Before modernizing, set a baseline and plan a measurable path forward.
In our last two blog posts, we introduced Health Fidelity’s 360° risk adjustment framework and explained why it is an important strategic lever for risk-bearing entities in the value-based care era. Our series of eBooks, which we will continue to release over the coming months, delves into each component of 360° risk adjustment in greater detail and outlines our recommendations for success.
It’s important to acknowledge the high degree of variation across healthcare organizations; 360° risk adjustment is not a one-size-fits-all approach. Each organization’s path to achieving the 360° view will differ depending on baseline performance and internal readiness, among other factors. That is why, before launching into a risk adjustment modernization effort, organizations must assess their current state and determine the most appropriate strategies for improvement.
Our initial process of discovery, assessment, and planning is designed to do exactly this. It results in a customized blueprint that outlines how organizations should focus their efforts for maximum impact.
Developing a blueprint for transformation
Given the imperative to modernize risk adjustment, organizations must first understand what gaps currently exist for achieving the full 360° view. During this process, organizations have the chance to reflect, document, and strategically plan a measurable path forward. Understanding and quantifying the opportunities for improvement are also critical to setting the right strategies and expectations. Some organizations consider bringing in proven external consultants not only to have a fresh look, but also to foster objectivity and sufficient dedication of time and resources.
Let’s examine the five phases of the blueprinting process.
Phase 1: Discovery & Data Collection
Understand your organization’s current risk adjustment processes and initiatives to identify the baseline and opportunities for improvement
The Discovery & Data Collection phase is a review of current processes, people, and technology. Typically, it involves interviews with key stakeholders to document the end-to-end risk adjustment workflow. The objective is to identify gaps and issues that would benefit from new strategies. This phase requires time from leaders, staff, and facilitators to dig into the as-is details of organizational alignment and processes. Common findings may include:
- Risk adjustment initiatives for MA and ACA commercial populations are separately managed, leading to lack of economies of scale
- Managers and staff have to manage multiple processes depending on groups of members (e.g., owned vs affiliated physicians)
- The realized ROI on vendor(s) is not what was anticipated
- There are issues related to data flow
Phase 2: Financial Opportunity
Quantify and localize the financial opportunity in both retrospective and prospective review, and identify the best methods for improvement
The Financial Opportunity phase quantifies the gaps in uncaptured revenue in both prospective and retrospective settings. Where does revenue opportunity exist, and how can the organization get it? By analyzing the past 2+ years of claims, submission data, and CMS/HHS files, the organization can develop a prioritized list of opportunities – by provider group, condition category, member, etc. – stratified by probability of success. The analysis must also consider the costs required to capture the identified opportunities. Financial targets and resources (people and dollars) must be discussed for a clear understanding of the opportunity.
Phase 3: Clinical Data Landscape
Understand and document the current availability and access to clinical data to ensure risk is captured based upon sufficient information
Organizations often over-estimate the completeness and quality of data. The Clinical Data Landscape phase is crucial to understand the status of clinical and other data housed by the organization. Questions should arise concerning data generation, acquisition, storage, cleaning, quality, and accessibility. This phase prompts organizations to reflect on the data being used (and data not being used) for risk adjustment. How many clinical charts are being pulled across members and provider groups? What methods are used to extract medical records across the network? What about prescriptions, self-reported health status, and lab results? To be clear, this exercise requires participation from all departments across the organization – not just risk adjustment – since overlaps in data needs often exist. At the end of this phase, organizations will prioritize targets for data acquisition based on the availability of data, the business case for acquiring the data, and the associated costs.
Phase 4: Network Readiness
Understand the organization’s readiness for capturing identified opportunities as well as gaps that exist in network alignment
The Network Readiness phase is used to reflect upon internal readiness, as well as network alignment and incentives which would support risk adjustment modernization and strategic aims. A common finding is a disconnect with providers, often lacking an incentive mechanism to get new initiatives off the ground without platforms for relationship-building, effective use of technology, and real-time communication. Organizations may also lack internal resources that need to be dedicated to support the necessary transformation, such as physician educators, member outreach coordinators, and provider relations managers.
Phase 5: Blueprint to 360° Risk Adjustment
Develop a strategic blueprint based on outputs from previous phases, with defined timelines and success metrics
The blueprint development begins with a determination of improvement methods based on the organization’s needs for modernizing risk adjustment. The organization can then create a detailed plan to address the opportunities identified, along with expected resource requirements, timelines, and outcomes. What should be done within the next two months vs. the next two years? What items are low priority? Identifying dependencies such as systems migrations, employee training, network contracting, and other activities which must happen for future steps to occur, is also essential.
Final thoughts
A comprehensive and customized blueprint is the first step toward the 360° view, and it helps to build buy-in across the organization for a strategic risk adjustment modernization effort. Once the initial blueprint is developed, the journey to 360° risk adjustment is an ongoing process where solutions are implemented, performance is continuously measured, and the blueprint is refined as needed to better reflect the organization’s progress, evolving priorities, and market trends.
