Looking Ahead: Technology Developments in the Areas of Risk and Quality

TripleTree rounded out the healthcare conference circuit in Nashville earlier this month with the 11^th Annual RISE Summit.  The town was buzzing with country music and rumors surrounding aspects of the GOP’s “repeal and replace” of the Affordable Care Act (ACA), later rolled out as the American Health Care Act.  Among the uncertainty in today’s healthcare marketplace, there are a handful of realities that providers and payers alike will continue to wrestle with: risk adjusted reimbursement, quality reporting, and compliance in the value-based care paradigm are all here to stay.  Although changes can be expected to many government sponsored initiatives as enacted under the ACA, Medicare Advantage remains a relatively safe haven in terms of projected growth and continued focus in the areas of risk and quality.

Many stakeholders in the risk adjustment marketplace are left with daunting questions:  how will the traditional functions of medical chart reviews and in-home assessments evolve in this new environment?  How will health plans advance their efforts to access and consolidate real-time clinical data?  In a world of unstructured data and disparate EMR and database systems, how can data analytics be implemented and leveraged by all interested parties in the risk adjustment process?

According to Talix, an industry-leading provider of risk adjustment analytics, 80% of all clinical data needed to accurately code a patient’s health status is unstructured – be it free-text physician care plans, historical and handwritten chart notes, or specialist reports.  To address these challenges, vendors are leveraging advanced NLP technologies and machine learning to redefine the risk adjustment workflow.  Technology has enabled vendors to process clinical data in a more efficient manner, supplementing coding efforts to identify missed or inaccurate codes on the most complex, and financially critical member charts.  Through the use of these tools, many plans and outsourced coding vendors have experienced a 3-4x productivity increase in their coding function.

Advances in this space have also allowed vendors to drive optimal performance via direct integration with the EMR.  Tighter integration with the EMR has obvious benefits and reimbursement ramifications: improved prospective risk-adjustment results are achieved by identifying population groups that are more likely to require certain procedures, and allow providers to proactively address gaps in care in real-time.  These solutions have the ability to provide least-cost intervention programs and prioritize a members’ care plan adherence and behavior.

Managing the cost of intervention programs can be a challenging task for health plans pursuing up-to-date risk adjustment data.  Chart reviews and in-home assessments are critical for identifying gaps in care and/or missing HCC codes; however, if certain gaps are expected to be closed in normal course, there is no reason for a health plan to incur this expense.  Vendors such as Pulse8 are leveraging broader sets of both traditional (claims) and non-traditional data sources (social, lifestyle, etc.) to provide a more accurate roadmap for a health plan’s intervention needs.  By leveraging non-traditional data sets, health plans can more accurately predict certain member behaviors, such as the likelihood that a member will see their primary care provider within the next 90 days, or the probability of adhering to a prescribed care plan.  All in-all, these capabilities provide health plans with more insight and control over their downstream intervention planning.

As a final point, industry consensus compares risk adjustment technology to any other technology tool: the platform requires guidance, oversight, and subject matter and clinical expertise to pass quality and reimbursement standards. This point is critical.  Whether you are a health plan or a risk-bearing provider, the vast majority of risk adjustment submissions are to government entities.  If a member’s chart is miscoded or inaccurate, a payer will have permanently lost a reimbursement opportunity and potentially expose themselves to rigorous government audits and oversight that results in a significant strain on resources.

We will continue to monitor this space as growing developments take hold among stakeholders.  In the meantime, please let us know what you think.