Industry Voices—A path forward for successfully managing risk adjustment, care quality amid COVID-19

The shockwaves of the COVID-19 pandemic are reaching far and wide and having a particularly acute impact on our healthcare system.

The current focus is, and should be, on treating those infected with COVID-19 and flattening the curve. However, with the intense focus on the sick and those brave healthcare providers who are facing unfathomable challenges every day, we should also begin to think about the implications we’ll face after the immediate crisis is over.

We’ve essentially put a huge chunk of everyday healthcare services on hold, which could have serious consequences down the road for both health plans and physicians. Many basic healthcare needs, preventive services and wellness visits—which represent the bedrock of keeping populations healthy—aren’t happening for millions of Americans.

This has a disproportional impact on the most vulnerable populations—especially Medicare beneficiaries. Delaying care is not only bad for seniors who cannot receive the treatment they need but also hurts health plans' risk adjustment and quality programs—not to mention providers who need to generate income to keep practices open.

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In these extraordinarily challenging times, it’s important to be creative and proactive to keep patients healthy and the system financially afloat. For MA plans, it is essential to keep members engaged in their well-being and to empower providers to deliver care in a flexible manner.

In the absence of creativity and collaboration, health plans will face a reduced ability to risk adjust their membership and close gaps in care at a time when the dollars for care are needed most.

This is a challenging situation, to say the least, with more questions than answers at this point. The good news is that there are solutions that can help health plans avoid falling behind on their risk adjustment and quality programs. Here are three things to do right now that will make a difference.

Focus on preventive care

Though it may not be top of mind, reinforcing preventive health of seniors is critical to mitigating more serious and costly health conditions. This, however, is incongruent when most of the country (especially seniors who are the most vulnerable) are being advised to stay at home and avoid all nonessential contact with others.

As a result, many seniors have already stopped visiting their primary care providers for preventive services such as Medicare Annual Wellness Visits (AWVs), recommended screenings and health monitoring.

What can an MA plan do? Fortunately, the Centers for Medicare & Medicaid Services (CMS) announced in March that it has expanded access to telehealth services that are covered by Medicare. While limited before, CMS has broadened telehealth-based coverage to include AWVs, office visits and other preventive services.

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Given seniors’ increased risk, health plans should encourage members to use COVID-19 as a catalyst to seek preventive care via telehealth, ideally from their existing PCPs. This will help them limit the risk of exposure as well as manage chronic conditions, which can increase the risk of complications from COVID-19.

Ultimately, telehealth should be viewed not only as a health system pressure valve and a social distancing mechanism but also as a coding and risk adjustment strategy.  

Rethink health assessments

MA plans frequently utilize home assessments as a component of their risk adjustment programs. However, given their vulnerability, seniors are understandably wary of allowing home assessment professionals to enter their homes during this pandemic.

Once again, health plans should encourage and incentivize providers to use telehealth to perform appropriate encounters and coding.

This unprecedented situation also shines the light on an important question about health assessments: Who should do them? Now is the time for health plans to lean into a provider-centric risk adjustment strategy that improves the accuracy of coding, enhances patient care and outcomes and reduces risks associated with RADV audits. Seniors should be working with their PCPs, not third-party clinicians that have no connection to treating providers or access to appropriate medical records.

Promote telehealth and support member engagement by providers

Since CMS approved that massive expansion of telehealth services covered by Medicare during the COVID-19 health emergency, seniors can now access a broad range of services via telehealth, including routine care, AWVs and other preventive services.

Importantly, telehealth visits will be reimbursed at the same amount as in-person visits. While the vast majority of telehealth services require the use of audio and video capabilities, HHS has indicated that providers may use popular apps that allow for video chats without risk of penalties for noncompliance with HIPAA.

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The temporary expansion of telehealth is a tremendous opportunity—if it’s utilized. Since telehealth is new for most provider and seniors, it is important to implement easy-to-use technology and efficient workflows.

Providers and health plans also should collaborate on effective member-engagement strategies and tools. Expanding the breadth of telehealth enables seniors to minimize their risk of contracting the virus while also receiving routine care and staying current on important preventive services.

There will be light at the end of the tunnel. For now, health plans shouldn't lose sight of the long-game and develop creative risk-adjustment and quality-of-care solutions to avoid a post-COVID-19 crisis.

Hassan Rifaat, M.D. is CEO and board member of Vatica Health. He has over 25 years of experience leading healthcare organizations. He served as CEO of Windsor Health Group with 300,000+ members, held senior executive positions at Humana, and served as SVP at Coventry Health Care for over 1.5 million members across 11 states.