Aligning Risk Adjustment and Quality Management to Impact Profitability and Compliance

Steve Whitehurt Health Fidelity Quality ManagementThere seems to be a tremendous opportunity for collaboration at health plans when it comes to risk adjustment and quality management. Allow me to explain.

Health plans have established quality management programs in place and have been reporting on quality measures for years. Likewise, Medicare Advantage health plans are well versed in the risk adjustment concepts that have been a part of the Medicare program for more than 15 years.

These two different health plan programs typically operate in distinct silos, despite the fact that they are both working to achieve goals that are closely related. There’s an opportunity for collaboration between these different but closely aligned components within today’s health plans. This opportunity is especially important in the current market, where accountable care organizations (ACOs) and health plans that participate in the exchanges under the Affordable Care Act (ACA) continue to proliferate.


HEDIS, Star Ratings, and Shared Goals with Risk Adjustment

The Healthcare Effectiveness Data and Information Set (HEDIS®) is a tool used by more than 90 percent of America’s health plans to measure performance on important dimensions of care and service. HEDIS reporting is required for accreditation by the National Committee for Quality Assurance (NCQA), and HEDIS ratings are a component of Medicare Advantage plans’ Star ratings that impact plan attractiveness, bonus payments, and rebate payments. HEDIS 2016 consists of 88 measures across seven domains of care:

  1. Effectiveness of care
  2. Access/availability of care
  3. Experience of care
  4. Utilization and risk adjusted utilization
  5. Relative resource use
  6. Health plan descriptive information
  7. Measures collected using electronic clinical data systems

Many HEDIS measures are closely aligned with the focus of risk adjustment programs that strive to accurately assess the health status of individual members. Imagine the data sharing opportunities that exist between risk adjustment and quality management initiatives. For example, each patient encounter for screenings, tests, and vaccines is an opportunity to collect information about a patient’s health status and risk conditions. As risk profiles become more accurate, risk adjustment becomes more effective so health plans are appropriately compensated for the risk of their enrollees.


Differing Priorities

One of the main challenges of information sharing between risk adjustment and quality management programs is that they have different priorities. While one program may be focused on care quality to improve compliance and ratings, the other is focused on capturing data that drive reimbursements. Although the two may have different priorities on the surface, both ultimately work to contribute to efforts that sustain or enhance health plan performance while improving patient care.


Creating Incentives for Data Sharing

For all of this data sharing to take place, there must be appropriate incentives and systems in place. Value-based care models provide a financial incentive for providers to improve quality. These models also create the foundation for providers to share patient information that can assist risk adjustment programs. Building upon this foundation with additional incentives to increase information sharing can elevate the accuracy of risk adjustment profiles. Platforms and processes that engage providers with minimal workflow disruption will also facilitate payer-provider data exchange. In addition, collaboration between payers and providers to improve care quality benefits both parties, as well as the patients who improve their health.


Big Data Management and Analytics

While most health plans are already overwhelmed with data, this collaborative data sharing opportunity will further expand the depths of data that needs to be stored and analyzed. For the collaboration to be effective, organizations need to implement technology solutions that can scale data management and analysis. As both risk adjustment and quality datasets draw from a common set of clinical encounters, organizations should create a data repository that is centralized and easily retrievable and ensure that member data – including retrieved clinical documents – can be leveraged across both departments. With a centralized data repository built in a way that (1) houses all member data (both clinical and administrative) and (2) enables a truly longitudinal view of the member over multiple years of service, care/quality gap and risk condition identification will improve. Additionally, gaps identified for risk adjustment can inform quality metrics and vice versa.


Align Initiatives

Health plans should adopt a holistic approach to revenue integrity that considers both risk adjustment and quality. First, they should consolidate chart retrieval requests to eliminate redundancies and minimize provider abrasion. Advanced analytics should be used to help prospectively identify likely care gaps for both risk adjustment and quality improvement together. This would allow physicians to kill two birds with one stone during their patient encounters. Plans would also be wise to consider implementing solutions that track provider gap closure rates for both risk adjustment and quality and allow for provider segmentation.


Are You Ready for the Collaboration Challenge?

Incentivizing collaboration and managing big data isn’t easy, but the benefits are worth it so that health plans can deliver higher quality care that earns commensurate reimbursement under value-based care. After all, poor health plan ratings often lead to enrollment decreases, and poor risk adjustment may contribute to lost profits. It’s imperative that the opportunity for collaboration be thoroughly explored.


If you would like to discuss the tremendous opportunity for collaboration at your health plan when it comes to risk adjustment and quality management, please contact us.