Health plans realize the value of comprehensive risk and quality programs to meet the needs of providers and members. These programs are also critical to addressing increasing regulations and the focus on quality. For Medicare Advantage in particular, it’s important to address quality as defined by the Star Rating system and the bonuses that are applied there, as well as risk adjustment coding and the CMS-HCC model.
Even when risk and quality are managed separately, it’s important to understand how to align budget and program dollars while minimizing member and provider abrasion.
Constructing a comprehensive risk and quality program
A comprehensive risk and quality program factors both retrospective services and prospective services.
Prospective services: Enable maximum value at the point of care
• Segmentation of population
• Suspecting and targeting
• Risk and quality segmentation
• Chronic care management
• In-home assessment
• In-office programs to close gaps in care and improve Star Ratings
• Field-based resources that support providers
Retrospective services: Occur after the point of care
• Chart reviews from different points of care
• Validation coding and data submission to CMS, RAPS and EDPS.
• HEDIS medical record retrieval process on the quality side
Integrated analytics and reporting
Comprehensive risk and quality programs incorporate integrated analytics and reporting. Member analytics focuses on members with a declining risk adjustment factor (RAF), members without office visits, medication adherence and the health care quality patient assessment forms. Some of these areas don’t require advanced analytics to segment. But others, such as medication adherence, require a higher level of analysis.
Other required population metrics include HCC prevalence and recapture rates. Provider and group summaries are also essential, particularly benchmarking data to determine how providers are performing in your market.
Reporting and analysis of the revenue projections and financial management will help you determine where to draw the line to help ensure adequate return, and answer the question, “Where’s the best bang for my buck?”
Reporting and analytics tools should show the performance of a population against a variety of parameters. In a multi-payer environment, it’s important to see where gaps are and then deploy resources to address them. Maximum data visibility is key to drive performance and make sure you meet your resource deployment.
Are you getting the risk adjustments you need? Are your Star Ratings headed in the right direction? The art is in bringing it all together and making it work: analyzing, adapting, pivoting programs and redirecting resources.
Download our white paper, “Medicare Advantage risk adjustment: How deep is the well?” for a deeper dive into this topic.
About the Author:
Ryan McKeown, Quality Lead, Network and Population Health Consulting, Optum
McKeown leads the strategy and delivery of consulting offerings to develop, implement and drive successful integrated quality programs in the Medicare Advantage, Medicaid and commercial/ACA space. His specific areas of focus include governance, strategy, financial/ROI, engagement programs, technology, data management and analytics across HEDIS, CAHPS, HOS, pharmacy and operations measures.