Industry Voices—Optimizing risk adjustment during COVID-19

primary care
Health plans will continue to face challenges in risk adjustment and quality of care as long as traditional methods remain impractical. (Getty/Milkos)

As stay-at-home orders are lifted and states begin to reopen, healthcare is starting to get into the rhythm of a “new normal” with COVID-19.

Patient volumes are beginning to rebound, particularly related to preventive and routine care visits. While this a refreshing trend, it is unclear how long it will last given the rise of coronavirus cases and the rollback of state reopening plans.

Some of the consequences of this trying situation are that providers are in dire straits and health plans will continue to face challenges in risk adjustment and quality of care as long as traditional methods remain impractical.

Fortunately, there is a solution—a PCP-centric approach to risk adjustment and quality. As we enter the second half of the year, health plans can aggressively support their PCPs to close gaps in care and improve risk adjustment revenue through continued use of telehealth and more targeted member engagement. 

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Today’s pandemic could be tomorrow’s problem

During the pandemic, patients have skipped most preventive and routine healthcare visits—annual wellness visits, regular check-ups, chronic condition management and more. And understandably so. Office closures, social distancing guidelines and a nationwide emphasis on acute care has made it difficult for patients to envision or even get to a PCP visit.

As a result, PCPs have experienced an unprecedented decrease in volume and revenue—up to $65,000 annually by some estimates.  

Conversely, health plans are currently experiencing favorable trends in Medical Loss Ratio (MLR), though not for ideal reasons. Fewer routine visits and canceled elective procedures mean lower utilization.

While this creates a positive financial impact in the near-term, lower utilization translates to missed routine care and management of chronic conditions, especially for seniors who are at greatest risk of coronavirus and hospitalizations, which leads to much more expensive care down the line.

All of these factors make risk adjustment and maintaining quality of care even more critical for health plans. But, plans are already starting to see disturbing trends resulting from PCPs not being armed with the rights tools and support to capture accurate diagnoses coding.

RELATED: Medicare Advantage plans face 'double whammy' of pent-up care demand and risk scores, experts say

A recent Avalere study on the potential effects of COVID-19 on Medicare Advantage risk adjustment revealed that 2020 claims among members between January, February and March, dropped from more than 20% to just 4% in April. Additionally, the number of diagnoses reported per member decreased. In January 2020, 28% of members had 10 or more diagnoses. By April 2020, the percentage of patients with 10 or more diagnoses dropped to just 14%. In short, diagnoses and claims are down. And, that’s not because people are getting better.

Avalere estimates that these effects could drive a 3% to 7% decrease in risk adjustment payments for plans. Distribute that across a population, and that is a lot fewer dollars for care next year—right when PCPs and plans will be playing catch-up on care management.

Today’s solution could be tomorrow’s saving grace

The picture for health plans and their PCPs is not all cloudy skies. The good news is that members want to reconnect with their PCPs, especially seniors—the ones that need preventive and chronic care the most.

In a June 2020 survey conducted by William Blair Equity Research, seniors reported that their primary reasons for canceling care visits were related to logistical challenges of provider office closures and stay-at-home orders, as opposed to fear of COVID-19 exposure. Now that more practices are reopening, and CMS is encouraging people to “get back to non-COVID healthcare,” seniors are likely to return to get the care they need. This gives both PCPs and health plans the chance to address chronic conditions and document diagnoses for more accurate coding and risk adjustment.

Though some patients will return, the reality is that many others will stay home, especially as the second wave of coronavirus spreads across the country. In a recent survey, 40% of Americans said they are still delaying medical care due to COVID-19 risks. For health plans, continued support of telehealth and effective member engagement will be the key moving forward.

RELATED: UnitedHealth exec on telehealth use, reimbursement: 'The genie is out of the bottle'

Telehealth can help PCPs and plans bridge the gap between those who want to be seen in-person and those who will want to stay home. And given that CMS formally allowed risk adjustment to be performed via telehealth using real-time audiovideo encounters in April, telehealth can also help health plans continue to perform well on risk adjustment and quality initiatives. Health plans should encourage continued use of telehealth among PCPs, especially as telehealth usage is starting to decline after an April-May peak.

When considering how to do support PCPs’ use of telehealth moving forward, health plans should prioritize:

  • A PCP-centric approach: A solution that is PCP-centric (as opposed to an independent telehealth solution with no connection to PCP or the EMR for continuity of care) enables PCPs to provide better care and perform more accurate and complete coding for risk adjustment. It also enables PCPs to generate much needed revenue.
  • Audio and video emphasis: While CMS has loosened restrictions on audio-only for certain encounters, risk adjustment still requires an audio-video connection. Plus, numerous studies have shown that live video visits are also a better and more comprehensive experience for both the provider and patient when compared with audio-only. 
  • Member engagement: For members, overcoming perceptions of telehealth can be a significant hurdle to jump. This requires more patient education, coordination, and hand-holding, which takes time that strained and short-staffed PCPs do not have. Health plans can help PCPs by sponsoring solutions that help providers engage members to schedule appointments and effectively utilize audio-video telehealth.

Now, more than ever, health plans should aggressively support PCPs to implement telehealth and member engagement solutions that optimize risk adjustment and quality initiatives for everyone’s long-term health and success.

Hassan Rifaat, M.D., is CEO and Board Member of Vatica Health.