Risk Adjustment Helps You Succeed in the Fee-for-Value World

The transition to fee-for-value healthcare drives provider groups to be more focused on managing population health than ever before.

To provide high-quality, affordable care, providers need to better understand who their patients are; from health status to living situation. Critical importance is understanding the total picture of chronic conditions to ensure appropriate revenue is available to provide care.

Missing on Risk Adjustment can lead to significant financial losses…

Not using risk adjustment to determine your reimbursement levels can result in significant losses and broader financial instability in a downside risk arrangement. Risk adjustment also poses challenges for providers who are trying to adapt their business models from fee-for-service care (where expenditures can be directly tied to specific healthcare services received) to value-based payments where spending often occurs as a result of multiple events across different clinical settings over an extended period of time—making it more difficult for payers and providers alike to attribute costs with certainty.

David Duel is an entrepreneur, philanthropist, and the founder of the healthcare platform EasyHealth. EasyHealth is a 400-person Medicare platform that combines insurance and healthcare services for their patients’ benefit. Duel comments, “Without the proper tools and strategies in place, many providers will find themselves unable to compete with larger organizations that already have greater economies of scale and more advanced technology than what smaller practices may be able to use effectively.”

FORMAT: File needs to be organized in side-by-side column format

Justify side (in order going down page): What is risk adjustment, what are benefits, how does it help providers

Right side (in order going down page); How Can You Make Use of Risk Adjustment, How Can Primary Care Physicians Improve on Their Current Methods of Risk Adjustments?

 (JUSTIFY COLUMN) What Is Risk Adjustment?

Risk adjustment is a statistical model to help appropriately map resource requirements to chronic disease burden at a patient. More simply, it is an effort to establish, prospectively (CMS-HCC model), an expected annual cost at a by-patient level.

(JUSTIFY COLUMN) What Are the Benefits of Risk Adjustment?

Risk adjustment is a way for providers to ensure they are appropriately cohorting their patients in an attempt to stratify resources against those patient populations. “Walking well” patients require less intensive ongoing care than those who are home-bound or have limited mobility. Appropriately mapping the risk score for each patient is critical to receive appropriate funds to cover the total cost of care (TCOC) for patients.

(JUSTIFY COLUMN) How Does Risk Adjustment Help Fee-for-Value Providers?

David Duel continues, “As healthcare moves from a fee-for-service model to value-based care, we’re seeing an increasing focus on innovative care models to better manage a cohort of patients, like a diabetic population. By appropriately and accurately capturing risk adjustment factor (HCCs), provider groups are able to provide additional and targeted resources for the patient cohorts to manage TCOC and ensure patients live happier, healthier lives.”

“Additionally, we know providers don’t go to medical school to code CPTs. They learn to develop care plans to manage patient disease. Risk adjustment and HCC capture is an alignment of provider’s past learnings with a statistical model that equates in targeted clinical disease management, oversight, and data at a more specific level.”

(RIGHT COLUMN) How Can You Make Use of Risk Adjustment?

By implementing risk adjustment, you’re better able to assess your expected expenditures against actual results which allows you to stay ahead of changes in patient needs while improving your overall financial performance at the same time. By identifying patients who are more likely to incur high costs over time, you can target your efforts to help them stay healthy and avoid unnecessary treatment. By partnering with providers that have a proven track record of success in the fee-for-value world, you can also gain access to best practices for risk adjustment which you may not be able to implement effectively on your own just yet.

While adjustments pose many challenges for healthcare organizations at all levels, they’re still an essential tool used by payers—and eventually will become one of the most crucial factors in ensuring successful patient outcomes overall.

(RIGHT COLUMN) How Can Primary Care Physicians Improve on Their Current Methods of Risk Adjustments?

Different factors influence the determination of risk adjustment scores. Three critically important variables include socioeconomic status (SES), social determinants of health (SDOH), and medical history.

Primary care physicians typically already do a good job of using medical history to calculate risk adjustment. Most primary care physicians, however, do not do much to document patient socioeconomic status or capture SDOH.

Patients with lower SES typically have less access to preventative care and will therefore suffer from a higher rate of illness or injury due to their lack of early diagnosis or treatment options.

Providers can establish prevention plans and support mechanisms to prevent emergencies and unnecessary hospitalizations.

How Can I Find Out More?

David Duel offers, “If your team has questions on the risk adjustment model, EasyHealth is here to help. We have over 50 years of combined experience with deep subject matter expertise in the area driving gold-standard performance for national provider groups and health plans alike.”

For more info on EasyHealth and David Duel, see : Medicare startup EasyHealth gets $135M in series A to fill information gaps