018 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. IDENTIFY WHERE GAPS EXIST Two Pronged Approach to Improving Risk Scores & Quality Outcomes Documentation & Coding Gaps • Ensure patients with histories of chronic conditions have care and documentation gaps closed each year (year over year comparisons) • Prospectively identify patients and providers with likely documentation issues • Utilize retrospective and prospective gap closure tactics • Benchmark performance to stay ahead of performance targets Quality Measure Gaps (HEDIS & P4P, Stars) • Know your compliance at the group and individual provider levels • Work with outlier providers/groups to close quality gaps • Focused patient outreach and education to drive engagement • Understand where your greatest opportunity to impact quality outcomes exists
  7. 7. |7©2018 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. ACCURATE CODING & REVENUE ACCURACY A View by Revenue Opportunity Group Physician Member Number HCC Code Last Reported Payment Year PY 2017 Missing 2016 DOS GRP142 PCP866 MBR1234 18 2015 ($372.80) GRP226 PCP252 MBR3456 48 2015 ($287.15) GRP315 PCP788 MBR7891 58 2015 ($555.88) GRP142 PCP866 MBR1234 18 2015 ($376.80) GRP226 PCP252 MBR3456 48 2015 ($299.15) GRP315 PCP788 MBR7891 58 2015 ($675.22) GRP265 PCP567 MBR7894 48 2015 ($1,578.22) $4.5M Missed Revenue Patients with previously documented HCCs missing for current year
  8. 8. |8©2018 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. ACCURATE CODING & REVENUE ACCURACY A View by Providers FACILITY NORTH • LOWEST POPULATION RISK FACILITY EAST • MEDIUM POPULATION RISK FACILITY WEST • GREATEST CONCENTRATION OF PROVIDERS & PATIENTS • HIGHEST POPULATION RISK • GREATEST OPPORTUNITY FOR CODING RECAPTURE By sites of service, how are providers varying in coding practices? Patients Avg Age Avg Age Avg Age Avg HCC <65 >65 Weight
  9. 9. |9©2018 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. ACCURATE CODING & REVENUE ACCURACY A View of Performance by Conditions *The book of business benchmark is nationwide data of + 2.5 Million Medicare members for a closed CMS performance year` 21.5% 16.3% 14.8% 13.1% 10.1% 10.4% 9.1% 5.7% 4.4% 3.8% 3.2% 3.1% 2.6% 3.0% 3.3% 23.0% 18.2% 17.6% 16.0% 11.6% 11.5% 10.2% 6.9% 5.8% 4.6% 3.9% 3.8% 3.8% 3.5% 3.5% 20.8% 22.1% 8.9% 20.1% 10.5% 13.0% 4.4% 5.9% 13.8% 6.2% 5.2% 2.5% 6.9% 1.5% 1.7% 0% 5% 10% 15% 20% 25% Diabetes without Complication Vascular Disease Specified Heart Arrhythmias Diabetes with Chronic Complications Congestive Heart Failure Breast, Prostate, and Other Cancers and Tumors Chronic Obstructive Pulmonary Disease Rheumatoid Arthritis and Inflammatory Connective Tissue Disease Major Depressive, Bipolar, and Paranoid Disorders Coagulation Defects and Other Specified Hematological Disorders Other Significant Endocrine and Metabolic Disorders Acute Renal Failure Morbid Obesity Colorectal, Bladder, and Other Cancers Ischemic or Unspecified Stroke NEMG Service Year 2015 NEMG Service Year 2016 Book of Business BenchmarkService Year 2015 Service Year 2016 Book of Business Benchmark
  10. 10. |10©2018 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. ACCURATE CODING & REVENUE ACCURACY A View of Performance by Conditions Chronic conditions - with prevalence lower than benchmark 2015 2016 Book of Business Benchmark Attaining Benchmark # No HCC Members needed to attain benchmark levels # Member Weight $ Opportunity Vascular Disease 16.30% 18.19% 22.11% 3.92% 900 4,177 0.298 $227,607 Diabetes with Chronic Complications 13.10% 15.96% 20.12% 4.16% 955 3,664 0.318 $257,688 Major Depressive, Bipolar, and Paranoid Disorders 4.40% 5.80% 13.00% 7.24% 1,663 1,323 0.395 $557,346 Morbid Obesity 2.60% 3.80% 6.88% 3.13% 718 860 0.273 $166,275 $981,309
  11. 11. |11©2018 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. LEVERS TO MANAGE YOUR RISK-BASED ARRANGEMENTS IDENTIFY WHERE GAPS EXIST Closing both documentation and quality gaps across your population will enable you to improve revenue accuracy as well as quality compliance. OPTIMIZE NETWORK PERFORMANCE Your providers are some of your best assets. Work across your network to manage provider performance related to utilization, costs and leakage. IMPLEMENT SHORT & LONG TERM POPULATION PROGRAMS Design and implement care programs that leverage advanced insights into opportunities for short term and long term clinical and financial return.
  12. 12. |12©2018 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. ENGAGING & IMPROVING THE HEALTH OF AT- RISK POPULATIONS 360o Track & Manage Population Risk Profile • What does my population risk look like? • Are we trending up or down year over year? Enhance With Advanced Insights • Identify the most impactable patients, those who will have the highest financial impact if care gaps are closed • Further stratify patients by intervenability, or those most likely to comply with given interventions • Intervene earlier to treat preference sensitive conditions • Implement effective care management programs
  13. 13. |13©2018 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. ENGAGING & IMPROVING THE HEALTH OF AT- RISK POPULATIONS Risk & Opportunity
  14. 14. |14©2018 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. ENGAGING & IMPROVING THE HEALTH OF AT- RISK POPULATIONS Where is My Greatest Opportunity % of Population Risk Bucket Impactability Bucket High Medium Mild Low High 14.6% 6.3% 9.2% 48.5% Medium 0.4% 0.4% 0.3% 13.0% Mild 0.0% 0.1% 0.1% 5.8% Low 0.0% 0.0% 1.5% Potential Savings Risk Bucket Impactability Bucket High Medium Mild Low High $1,363,086 $69,264 $16,162 $136 Medium $80,984 $37,529 $5,558 $81 Mild $20,040 $12,580 $2,865 $67 Low $746 $417 $0 Risk ScoreRisk Score Where to find highly impactable patients
  15. 15. |15©2018 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. LEVERS TO MANAGE YOUR RISK-BASED ARRANGEMENTS IDENTIFY WHERE GAPS EXIST Closing both documentation and quality gaps across your population will enable you to improve revenue accuracy as well as quality compliance. OPTIMIZE NETWORK PERFORMANCE Your providers are some of your best assets. Work across your network to manage provider performance related to utilization, costs and leakage. IMPLEMENT SHORT & LONG TERM POPULATION PROGRAMS Design and implement care programs that leverage advanced insights into opportunities for short term and long term clinical and financial return.
  16. 16. |16©2018 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. OPTIMIZE NETWORK PERFORMANCE Your Providers are one of Your Greatest Assets • Understand where care is being delivered in and out of network • Track and manage outlier providers to ensure optimal utilization • Manage provider variation patterns • Manage provider performance across key cost metrics Manage Utilization & Network Leakage
  17. 17. |17©2018 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. OPTIMIZE NETWORK PERFORMANCE Who are the groups and providers with the highest out of network utilization & costs? What is out of network utilization costing our network?
  18. 18. |18©2018 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. OPTIMIZE NETWORK PERFORMANCE Why are our patients seeking care outside of the network?
  19. 19. |19©2018 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. LEVERS FOR FINANCIAL OPTIMIZATION IDENTIFY WHERE GAPS EXIST FOCUS ON YOUR NETWORK PERFORMANCE BUILD SHORT, MED & LONG TERM POPULATION PROGRAMS
  20. 20. |20©2018 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved.
  21. 21. |21©2018 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. San Diego, CA Not-for-Profit Single Corporate Member: Scripps Health Current Membership: ~116,747 members Lines of Business: Medicare Advantage and Commercial Limited Knox-Keene License: 1999 Full Knox-Keene License: 2015
  22. 22. |22©2018 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. SCRIPPS CORPORATE STRATEGIC FOCUS Ensuring Successful Value-Based Care Outcomes QUALITY OF CAREUTILIZATION ACCESSCOSTS
  23. 23. |23©2018 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. RISK ADJUSTMENT & QUALITY PROGRAM “It’s about ensuring we have the means to provide the highest quality care to the patients we serve” Patients Care Gap Closures & Quality Outcomes Providers End-to-End Partnership Health Plans & CMS Transparency - Manager, Risk Adjustment, Scripps Health Plan Services
  24. 24. |24©2018 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. MEET THE HCC Risk Adjustment “A” TEAM RISK ADJUSTMENT & QUALITY PROGRAM Certified Risk Adjustment Coders/Auditors Manager, Risk Adjustment Director, Risk Adjustment & Compliance Physicians Natural Language Processing Chart Auditing Front-End Auditing
  25. 25. |25©2018 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. IT STARTS WITH OUR TEAM OF PROVIDERS Ensuring Providers are Equipped, Informed & Engaged Robust Physician Education Program • New Practitioner Education, including Nurse Practitioners & Physician Assistants (HCC team participation) • Quarterly Trainings including HCC team, auditors, physician leadership, internal practitioner champion • Annual LMS Education – HCC team is part of education delivery – Delivered in LMS learning system – Consists of educational and testing components (1:1 follow up as needed) – Incentive plan to encourage provider participation – Participation tracked & results shared with senior leadership Ongoing Physician Communication & Transparency • Real-time communication of audit details/findings • Weekly HCC coding communications (Flashes/Alerts) • Monthly newsletters • HCC Coder/Auditor attends & delivers updates at annual operational meetings (1 per site; 29 total meetings)
  26. 26. |26©2018 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. FOCUS ON DRIVING QUALITY PATIENT OUTCOMES Medicare Advantage HMO HCC Program HCC Health Assessments • Key Program Goals: Improve patient satisfaction & improve HCC RAF Score • Provide comprehensive HCC Health Assessments for all Medicare Advantage HMO members – Deliver quality assessments & provide appropriate care to patients with conditions – Identify opportunities to recapture and diagnose new chronic conditions – Ensure correct diagnostic coding and supporting documentation • Includes auditing: – Annual Assessments – Best Practice Advisory (BPA) – Wellness Visits – Real time documentation opportunities, care consideration and communications sent to practitioner – 5 day review window • Diagnosis list can be adjusted (add or delete) based on higher specificity codes supported by clinical documentation submitted
  27. 27. |27©2018 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. ENGAGING MEMBERS FOR IMPROVED OUTCOMES Multi-Channel Approach Telephonic PCP Selections • Establish care with PCP: Telephone outreach to new Medicare Advantage members • Facilitate live phone transfer to identified PCP to schedule appointment • Further phone validation/efforts to ensure member selects PCP (suggestions based on Medical Group ad Site selected) Direct Mail Annual Visit Notices • Annual letters to Medicare Advantage members • No activity for the last 10 months • Annual visit longer appointment (include quality assessment of their conditions) Include any screen shots?
  28. 28. |28©2018 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. TRANSPARENCY ACROSS HEALTH PLANS & CMS Medicare Advantage HMO HCC Program Natural Language Processing – Senior Medicare Advantage Population • Senior Medicare Advantage Population: ~28,500 lives • Identify possible HCC conditions not reported to CMS • Leverage computer learning and linguistic pattern analysis • Auditors rapidly validate findings and select relevant ICD-10 codes • Newly documented/diagnosis codes provided in a submission-ready file to Medicare Advantage health plans, then on to CMS via alternate submission file or 837 • 30-60 days post submission, validation of accepted codes by CMS is conducted Risk Adjustment Factor Score (RAF) Capitation Payments
  29. 29. |29©2018 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. TRANSPARENCY ACROSS HEALTH PLANS & CMS Ensure all capitated risk adjusted members are accurately coded, include appropriate supporting documentation and are accepted by the health plans and CMS Chart Audit Program • Retro chart audits conducted 2-4 times per year • Risk stratify population based on highest risk • Quarterly comparative prevalence reports inform (quality assessments) • Monthly variance reports confirm encounters are accepted (sent via ASM/837 file) • Newly documented/diagnosis codes provided in a submission-ready file to Medicare Advantage health plans, then on to CMS • Validation of accepted resubmission files 30-60 days post resubmission
  30. 30. |30©2018 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. Contact us Corporate Headquarters SCIO Health Analytics® 433 South Main St., Suite 203 West Hartford, CT 06110 info@sciohealthanalytics.com www.sciohealthanalytics.com

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