Health care market dynamics now impose risk adjustment and quality standards on financial performance across all market segments — Medicare Advantage, Managed Medicaid and commercial plans. To balance risks, improve quality and decrease costs, plans must move beyond retrospective claims analysis and basic assessments. Improving plan performance also hinges on provider engagement.
A changing market presents obstacles
Plans are faced with new obstacles such as member movement, coding variables, physician resistance, and documentation and data accuracy. To manage these challenges, plans should focus on the following actions:
- Reevaluate and prioritize a list of members to engage, focusing on those who can have the most impact.
- Overcome physician resistance with physician engagement tools and services.
- Fill gaps in physician engagement with member engagement tools and services so assessments become more beneficial to both.
- Establish an overall performance management infrastructure.
Know your engagement level
Improving provider engagement can be less daunting if plans follow two key steps:
- Focus on the top 30 percent of the member population first as it typically drives about 90 percent of care gaps. The remaining 70 percent of the population can’t be ignored, but honing in on members at the greatest risk puts the right capabilities in place to close care gaps.
Plans can then support providers serving top tier members by recapturing previous hierarchical condition categories (HCCs), embedding clinical extenders or establishing physician champion programs. Doing so will often yield improved closure of previously identified care gaps, improved comprehensive review of suspect data with patients, and improved verification of suspects.
- Identify where providers are on the spectrum of physician engagement and develop plans that will move them along on that continuum. It’s important to realize there is not a single approach that will work for every provider. Most plans are at one of three stages of provider engagement: (1) no foundation/just starting out, (2) foundation exists, but needs enhancement and (3) foundation is established, but refinement will enhance results.
With a higher level of provider engagement, plans can enhance their most important assessment tool — the relationship between the physician and the member.
To learn more about the impact of provider engagement, download our article, “Provider engagement has a major impact on quality, costs and outcomes.”
About the Author
Stephanie Will, Vice President Risk Adjustment, Optum
Will leads Market & Client Strategy for the Optum Risk Adjustment and Quality business. She has over 17 years of experience within the health care and managed care industries including, 10 years within the nation’s largest Medicare Advantage plan. Will has extensive experience in risk adjustment across all markets.
Steven E. Mueller, Senior Vice President, Business Platforms and Operations, Optum
Mueller is the leader of Physician Transformation and Provider-based RAF Prospective Services activities for Optum. Prior to joining Optum, Steven was the CIO for UnitedHealth Networks Physician and Hospital Contracting as well as led the Network Technology and Integration since 2002. He brings over 20 years of experience in the Operations and Technology industry.