The case for prospective strategies
Prospective strategies deliver up-to-date information that helps health care organizations understand the current health of patients. This information allows payers and providers to be more proactive in reaching out to patients, which should ultimately result in better health outcomes.
Tools for success
A successful prospective risk adjustment strategy requires the right tools. An advanced analytics platform that is capable of data management, reporting, and creating customized dashboards can deliver information directly to providers in a format that is easy to understand. With in-depth, up-to-date information about patients, payers and providers are able to engage patients with tailored outreach instead of a generic, population-wide approach.
A case study in prospective strategies
One of Episource’s clients found noteworthy success with prospective strategies. This health plan serves a large area along the southern border of Texas. The location of this service area presents some unique challenges in providing care. First, this is a mostly rural area with providers located far from some members. Secondly, this area includes the border with Mexico, so language barriers and other social determinants of health (SDoH) factors prevent some residents from seeking care.
To address the unique challenges they face, the health plan implemented some novel solutions. For example, they enlisted a fleet of airplanes to bring care to their most remote members.
The health plan has also built a strong physician engagement program that gives providers the tools they need to reach and care for members. An important component of this program is client care gap management. Representatives from the health plan visit and work with provider offices to identify which patients may need additional care. Then, the health plan and provider reach out to those patients and get them the care they need.
Recently, the health plan visited over two dozen providers representing one-third of the plan’s total membership. These providers were identified as influential leaders among their peer group and one of the goals of the roadshow was to leverage peer influence to encourage all providers to adopt best practices for risk adjustment.
Many strategies shared during these visits centered around prospective risk adjustment’s ability to pinpoint gaps in care. Using Episource Analyst, the health plan was able to share real-time member data with each provider they visited. In many instances, the data revealed conditions that the clinicians were previously unaware of. Other topics covered included:
- The importance of annual coding: If an HCC is not documented during a given year, then the provider is no longer treating the condition in the eyes ofthe Centers for Medicare & Medicaid Services. Even chronic conditions that the provider has been treating for years must continue to be documented annually for as long as the provider is treating the patient.
- Chronic disease management: The mandate to code annually should also serve as a reminder to reach out to patients with chronic conditions regularly. Providers need to make sure the condition is still being treated properly.
- Recognizing new diseases: Similarly, providers should always be aware of any new conditions a patient develops. New diseases and changes in health could impact the patient’s future treatments.
The drive to emphasize the benefits of a prospective mindset appeared to yield direct results. The providers who were visited posted an increase in recapture rates of eight percent, on average, in the last quarter of the fiscal year. Anecdotally, the providers also voiced support for the data and prospective strategies that served as the foundation for the roadshow. Why? Because this forward-looking approach is enabling more proactive care.
Developing a prospective mindset
Prospective risk adjustment begins with data and analytics. You must also have the right team and technology in place to analyze and interpret that data. Finally, you must leverage these data insights to engage proactively with patients about treatment. These interventions should, in turn, yield new data that will feed back into improving the entire risk adjustment process.
When prospective strategies are implemented effectively, everyone benefits. Health plans capture complete information on their members, which should lead to more accurate risk scores. Providers gain a better understanding of their patients’ health and are able to plan treatments proactively. Most importantly, patients receive preventive care in a timely manner that will help them lead healthier lives.
About the author
As Sr. Director of Platform Strategy and Solutions, Eric is at the intersection of Product, Operations, and Client Services with a focus on the development and execution of innovative health care solutions. He has a background in mobile technology and served as an Emergency Medical Technician in South Los Angeles. Eric holds a BA from Lehigh University and an MBA from the USC Marshall School of Business.