CenseoHealth & GHG: Retrospective Review Poll Results
Drum roll please…
Question: What percentage of your membership are you targeting for retrospective evaluations?
Answers: Prof. McCallum Report Card:
32% of webinar attendees said 80-100% of members B-
Far too large a net is being cast and possibly too much money spent on charts that are not yielding much clinical or financial impact. Let's focus this and use stronger analytics to reduce this number.
Remember only 60% of HMO & PPO members actually have an HCC.
**Score: B
If you are a dual SNP, this may be a reasonable starting point but even this volume should be reduced as your evaluations increase.
20% of webinar attendees said 65-79% of members B
This is a good foundation but as you increase your prospective evaluation this volume should continue to drop. Retrospective review doesn't impact HEDIS or STARS so pushing more work over to evaluations will have a great result across your health plan with the right evaluation partner.
25% of webinar attendees said 50-64% of members B+
This is an excellent foundation if you are targeted 25-30% in member evaluation for 2010. Continue the good work and reduce this volume next year as you increase the evaluations
8% of webinar attendees said 35-49% of members A
If you are targeting, 30-50% in member evaluations for the same year this should cover the bases. If you aren't, you may be not accurately reporting the health status of your members and missing needed premium to cover the medical expense for next year.
15% of webinar attendees said Less than 35% A+
If you are targeting, 60-100% of your membership for evaluations in the same year, feel safe and confident in this approach. If not, increase your evaluations immediately because you have not capture your membership's health status.
Facts to remember:
• Charts may be difficult to find during RADV
• Retrospective review does not impact HEDIS, STARS, medical management, plans of treatment or medical home strategies or scores
• On average in a HMO, POS, or PPO Medicare Advantage population only 60% of the members have an HCC (don't over review your population)
• It is not cost effective to review charts to find suspect charts; improve your analytics
• Providers work with multiple health plans with both risk adjustment and HEDIS chart review needs. Try to knock on their door as infrequently as possible.
GHG Announcement!
We're thrilled to announce the launch of CenseoHealth, a new kind of HCC Management company. Stand by for more discussion on these pages with my colleagues Jack McCallum, M.D. and RaeAnn Grossman. If you have any questions or feedback I welcome it at ngoldstein (at) ghgadvisors.com--- or just leave a comment here.
What is the "advantage" in Medicare Advantage?
All the clamor over cuts in MA reimbursement and audits of MA payments has caused us to lose track of what this program can do that traditional Medicare cannot.
Risk adjustment has made direct, careful clinical assessment of MA members a financial imperative. The Stars program has made measuring quality of care for those members a necessity. MA plans have the unique advantage of being able to: 1) merge claims and clinical data in a single, actionable database and 2) use that data to positively impact the care their members receive.
The recent push to prospectively evaluate MA members' chronic care conditions and the care they receive for those conditions does both—and traditional Medicare cannot do either.
This is a marvelous example of a situation where CMS is using financial incentives to effectively drive care for America's seniors. Maybe there really is a strong case for moving more Medicare beneficiaries into this well-designed model.
Member Evaluations Don't Replace the PCP
For obvious (and very good) reasons, Medicare Advantage plans want to maximize the unique opportunity afforded by in home evaluations of their members. There is no question that these evaluations can yield diagnostic information that is essential to risk adjustment revenue management. The opportunity to collect clinical information and merge it with data from claims and Medicare return files makes it possible for MA plans to positively influence care in a way that fee for service Medicare cannot. Direct member evaluations also provide a way to quantify and improve measurable standards of care such as those included in HEDIS, ADA standards of care for diabetics, ACC standards of care for cardiovascular disease, and Star ratings.
One question that comes up repeatedly in our conversations with plans is whether we can collect even more data during these encounters. Specifically, plans are interested in having our physician evaluators collect specimens for laboratory studies that factor into HEDIS and Stars measures. On the face of it, this seems like a natural extension of the service, but there are a couple of not so obvious drawbacks.
First, we are very hesitant to do anything that might be seen as coming between a member and his or her treating physician. That is a unique and valuable relationship and we want to make sure that what we do only enhances it.
Second, we are concerned about the chain of responsibility in collecting that information. First, a physician or other licensed provider has to order the test in question. Our physicians can certainly do that, but then someone has to take the responsibility of checking the result and providing appropriate care based on the results. That our doctors cannot do since that would require establishing an ongoing clinical involvement that would directly conflict with our determination not to interfere with the member's relationship with their treating physician. An alternative would be for the plan medical director to accept responsibility for ordering and following up on the lab studies, but most plan CMOs are not willing to do that.
For those reasons, we have been hesitant to collect lab specimens as part of our evaluations, although we willing to discuss alternatives with our clients who need that service.
Risk Adjustment: This isn't Dodgeball, People
Let's have a quick check in about risk adjustment and the multi-disciplinary team that should be pushing it to success.
Remember the days of dodgeball? ...picking teams and getting smacked by the red rubber ball? In risk adjustment, you must ensure your team has the right members, or you're gonna be left with more than just a ball-shaped bruise on your thigh. Here are the teams, and some of the members you must ensure are on your committees:
- Risk Adjustment Strategy: Risk Adjustment, Finance, Network Management, IT, Compliance and Medical Management, plus an Executive Sponsor
- Risk Adjustment and STARS Synergy: Risk Adjustment, Finance, IT, Medical Management, Quality/STARS, Network Management, and Member Services
- Risk Adjustment & EDPS: Risk Adjustment, IT, Claims, and Vendor (if you have one selected)
Make certain your team members:
- Understand the basic rules of risk adjustment
- Clearly recognize the importance of risk adjustment success
And don't forget:
- You MUST have an executive sponsor for those inevitable bumps in the road
- There MUST be alignment between the departments on priorities and strategies so that there is a clear path to your objectives.
This isn't dodgeball. Risk Adjustment is more like Capture the Flag. There will be winners; there will be losers. NO TROPHIES for participation. Pick your team well and keep them focused.
June is GO Time for Risk Adjustment: Your Program Check List
It's June! And most people are thinking about summer vacation... unless, that is, you work in risk adjustment.
This is Go Time.
Those living in the risk adjustment world should have their programs designed and launched by now. Are you on target? Here's your checklist:
- Chart Review: List Developed, Outreach Done, Collection and Coding Started
- Goal: 20-30% by the end of June
- Hospital Data Collection: You've contacted your high admission hospital and you are on schedule for receiving tons of hospital data electronically by August 15th to insert into your September Sweeps.
- Goal: All 2010-2011 through QTR 2 in by August 15th
- Prospective Evaluation: List developed, outreach done, evaluation scheduling started
- Goal: You should be sitting at about 20-20% completed
After doing this for the year, we realize that from Thanksgiving to the New Year the physician offices, hospitals, and members are much harder to reach. Retrieval and closure rates fall significantly.
Save your vacation requests for a winter getaway ... It is Go Time Now