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RISE to the occasion: quality, risk adjustment, payers, and providers converge

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March 22, 2017

Although its Nashville location remains the same, the Annual RISE Summit continues to grow in size and importance each year. RISE, or the Resource Initiative and Society for Education, has been bringing its membership together for 11 years to address fundamental issues in risk adjustment, performance measurement and improvement, and payment integrity. The American Health Care Act, the GOP alternative to the Affordable Care Act, was a focal point for this year’s meeting with its release on the eve of the conference. However, RISE is well known for its best-practice sessions, and while the future continues to be debated, there is clearly plenty of work still getting done to move the industry closer to value-based healthcare delivery and payment even in the midst of uncertainty.

Here are some of our key takeaways from this year’s event.

collaboration is growing between quality and risk adjustment teams

A key topic for presenters and networking attendees was how aggressively many health plans are bringing their quality improvement and risk adjustment “shops” together. Typically, risk adjustment has been aligned more closely to payers’ financial strategies, while quality programs have focused on exactly that: ensuring health plan members are receiving appropriate care and that care gaps are closed, with a secondary purpose of serving as marketing tools for those plans that can tout exceptional results in programs such as HEDIS or the Medicare Advantage Star Rating System. As major payers, including Medicare, Medicaid, and private plans, move to incentivizing quality or penalizing the lack thereof through financial rewards, a new perspective is emerging. The operational and financial benefits of integrating these programs is driving change.

payers need more guidance on risk adjustment best practices

RISE panel discussions and client conversations indicate that payers do not anticipate that the risk adjustment program will change dramatically under the new administration. However, they are grappling with the lack of standardization in risk adjustment practices, and the industry may begin to move more aggressively towards self-enforced compliance as it waits for the Centers for Medicare &

Medicaid Services (CMS) to introduce more certainty into the process by more clearly defining what’s allowable and what’s not. Otherwise, payers will continue to be nervous about being selected for a Risk Adjustment Data Validation (RADV) audit and potentially having to pay back money in the future.

Another major concern for payers is the risk of “whistleblower” lawsuits for alleged Medicare risk adjustment fraud. These lawsuits in many cases are being brought over standard practices that are perfectly in line with the principles of risk adjustment. Poor provider documentation, incomplete or inaccurate data, and other issues open the door for confusion and accusation, yet these are fixable by instituting data integrity and other best-practice programs that ensure operational excellence.

providers are beginning to know what they don’t know about managing risk

As providers have moved into risk-based contracts, they have had to simultaneously balance the demands of “business as usual” while learning and mastering new skills that at times are at odds with their existing ones. The majority of these new skills have at their core the desire to improve clinical and financial outcomes by better managing health at a population level. It’s been a struggle, as several presenters pointed out, and technology vendors are not doing enough to make it easier for providers.

RISE presenters and attendees do not expect the transition to value-based care to slow under the new administration, but one significant difference we observed this year is that providers are developing a greater understanding of the difficulty of mastering the first critical steps in risk management: aggregating and analyzing data to find the insights necessary to manage populations rather than individuals. As one attendee put it, “I have data. I just don’t know what to do with it.” Even where organizations have had analytics in place, they often lack a strategy for change.

 

The opportunity for providers and payers to collaborate around common goals while allowing each group to play to its strengths has never been greater—but requires understanding and trust.

a balance of high-tech and high-touch is needed to optimize quality and risk adjustment improvement

Healthcare seems to fall in and out of love with technology. This year at RISE, the pendulum seemed to be swinging toward high-touch approaches, with many vendors and sessions sharing the ways in which clinical and other teams are deployed to fill gaps in technology-driven approaches—for example, to gather far more information from members more efficiently and with a higher degree of member satisfaction through mobile clinics, home visits, and similar “blasts from the past.” However, there was still plenty of discussion about machine learning, natural language processing (NLP) within risk identification analytics, and automated chart coding for those of us who love geeking out over the latest technologies—or just get excited when the not-so-new ones start proving their value.

Are high-touch and high-tech approaches at odds? Of course not. If anything, this year’s RISE Summit was a reminder that healthcare is equal parts art and science, people and technology, old ideas and new.

 

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As vice president of product at Verscend, David Bartley drives the product development strategy for Verscend’s quality improvement line of business, working closely with sales, client services, data operations, and development teams. David has more than 10 years of experience leading product development at a variety of leading healthcare companies, including Humana, Healthways, and eviCore. He holds a BA in economics from the University of North Carolina at Chapel Hill and an MBA from Vanderbilt University.

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