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Clinically Enhanced Risk: A Payer-Provider Partnership

Session 174, February 22, 2017

Rowena Bergmans, VP of Clinical Integration and Population Health,

Western Connecticut Health Network

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Speaker Introduction

Rowena Bergmans

VP of Clinical Integration and

Population Health

Western Connecticut Health Network

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Conflict of Interest

Rowena Bergmans

Has no real or apparent conflicts of interest to report.

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Agenda

• Plan-Provider Partnerships Can Support Fee for Value Success

• Risk Adjusted Reimbursement

• A New Approach to Identifying Risk in a Patient Population

• Pilot Program with Health Plan: A Detailed View

• Recommendations: Ultimately, It’s About the Patient

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Learning Objectives

• Apply lessons learned from this strong, data-focused payer-provider

collaboration to improve the health of a defined population.

• Define the five key types of data capture gaps that can impact risk adjustment

• Choose an appropriate intervention approach to close different types of prospective data capture gaps at the point of care

• Formulate a plan to close retrospective data capture gaps that directly impact risk-adjusted premiums for a prior plan year

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An Introduction of How Benefits Were Realized for the Value of Health IT

Care teams see open risk, tied

to provider appointments

Risk can be assessed and

documented at the next point of

care opportunity.

Unlike claims-only reporting, this

is actionable by the practices in

a timely manner.

Integration of 3 EHR data

sources and 1 claims source -

with integration expanding to

include 8+ EHR platforms and

8+ claims feeds.

Management of patients with

complex or chronic conditions

System-wide view of patient

conditions and risk enables

appropriate planning and

deployment of care management

and other services

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Plan-Provider CollaborationWhy working with a health plan made strategic sense for Western Connecticut Health Network

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Western Connecticut Health Network

WCHN has made a commitment to value based care:

500,000+ lives In service area

100,000+ lives Managed under risk

Market threats:

taxes and competition!

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WCHN and Health Plan

+ = SHARED

GOALS

Large community

hospital system,

with strong,

engaged network

Health plan with

resources to

support investment,

and claims data

Improved patient care

and more accurate

risk-adjusted

reimbursement

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Why a Plan-Provider Partnership?

Transformed care delivery and ongoing care management

SHARED

CHALLENGES

• Moving from fee-

for-service to fee-

for-value is difficult

for both payers

and providers

• Requires upfront

investment for

success

SHARED

OPPORTUNITIES

• Health systems

that partner with

plans can create

shared

opportunities

• Improve patient

care while also

improving financial

performance

Comprehensive

data about patient

population

Appropriate network

development and

physician incentives

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Priority: Improving Patient Care

RISK MANAGEMENT

INVESTMENT

Investing in accurate

capture of patient risk

ensured funding that could

be directed to needed but

non-reimbursable

resources

DATA FOUNDATION

INVESTMENT

Data offers tremendous

clinical value beyond risk-

adjusted reimbursement,

and has changed how we

deliver care

COMMUNITY

HEALTH WORKERS

WORKFLOW

AND SERVICE

REDESIGN

CLINICS FOR

CHF, COPD

BH REFERRALS

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Risk-Adjusted ReimbursementMedicare Advantage contracts reimburse providers based on documented patient risk

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Risk-Adjusted CompensationWHCN takes on risk for Medicare Advantage, Commercial, and ACO populations, where payment

is adjusted based on patient risk scores – and is dependent on the quality of documentation.

MEDICARE

ADVANTAGE

• Risk-adjusted

premiums (HCC)

• Traditionally, plans

submit data from

claims to CMS

ACO (MSSP)

• Risk determined every

3 years or at renewal

• Adjustment down –

but not up – within

period

COMMERCIAL

• Private algorithms, but

similar documentation

requirements

• Full risk = critical to

understand

population’s health

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From Data to a Risk Score

Image used courtesy of Arcadia Healthcare Solutions

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Resolving Information Lost Along the Way

Claims data is often incomplete due to information loss – impacting

documentation collection and risk-based intervention efforts.

Retrospective Resolution

Required care often provided and

documented – but not submitted.

Data alone can improve risk

adjustment accuracy, without

burdening the provider.

Prospective Resolution

Historical information can suggest a

diagnosis that was not captured.

• Example: Antipsychotic Rx, but no

diagnosis of a psychiatric condition

Care teams can be engaged to

address (and document) risk.

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A New Approach to Managing Risk

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A New Approach to Managing RiskWCHN and the health plan adopted a four-part plan to improve risk documentation and patient care for Medicare Advantage members:

POINT OF CARE

WORKFLOWS

Integrate clinically

enhanced risk

information into

workflows at the

point of care

PROSPECTIVE

IMPROVEMENT

Identify current year

(prospective)

opportunities to

improve risk

documentation and

care

RETROSPECTIVE

RESUBMISSION

Identify retroactive

resubmission

opportunities

(improving accuracy

of prior year

premiums)

USE EHR AND

CLAIMS DATA

Supplement claims

data with robust EHR

data

1 2 3 4

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Data Foundation

• Identification of

documentation gaps

• Identification of missing

clinical evidence

• Not just a point solution

for Medicare Advantage,

but a platform for all

initiatives

HEALTH PLAN

CLAIMSEHR #1 EHR #2 EHR #3

RETROACTIVE

RESUBMISSION

RAPS

Analytics

Data Warehouse

Data Extraction

Image used courtesy of Arcadia Healthcare Solutions

MEMBER #MEBXXXXRFemale 65-69 years old

Treated by Karen Tarbell in

August and December 2015.

Assessed with diabetes (250;

HCC 19), morbid obesity

(278.01; HCC 22), and CHF

(416.8; HCC 85) in signed

encounter. Also has history of

vascular disease (HCC 108).

Potential recovery of

assessments in PY16 through

confirmation with provider.

Est’d Value: $1,127 per month

MEMBER #MEBXXXXNFemale 70-74 years old

Prescriptions from Danbury

Primary Care and Med Assoc of

Danbury

Ongoing prescription for

Ropinirole (NDC 00054011625),

principally used to treat

Parkinson’s and Huntington’s

Diseases (HCC 78). Also has

outstanding Problem List entry

of vascular disease (HCC 108).

Est’d Value: $838 per month

MEMBER #MEBXXXXSMale 65-69 years old

Currently treated for

uncomplicated diabetes and

heart arrhythmias

Problem list and historical

claims indicate cancers (C73;

HCC 12), hematological

disorder (D69.6; HCC 48), and

complex diabetes (250.7; HCC

18).

Est’d value: $555 per month

Example (De-Identified) Opportunities

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Retrospective Resubmission• CMS allows retrospective submission as much as 13 months after the end of the

service year for Medicare Advantage.

• EHR data can be used for resubmission with no provider effort when there are:

– Signed progress notes for face-to-face visit

– Assessments on encounters where diagnosis is present in face-to-face visit, but there is no signed note.

• EHR data can be used for highly targeted chart reviews when:

– Inactive prescription claims, medications on medication list typically associated with a disease, or diagnoses marked as active on problem list.

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Prospective Opportunity Identification• Plans, providers, and patients benefit from early intervention and documentation –

but this is hard for a plan to do alone.

• EHR data can be used to support targeted reviews at the point of care when a patient has:

– Inactive prescription claims

– Medications on EHR medication list that indicate a diagnosis

– Diagnoses marked as active in EHR problem list

– Diagnoses present on a prior year claim with no E&M code

– Historical claim with no prior year entry

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Point of Care SupportActing on current year or prospective opportunities requires tools that present the information at the point of care – and ongoing leadership and coaching.

To avoid

burdening

physicians…

WCHN used

medical

assistants.

• MAs use registries to

identify gaps

• Standing orders for MAs to

close routine gaps

• For non-routine items, MAs

put notes in the EHR

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Challenges: Technical

Data Source Availability

Some members had data in EHRs that were not yet integrated into WCHN’s data asset

These members could not be analyzed

Time Constraints

WCHN and the health plan were under contracting-related time constraints, and had to move forward before all data elements were available

Results are likely understated

Avoiding False Positives

Not all gaps are actionable – for example, diagnoses stemming from pathology or radiology test offer too many false positives

Invest effort appropriately

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Challenge: Operational• Driving improvement at the point of care is a challenge – traditional lists

generated by health plans are often rejected by practices

• WCHN approach:

– Suggestive analytics at the point of care

– Integrated data platform supports care teams

• Automated patient outreach

• Reminders about care gaps and upcoming appointments

• Workflows and analytics for care managers

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Pilot: Population analyzedThe health plan provided details on 1587 MA members that were attributed to WCHN in 2015. WCHN

matched these to available clinical records and analyzed the performance of the health plan’s finalized

RAPS submission against the 1331 MA members with matching clinical data at WCHN.

RAPS and Historical Claims

data supplied for the 1587

MA members the health

plan attributes to WCHN.

WCHN has providers on 10+ different

EHRs. At the time, the data foundation

included the 3 EHRs that have the

most coverage of WCHN’s provider

network.

These 3 EHRs contain demographic

and/or clinical data on 1331 of those

MA members. It is expected that the

other 256 MA members are spread

across the other EHRs.

1587 MA LIVES 3 OF 10 EHRS 1331 MA LIVES

EHR #1

EHR #2

EHR #3

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Opportunities Identified

12.3%

Premium

$687.91pmpm

$7.28pmpm

$77.65pmpm

$772.86pmpm+ + =

Finalized Premium from

RAPS & Demographic

Premium Adjustment from

Retrospective

Opportunities

Premium Adjustment from

Prospective

Opportunities

Total Premium

Opportunity

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Recommendation: Data Foundation

• New approach to risk requires a data asset aggregating EHR and claims data

• Investment can be shared across a network or with a health plan

– Plans get straight-line ROI

– Providers get clinical value beyond risk documentation

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Recommendation: Timing

• Factors to consider when planning a clinically enhanced risk project:

– Build in time for data quality

– Consider window of opportunity for retrospective resubmission to CMS

– ACO can only adjust risk every application period

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Recommendation: Technology + Leadership

Two kinds of investments are necessary from the health plan and the health system to make this kind of collaboration work:

LEADERSHIP

• Ensure care teams incorporate risk

review into their workflow over the

course of the plan year

• In-practice training for front line

clinicians and pre-visit planning

TECHNOLOGY

• Identify prospective opportunities to

review risk and document at point of

care.

• Activation, engagement, and

management of high risk patients

managing complex conditions

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Ultimately, It’s About the Patient

This plan-provider collaboration enabled WCHN to:

Accurately pinpoint patient need

Target resources appropriately

Measure intervention effectiveness

Support non-reimbursable services

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A Summary of How Benefits Were Realized for the Value of Health IT

Care teams see open risk, tied

to provider appointments

Risk can be assessed and

documented at the next point of

care opportunity.

Unlike claims-only reporting, this

is actionable by the practices in

a timely manner.

Integration of 3 EHR data

sources and 1 claims source -

with integration expanding to

include 8+ EHR platforms and

8+ claims feeds.

Management of patients with

complex or chronic conditions

System-wide view of patient

conditions and risk enables

appropriate planning and

deployment of care management

and other services

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Questions

Rowena Bergmans l Vice President, Clinical Integration and Population Health

Rowena.Bergmans@wchn.org