Physicians typically do not embrace risk adjustment with open-arms. While efforts to accurately document and code chronic conditions can make the difference between profit and loss to health systems and provider-led plans taking risk, physicians often feel that this extra “administrative” work does not contribute to their primary mission, to make patients well.
In our recent webinar, we invited Dr. David Koehler, Market Medical Director and Physician from Deaconess Health System, to discuss with attendees how he’s been able to convince physicians that risk adjustment is worthy of their time and attention.
The purpose of risk adjustment is to standardize understanding of providers’ relative risk to assist appropriate reimbursement. But we know for executives, the term “risk adjustment” often conjures images of large pay-outs from failing exchange plans to their competitors. And for physicians, risk adjustment can connote stacks and stacks and stacks of papers from insurers blanketing their offices.
So how do you pull off running a risk adjustment campaign that is successful and engages your physicians?
Three of Evolent’s risk adjustment experts discussed just that during the webinar’s panel discussion. Dr. Koehler was joined by Michelle Nelson, Medical Coder and Director of Risk Adjustment operations who has led “boots on the ground” efforts in risk adjustment campaigns and Mike Lee, Managing Director of Risk Adjustment at Evolent.
Below are a few of the key insights shared:
#1. Risk adjustment goes beyond just dollars and cents
While risk adjustment was born out of an actuarial function, Mike Lee pointed out that the act of capturing chronic conditions through proper documentation has windfalls that can impact both population health and value-based care efforts. While Mike worked to develop a solution that identified suspect conditions for risk adjustment, he found the solution was also a big benefit to risk stratification efforts: by providing an accurate, complete patient profile, care coordination became simpler to achieve across the patient population. As Dr. Koehler explained to the physicians in his network, through proper documentation in the medical record, submitting full information via claims data and closing the loop across the patient’s profile, everyone is finally able to operate off the same information. By closing this information loop and accurately documenting the illness burden for the entire patient population, patients with more complex needs requiring more effort can be appropriately prioritized. As Dr. Koehler pointed out, this allowed his ACO to more meaningfully deliver on their mission, engage physicians and drive success.
#2. It’s all about the docs
In order to capture those complex needs, risk adjustment relies on physicians providing accurate and complete documentation in the medical record. Dr. Koehler shared how he helped successfully launch a physician-led risk adjustment program at Deaconess Health System. While “going out and talking to the docs was key”, he spoke to a few of the barriers, stating that “there are gaps in education, and it is hard to get your head completely around risk adjustment and why it is so critical”. In fact, he noted that during some initial conversations, most of the docs had never heard of risk adjustment before, associating the acronym RAF more with Royal Air Force than Risk Adjustment Factor. Many physicians may see risk adjustment as an unnecessary step, further saddling their already overburdened daily routines. In order to win the attention necessary, successful risk adjustment operations make sure they proactively engage physician leaders to serve as program champions and help communicate the clinical value of the program. Communication in this context should not mean training. Dr. Koehler summed everything up by stating, “Physicians practice medicine because they want to treat patients, not so they can be treated as medical coders.”
#3. Solutions built by payers are built for payers, not physicians
Solutions built by payers traditionally crush practices with mandatory coding education and training, leaving them overwhelmed with paperwork. “Physicians went to medical school. They are not coders,” said Mike. He further explained that payer-led solutions put much of the burden on the physician practice to uncover whether the codes were missing or misrepresented, leading to documentation that would not pass a CMS audit. Solutions that do not put the physician first and think critically about how to flex to the practice’s culture and operational norms will miss the mark for accuracy and success in their risk adjustment program.
#4. Engaged physicians are only one piece of the puzzle
While removing the burden on physicians is important, physician engagement goes beyond having physicians understand the importance of risk adjustment and its impact on clinical value. Michelle Nelson discussed how robust data and analytics are necessary in order to catch conditions that may be present and not documented, or documented and not present. She also emphasized the importance of providing accurate data to ensure that a physician will trust its suggestions. To close the webinar, Mike highlighted how many solutions also show leakage between the physician and the payer – that is, a physician documents and submits their codes appropriately, but during the scrubbing at the payer side the codes never make their way to CMS. For a risk adjustment campaign to be successful, it is of the utmost importance to focus on reconciling submitted and recognized codes, and ensuring chronic conditions are captured year over year.
To review our webinar, the full recording is posted here.
For more information on Evolent’s Risk Adjustment solution, contact us at firstname.lastname@example.org.