Clinical Insights

Health Risk Assessments: At the Intersection of Risk and Quality

Creating an integrated approach to risk adjustment and quality can be complex, there are a number of factors to consider beyond the core activities health plans utilize to close gaps in care or obtain accurate member documentation, such as alignment of goals and financial impact to each program. However, building a strategy to integrate both business areas is achievable if health plans start taking small steps in that direction by slowly joining efforts in activities that share similar objectives.

This is where in-home health assessments come in — as one type of campaign that can be leveraged by both risk and quality teams. This integration is also best case scenario for the member, as it will only take one visit to capture pending HCCs and getting an accurate snapshot of gaps in care.

This is what a typical in-home health assessment entails: During a prospective visit, a clinician such as a nurse practitioner will visit a member at a site such as their home, a provider’s office or other inpatient setting. The clinician will take a current health history, review all medications, perform labs and tests and recommend follow-up care.

After a visit, clinical providers can also notify PCPs and the plan of any urgent findings. Referrals and recommendation reports can also be sent as required by the plan. And last, the clinical team completes QA and accurately document and code each visit to close any gaps addressed. As this can apply to both risk and quality gaps, prospective health assessments can be crucial to both Risk Adjustment and Quality Improvements — payers can leverage them to ensure the success of their objectives for both programs.

Prospective Health Assessments & Risk Adjustment

An accurate view of population health is key to successful risk adjustment. Payers who can answer the following questions about their patient population are a step ahead:

  • How sick are they?
  • Who is high-risk?
  • What are they high-risk for? (Which conditions should the payer anticipate?)

Payers often utilize suspect analytics to better identify, prioritize and reach members most likely to have undocumented conditions. With an up-to-date, prioritized list of patients, payers can better target conditions in a risk-adjusted payment formula. Also, the patient list will strategically guide their prospective health assessment outreach. When used effectively, prospective health assessments positively impact Medicare Advantage revenue integrity by closing risk-adjustable gaps through accurate documentation and coding.

Prospective Health Assessments & Quality Improvement

Similarly, prospective health assessments can also close HEDIS quality gaps in care. This is key for Medicare Advantage plans’ STAR ratings, as HEDIS scores are a primary data source for multiple measures. (And with the cut-point increases for many 2018 STAR ratings, payers again are reminded that achieving and maintaining STAR ratings requires a rigorous pursuit of success).

Closing quality gaps also can help ensure patient care compliance and improved care quality. For example, when assessments identify high-risk patients, they not only round out payers’ views of population health, they also can help ensure said patients are enrolled in the appropriate case or care management programs. Additionally, any follow-up care recommended will also likely include opportunities to close other quality or risk gaps. Case management programs typically result in better care and outcomes (which translates to improved quality metrics going forward) as well as higher patient satisfaction.

By capturing both risk-adjusting conditions and a variety of HEDIS measures, prospective health assessments can play a key role for both risk and quality initiatives. For patients, they also can improve care-delivery by promoting coordinated care between members and providers.

Through their ability to promote better outcomes financially and clinically for all participants in the care-delivery system—payers must assess whether their current risk and quality strategies are utilizing such assessments effectively.



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Presentation @ RISE VBC: Effective Collaboration Strategies Between Payer & Provider