Florent Moise and Peter Manoogian co-wrote this blog post with Josh Lacey.
The 2019 RISE Conference brought more than 1,000 leaders from health plans and provider organizations to Nashville to discuss a variety of topics impacting the delivery of healthcare today. Among these, risk adjustment was top of mind in many sessions, partly because it’s a relatively new endeavor and partly because it’s a key driver of plan revenue from CMS that requires focused inputs from providers. However, RISE wasn’t just a risk adjustment conference. Sessions also focused on member engagement, provider engagement and data integration. These three topics must be combined for successful risk adjustment, and they’re also critical for health plans in many other facets of how they operate:
1. Member engagement: Many participants across multiple sessions stressed the importance of annual wellness visits and closing gaps in care. In the context of risk adjustment, the value is clear: Annual wellness visits are providers’ easiest opportunities to engage with members and assess their overall health, with an eye toward preventive measures that will decrease future spending on costlier treatments. This, in turn, leads to increased risk adjustment payments. Beyond wellness visits, several vendors lined the exhibit hall boasting various solutions that addressed other care gaps, from meal delivery services to member rewards programs.
However, members have different aims. Their primary interests are receiving quality care and having a seamless experience. What does this mean for a plan looking to pursue member engagement beyond risk adjustment? Closing gaps can certainly improve patient outcomes, but it’s critical to do so in a coordinated way. As health plans partner with multiple vendors who touch only a piece of the care continuum, they also occupy the unique position of being the only stakeholder (other than the member) who has visibility of the various touch points both within and outside of the doctor’s office. This heightens the need for health plans to take a total view of the member and orchestrate engagement via the right channels at moments that matter most to the member.
2. Provider engagement: The provider’s role in risk adjustment is clear: to ensure that documentation is accurate and complete. Documentation was highlighted as a specific challenge during the conference as providers cited documentation fatigue and a lack of time and support as obstacles to successful implementation. However, provider engagement can be valuable for plans in other ways. In an increasingly competitive market, providing a superior provider experience can help attract the best providers to create and sustain a strong network. For example, if providers are already fatigued with documentation requirements, risk adjustment only adds to it. This challenge is compounded by several factors: for instance, the variability in EHR and risk adjustment documentation, and audits across the number of plans with which a provider may contract. Health plans should consider standardizing documentation requirements to make them easier for providers to complete—again, increasing the likelihood of accurate documentation.
Additionally, there are many instances where risk adjustment incentives aren’t clearly tied to outcomes, even when programs are said to work. The impact of reimbursement is diminished if a provider doesn’t know what activity its being reimbursed for. Health plans should continue to invest in provider education before and after participation in a risk adjustment program. Before implementation, make it clear why the health plan is pursuing certain risk adjustment activities. And during a program, provide regular communication to providers via their preferred channels to ensure that they can measure their progress. Next-best-action technology can also help guide providers to success.
3. Data integration: At RISE, there was significant dialogue around data management and integration to power many of the solutions mentioned above. Given the volume of data that exists and the number of options available to transform member and provider data into actions, health plans must first think about the business problems they want to solve and the use cases for how they manifest.
Algorithms require quality data (and the right data) to run effectively; otherwise, plans face a very expensive case of “garbage in, garbage out.” We heard several examples of plans who rushed to a solution before laying a strong data foundation tied to the business problem they wanted to solve.
While risk adjustment may have been the common thread running through many sessions at the 2019 RISE Conference, the main takeaway is broader: Risk adjustment may be the trigger for health plans to undertake many of the initiatives outlined above, but the benefits of these efforts will expand beyond this realm. Delivering seamless member and provider experience—powered by data—will allow health plans to set themselves apart from others as we head into a new decade.