In anticipation of his RISE Webinar, “How to Better Leverage Member Data to Radically Improve In-Home Health Risk Assessments” on Jan. 25th, Dr. Rulph Lamour, Episource’s Medical Director and V.P. of Clinical Services, set aside a few minutes to discuss obstacles that limit HRA effectiveness, as well as strategies for health plans to overcome them.
Thank you for joining us today. What are biggest pain points for health plans in terms the effectiveness of in-home assessments?
For health plans, the biggest pain points boil down to three things: identifying members who need the HRAs, engaging them so they will take part in the HRA, and then ensuring that the HRA’s clinical findings are translated into an effective care plan. One example of this is an appropriate Disease Management program enrollment. This last element is huge: The onus is on the plan to make sure the follow-up HAPPENS.
Can you expand on the first point, identifying members?
Yes. One of the biggest pain points for health plans as well as for MSOs and IPAs is data analysis and targeting. For best results, targeting should include HCC gap analysis and pharmacy claim data. This helps plans identify two types of members: the most ill members, as well as those who have had the biggest RAF score drop from one year to another.
- The most ill members are the ones who are constantly hospitalized with worsening conditions. They are also the members with the most HEDIS/STAR and care gaps, meaning that they will benefit greatly from a comprehensive health risk assessment and an accurate clinical documentation of the member’s health status.
- The same is true for members who have had a big drop with their RAF scores compared to previous years. This usually indicates that the member’s chronic and ongoing conditions have not been properly assessed, evaluated and submitted via claims for the current calendar year.
For both the member types, the plan can then facilitate encounters with mid-level clinicians such as nurse practitioners (NPs) and physician assistants (PAs).
Can you expand on the second point–member engagement? And what tools health plans have to overcome these obstacles?
There are two parts to this for members: outreach and engagement. For outreach, effective methods include mailers, texts and emails, as well as electronic surveys that can be completed using smart devices.
Engagement gets a little more complicated. To engage members involves engaging PCPs. Patients usually listen more to their doctors than anyone else. So when a physician communicates the benefits of an in-home program to a member, it is likely that more members will participate.
So for the sake of clarification, providers need to be engaged for two main reasons: First, they need to be engaged to communicate the HRA benefits to members and encourage them to take part of this initiative. And second, they need to be engaged to ensure that continuity of care happens after a member has taken part. What are the strategies for each?
Health plans need to clearly outline the clinical benefits of a comprehensive health risk assessment in addition to an Annual Wellness Visit (AWV). The message to the PCPs should explain that the mid-level clinicians who conduct HRAs are not competitors. Rather, they complement the PCP’s work by addressing different areas of the member’s care and well-being usually not addressed during a routine visit or an AWV (for example, PHQ-9 screening for depression as well as substance or alcohol use screening).
A regular doctor’s appointment lasts about 15 minutes on average while an HRA averages an hour. Over this hour, important aspects of the member’s health are covered. There is potential to provide many benefits to all parties involved, including members, providers, payers and CMS.
For the second part, ensuring continuity of care after HRAs are completed. Health plans must make sure that the relevant clinical findings are shared with a member’s PCP so they can can be incorporated into an effective care plan. This is key to close any care gaps identified during HRAs, especially urgent ones.
And how does the health plan ensure that relevant findings are shared with PCPs, and that follow-up happens?
When an HRA provider sends out an urgent or non-urgent case management referral, that is then handled through a Case Management (CM) triage team. Ultimately, findings are shared with the members’ physicians through a PCP letter, phone call and/or an electronic transmission in partnership with the HRA provider.
One strategy for health plans to ensure follow-up is by incentivizing providers to take part. Not only will this satisfy CMS, it also improves member outcomes. An alert system can be used to deliver specific HCC gaps and clinical documentation improvement opportunities to the PCPs for proper capture. As a result, the PCP would be rewarded for the completeness of their documentation and for addressing any suspected conditions.
This incentive plan should focus on:
- Assessment of suspected conditions
So in what you’ve just described, this is a win-win for all parties: the health plans, member, PCPs, and CMS?
Can you describe the benefits for each?
Sure. Let’s start with health plans. Accurate and compliant documentation of all HCCs translates into the following benefits for plans:
- Less RADV exposure
- Accurate risk scores, which often means improved risk scores. In turn, this equals to accurate reimbursement
- Improved quality ratings by enrolling members in appropriate care management services
This last one brings us to the members. A huge benefit for members will be better health outcomes and increased quality of life, especially for those with high-risk medical conditions.
High-needs patients benefit greatly when their urgent conditions are rapidly assessed, diagnosed, treated and effective care management is initiated and delivered. Both outcomes and quality of life improve. Also, ER visits and hospital admission/readmission decrease.
The advantages for members also dovetail on the advantages for providers, as ultimately, they will have more support for the provider-member relationship, which means quality scores will also increase.
And for CMS, now their objectives align with provider engagement in disease management programs, a reduction in overall cost of care will follow.
Can you give a clinical example of this?
Yes, let’s say an HRA is done on a patient with stage 5 chronic kidney disease (CKD) and no documentation whatsoever is present of a potential secondary hyperparathyroidism. Thanks to clinical-based evidence, we know the risk of having a secondary hyperparathyroidism due to advanced kidney disease increases by more than 60%. Based on that, we are able to recommend the physician to order a PTH intact for that member. If the result is above the normal range, there is then support for diagnosing that condition, which is an HCC.
At this point, the PCP will be engaged, which means they now have the chance to treat the secondary hyperparathyroidism. This is a win for members, because left untreated, uncontrolled secondary hyperparathyroidism is associated with an increased risk of fractures and mortality, in addition to other physical, emotional and mental impairments that decrease quality of life.
That is good news for the patient. I know we’re at the end of time, so I wanted to thank you for taking part.