Medicare Advantage risk adjustment: How deep is the well?

Medicare Advantage risk adjustment: How deep is the well? With increasing regulation and focus on quality, comprehensive risk and quality programs are more important than ever. Whether you re engaging providers or reaching out to members, your risk and quality objectives need to be aligned. For Medicare Advantage in particular, it is important to consider 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 if risk and quality have separate owners within your organization, it s important to understand the best use of aligning budget and program dollars and how to make sure you re minimizing member and provider abrasion. A comprehensive risk and quality program factors both retrospective services and prospective services. Prospective services are provided before the point of care, while retrospective services are actions or services taking place after the point of care. Retrospective services Prospective services Attribution CMS payment projection and bid support Revenue reconciliation Analytics and reporting Population segmentation Risk and quality segmentation Stars measures Medicare retrieval and reviews Hospital data capture chart reviews Attestations RAPS & EDPS submissions Retrieval, review and submission Care gap analysis HEDIS/STARS HQPAF Chronic condition management In home assessments RADV Claims verification (CV) Internal data validation OIG audits Compliance Provider and member engagement Field based resources Embedded in office Provider training and education Member outreach Creating a comprehensive risk and quality program Retrospective services include your chart reviews from different points of care, validation coding and submission of that data to CMS, RAPS and EDPS. They also include the HEDIS medical record retrieval process on the quality side. Prospective services consider the segmentation of population, suspecting and targeting, risk and quality segmentation, also the opportunity to close quality gaps to improve Star Ratings. They also include chronic care management, the role of in-home assessment, and how to leverage field-based resources to support provider offices. optum.com

Integrated analytics and reporting Integrated analytics and reporting are foundational, whether you re talking about retrospective activity or prospective opportunity. 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. Others, such as medication adherence, require a higher level of analysis. The actual patient assessment forms are really the end results of programs and analytics and targeting. It s also important to get population metrics that 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 are designed to answer the question: Where s the best bang for my buck? These projections can be critical to help you determine where to draw the line to help ensure adequate return. Integrated risk adjustment, clinical gaps and performance reporting identify the right intervention strategy PCP RAF report Members with declining RAF Group & provider Summaries Disease prevalence Population Metrics Member Analytics Members without office visits Medication adherence HCC prevalence & recapture rates Revenue Projections & Financial Management Health care quality patient assessment form Member & plan level revenue projections Restatement of MMR retroactivity Program attribution analysis Prospective programs Prospective programs enable maximum value at the point of care either at the clinic, mobile, urgent care, or the provider s office. They feature the following services: Member segmentation Segmentation provides an understanding of the member s engagement and the primary care provider s engagement against the underlying opportunity. With that information you can define an intervention strategy that will have multiple channels or touchpoints. Provider enablement strategies Provider enablement strategies allow you to identify areas where there are gaps and focus on how those gaps can be closed. These strategies leverage the analytics and reporting and then the nuances for gap closure. optum.com Page 2

Providers and provider groups can be categorized into three tiers. In the tier 1 environment, providers are really self-service. They just need the data, a portal, and access to forms very little support. The tier 2 providers may need resource support. They might need to attend a webinar, maybe HCC 101 or Stars 101, or possibly require a select number of charts to understand their opportunities. Basically, tier 2 providers just need a little nudge. Tier 3 providers need intensive support. They might have little or no exposure to risk adjustment. They may not be connected in terms of electronic medical record (EMR) connectivity and there may be geographic challenges as well. They may need embedded resources or partially embedded resources. Provider groups can fluctuate from tier to tier. So, if a tier 2 provider gets the training they need, maybe sitting down with one of our resources for an hour, they might move into tier 1. Your analytics and performance reporting should have the capability to measure that fluidity of performance to make sure you re adequately engaging providers. Analytics and reporting to identify gaps Reporting and analytics tools should show the performance of a population against a variety of parameters. In a multi-payer environment, we want to see where gaps are and then how to deploy resources to address them. Whether you have our own programs or you are partnering on programs built for someone else, 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 heading in the direction you want? The art is in bringing it all together and making it work: analyzing, adapting, pivoting programs and redirecting resources. In-office programs to close the gaps For providers, almost any ask is a workflow disruption. So how do you most effectively minimize workflow disruption to obtain data from providers in the most efficient way? It s all about making forms as simple as possible and standardized across all payers. For example, our one-page, member-specific Healthcare Quality Patient Assessment Form is standardized across health plans and combines risk and quality to maximize patient data and streamline reporting for providers. optum.com Page 3

Creating a concise view into program performance requires the ability to integrate all of these data elements across multiple complicated objectives and waves of data from multiple sources across timing. If you are implementing prospective programs to identify and close the gaps, how do you know if you are achieving your business goals? Precise, detailed reporting that shows your true performance is crucial to meeting your objectives. One tool Optum uses is an executive dashboard. This dashboard allows you to set key performance indicators (KPIs), to move around geographically and see how the markets are performing inside a specific contract. You can also see the RAF breakdown and can look at specific PCP groups. Provider field force support Even when providers are really excited to provide great care, they may not necessarily be empowered and trained to do the best job of optimizing risk adjustments, documentation, or coordinating gap closure in the instance of Star Ratings. Additional support may be the key to success. Whether you are doing this yourself or using somebody else s national footprint, it is important to: Collaborate Use some exchange of data and common tools Ensure that lag is low and the information is high Make these requests as concise as possible If you re not using a field force support program, consider having a candid assessment of the bandwidth, capability and interest of your network leads. Member outreach In addition to provider support and enablement, several member engagement programs are effective with regard to quality and risk. The outreach is integrated across risk and quality but the positioning to the members is always about wellness, quality gaps and making the best use of their benefits to stay healthy and manage any conditions they may have. optum.com Page 4

With wellness campaigns, member data is important. It s important to reach out to members without visits but first those members need to be appropriately identified. Reaching out to new members is also important. It s an opportunity for data capture to understand what has been done, what hasn t been done, and how members would like to be communicated with in the future. High-risk members need to be pushed more aggressively where there are many quality gaps or a lot of risk adjustment revenue at stake. Consider partnering with your CMO or health plan medical director to set covenants. For example, should you send colonoscopy reminders to someone on hospice? Understanding whatever clinical guidance and covenants your plan has in place relative to these programs will help you minimize member abrasion as you maximize risk avoidance. Outreach campaign strategies Successful outreach campaigns are all about reaching the right member, with the right message, at the right time. Your campaigns will be focused on target populations to close gaps you ve identified for example, members without office visits or high-risk suspects. It s also important to coordinate to make sure that call campaigns are not taking place at the same time as CAHPS, for example. When you re running a campaign, past activity will be a predictor of future compliance. Retrospective programs Retrospective programs aren t new: everyone needs a chart review program. But how do you go about it? There really isn t an end to how far a retrospective program can go, how precise it can be, how broad it can be. With a retrospective program, the member has left the office so the opportunity to assess the condition or document is done and now you are focused on data capture particularly chart review. Comprehensive chart review, suspecting and analytics Effective chart retrieval and the ability to collect the chart are critically important for both risk and quality. It s important to have different means of retrieval. Some people rely too heavily on electronic retrieval and encounter parts of their network that can t provide electronic charts. Others that don t have electronic means to charts are limiting larger providers. Anything you can do to cut down on the disruption to a provider s workflow will help enhance the relationship and pave the way for future participation. Once you have the chart, it s a matter of accurate coding, quality assurance, submission, reporting and attribution. Deep dive To identify which chart reviews are most likely to close the gaps in coverage that we see, assign each chart a score based on various data sets. Charts then can be stratified into different chart score groups with the appropriate groups being selected for review. The ability to stratify and be more precise allows your organization to budget your dollars appropriately and determine the type of activity level you want to pursue as well as the return you can expect. Chart selection How do you know specifically which charts to pursue for review? Different data sets are available to you to look at to get started with the chart selection process: 1. Your clinical data set 2. Your physician data set the specialty, place of service, the activity of that physician, how they have historically performed 3. The clinical risk profiles what kind of suspect member is this 4. The physician profile physician specialty dates of service and engagement optum.com Page 4

Because each chart group will yield a different kind of return, it can help you gauge how much investment you want to make. How deep do you go down this path? You don t need to chase every chart with the same level of resources or intensity to conduct an efficient, effective chart review. Chart segmentation and attribution Most plans want to achieve a certain return on investment (ROI). Stratification and targeting allows you to assign a value and categorize every single chart. While you may decide to only focus on charts in the top categories to maximize your ROI, how many categories you include in your review really depends on how broad of a total picture are you trying to get for your organization. The top two percent is going to provide a very high ROI, however a large percentage of your charts may be in that category with the lowest yield. You may still find, as some of our clients do, that the ROI is still worth it to pursue charts in those groupings. Or you may find that it makes sense to cut off at a higher grouping. The decision can be based on your budget, ROI calculations or a total revenue number.the analytics inform your decision so you know how deep to go. Chart waterfall How do you decide how many charts should be retrieved? This Waterfall example illustrates one method to calculate the number of charts for review. Starting with the total number of members, then subtract 10% as an estimate of those who didn t have a visit or the visit was to a specialist or a place of service that really doesn t count for risk adjustment or it doesn t yield anything. Some members will have more than one chart and some charts will be excluded for various reasons. Running the analytics will allow you to arrive at a fairly specific number with very little actual data so you get an idea of how many charts to target. But how can you be sure you re getting the right ones within that list? That s where the next focus comes in looking at the data. Stratifying by chart grouping, being able to put all of those in and rank them, you can see how the charts are distributed across score group. This provides a much more informed and valuable discussion. 2017 and beyond Although chart review has been around for a while, it s certainly changing as we look at emerging technologies. Some of the major changes include EMR, natural language processing (NLP) and computer assisted coding (CAC). EMR is here to stay. Integrating with EMRs is a request that the provider community makes all the time. Think of it as push and pull: The ability to pull information out of the EMR without bothering the physician office, or push information back in. How are you integrating with EMRs? optum.com Page 4

Even with the large EMR companies like Epic or Cerner, there isn t a simple way to automatically integrate. Any kind of integration requires consistent interaction with a provider practice to get the systems to talk to each other, often over a two- to five-year time horizon. Along with EMR integration, once you ve reduced the resource burden of retrieving a chart, there are technology applications to code the chart. One of those is NLP being able to scan typed text and determine that certain conditions are present, flag them and identify that information to set it up for CAC. Having a computer read the word Diabetes is NLP; using the computer to then calculate that into a code is CAC. These technologies significantly increase the number of charts per hour that your organization can review, and inform other programs to gain added efficiencies. Take your risk adjustment program to the next level As the industry shifts from a volume to a value approach, most payers have developed strategies for value-based reimbursement with their providers. But some haven t made the clear connection between quality and risk adjustment as part of their evolving strategies. Risk adjustment needs to inform and drive value-based reimbursement models with providers. This is a characteristic shared by the highest performers. Fortunately, there are more approaches and tools than ever prospective and retrospective to build a comprehensive risk and quality program and take it to the next level. Why Optum Medicare Advantage risk adjustment services from Optum streamline risk management processes and assist in closing gaps in care and improving quality. About Optum Optum is an information and technology-enabled health services business platform serving the broad health care marketplace, including care providers, plan sponsors, life sciences companies, and consumers. Learn how Optum can help you build a strategy based on a prospective and retrospective approach. Contact an Optum representative at: Email: empower@optum.com Phone: 1-800-765-6807 Visit: optum.com optum.com 11000 Optum Circle, Eden Prairie, MN 55344 Optum and its respective marks are trademarks of Optum, Inc. All other brand or product names are trademarks or registered marks of their respective owners. Because we are continuously improving our products and services, Optum reserves the right to change specifications without prior notice. Optum is an equal opportunity employer. 2016 Optum, Inc. All rights reserved. WF266736 11/16