The unique characteristics of the Commercial Health Insurance Marketplace mean healthcare organizations including Qualified Health Plans (QHPs), Accountable Care Organizations (ACOs), Patient-Centered Medical Homes (PCMHs), and many others are facing the difficult task of providing the highest levels of care while concurrently lowering costs and managing regulated payment models.
This is undoubtedly a new playing field. HHS has greatly expanded the traditional risk adjustment models to include a much broader, less homogenous, adult population. There are also now separate models for infants and children.
Payers are deliberating the best answers to several crucial questions, notably:
- How do we treat the newly insured in the risk adjustment assessment process?
- How do we impact individual risk scores and payer-level risk scores?
- What intervention types and strategies should we deploy?
- How do we avoid unnecessary interventions?
These sometimes conflicting priorities require thousands of decisions, from the programs to funding, to the networks required to manage care, to the types of data to collect from the many systems and infrastructures in place today.
The combination of managing multiple data sources (medical and non-medical) to significantly improve the accuracy of a population’s health complexity will be required to be competitive in the new marketplace. Trying to enrich risk adjustment factors and contain costs will require the use of predictive analytics to reach beyond claims data to improve confidence levels and realization rates that will positively impact members’ health.
[Related: 6 steps to prep for HIXs.]
With a condensed schedule of 15 months, health payers know that they will have to analyze populations more objectively and independently and manage effective interventions with speed and accuracy. The key for payers is to understand member behaviors, in addition to their conditions, so that they can improve targeting in a climate of anticipated high attrition. Moreover, a more comprehensive member profile will lead to better intervention capabilities.
These are important goals as we move into new Commercial risk adjustment models. To protect risk adjustment dollars, here are some things payers can do now as they prepare provider networks, systems and infrastructure for commercial risk adjustment:
- Perform analyses of conditions most susceptible to documentation issues within existing populations
- Identify and prioritize condition sources
- Establish performance benchmarks for providers that require targeted education
- Evaluate and identify possible coding abnormalities at the provider and group levels
- Analyze provider specialty patterns and sequencing for inappropriate diagnoses
- Integrate systems to ensure that providers adhere to health care standards for the exchange
- Establish online health self-assessment tools for new enrollees to complete
- Deploy mobile applications to educate new members about wellness and interventions
- Utilize patient/provider-influenced gap closure through integration of analytics
These sorts of activities will enable payers to customize interventions, integrate most recent findings, and adjust throughout their program to achieve optimal financial performance.
Improving efficacy
Health payers will be required to improve member targeting in a climate of anticipated high attrition. The estimates vary, but some payers project attrition as high as 30 percent within their populations. This level of member turnover means payers will be forced to examine intervention alternatives within their existing healthcare delivery system. Such forces mean that payers will have to apply innovative and timely solutions to inform members of the right intervention at the right time. Appropriate interventions should be tiered, based on member behavior and where they are within the calendar year. We also know that not all things work for any one group, doctor or patient. Perhaps it is better to begin with low-cost interventions such as text messaging and screening reminders, then work your way up to education materials and phone calls, before deploying more costly efforts like in-home assessments?
[Infographic: HIX race begins with Big Data.]
There is hope. Payers who deploy innovative methods to collect member and provider-reported data sooner will offer them more frequent access to their members’ needs. This sort of information means payers can avoid unnecessary waste and improve financial performance. It also means that by leveraging real-time data, payors will know exactly why, how, when and what interventions they should deploy — improving outcomes and containing costs.
More than risk factor improvement
While payers are concerned about revenue optimization, they are equally concerned about improving the overall health of their members. Chronic diseases — such as heart disease, stroke, cancer, diabetes, asthma and arthritis — are among the most common and costly of all health problems in the United States (National Center for Chronic Disease Prevention and Health Promotion, 2009).
The good news is that some chronic diseases are also among the most preventable diseases. For example, a recent CDC study showed that 44 percent of people who learn they are pre-diabetic are likely to avoid the disease. Timely, low-cost interventions can help members live healthier lives. Informing members means empowering them to not only help manage their chronic diseases, but also possibly help prevent disease occurrence or delay the onset of disease and disability. Timely interventions might lessen the severity of disease and improve the health-related quality and duration of members lives.
Visibility into member — and provider — behaviors will allow the most cost-effective and appropriate interventions.
Related articles:
Are health plans using the right HIX tools?
How are you fueling HIX analytics?
Are you on the cutting edge of risk adjustment?
