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Some things just go better together, like cowboy boots and country music, or the RISE Summit and Nashville. By blending the industry’s most respected authorities on risk adjustment and quality with Music City’s hospitality, you get one of the best healthcare conferences around.
Perhaps Verscend was prophetic in selecting “better together” for its RISE theme, as there were plenty of interesting pairings on display.
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We tend to focus on healthcare quality and cost at RISE because both are so important to the sustainability of healthcare in this country. However, the keynote sessions with actor and motivational speaker J.R. Martinez and country music legend Naomi Judd reminded us that individual patients are the reason for all that we do.
Martinez is the retired U.S. Army veteran known for sharing his story of injury and recovery after his Humvee detonated a landmine in Iraq. The theme of his talk was no matter how well you’ve defined the path you want your life to take, life often has other plans. Your ability to stay positive, to adapt, and to make the most of outside factors by redefining your goals ultimately determines your success.
Judd, in turn, shared stories from her new book, “River of Time: My Descent into Depression and How I Emerged with Hope.” She reminded us that mental illness is a difficult disease to recognize and successfully treat, but with more compassion and an understanding of early signs and symptoms, we can make meaningful progress. Her calm and comforting style was the perfect bookend to Martinez’s high energy. Thanks to RISE for inviting them both!
Do risk adjustment and quality improvement, in particular through CMS’s Star Ratings program, go together like cookies and milk? Although not a new topic, presenters shared their struggles and successes when their plans worked to combine the two, recognizing that accurate patient documentation has both clinical and financial benefits.
Plans still struggle with making meaningful progress toward integrating the technical aspects of siloed programs, such as care management IT systems, provider communication applications, actuarial data stores, and medical record reviews, just to name a few. The slow progress is understandable because change can have serious financial consequences.
Plans are achieving some success when they connect the two in simple ways, focusing on provider engagement. For example, PacificSource Health Plan co-presented a session on how to leverage revenue and quality efforts to deliver specialized diabetes care. Their in-home assessments and mobile testing equipment got more physicians on board with quality improvement efforts, which also helped collect data for accurate risk adjustment factor (RAF) scores and more appropriate funding.
For our part, Verscend introduced a new Star Ratings solution at RISE that deepens the level of information and support that health plans can receive from Verscend. Plans can now more easily model various scenarios, gain the insights necessary to efficiently close care gaps, and enlist providers as partners in quality improvement, which in turn can lead to more accurate RAFs. Read our new fact sheet on Star Navigator, or contact us to speak to someone about a demo.
Payer-provider collaboration has been a mantra in healthcare for at least the past decade, but opposing incentives and lack of integrated systems and data have thwarted efforts. This year’s RISE, more than any previous conference, seemed to cover the topic in practice more than just theory. Health plan panelists in the session, “Lessons Learned on Reaching the Top and Staying There: 4 and 5 Star Panel,” discussed how they collaborate with their provider partners to achieve better results. A representative from Health Alliance Medical Plan, for example, shared that the plan minimizes duplicative member/patient contact by talking to their physicians, understanding their goals, and aligning health plan goals for greater impact.
Another session addressed meaningful reductions in admits per thousand, bed days per thousand, and re-admissions by reforming both the practice and payment of care. The speaker discussed study results from a delegated medical group versus fee-for service and integrated health system models, showing that while there were significant improvements in care, the model alone wouldn’t get the industry to truly shift from volume to value. He said that health plans must also work with providers in closing their own gaps in risk adjustment and quality analytics, retrospective medical record review, and health risk assessments. Suggestions included more targeted intervention recommendations, appointment coordination, and provider education and training.
“Machine learning is not magic. It’s just hard work.” The statement by Verscend’s chief analytics officer, David Costello, kicked off a discussion about the practical application of technology in “Data Patterns and Predictive Magic: How to Improve Suspecting and Chart Valuations.” Costello and Presbyterian Health Services showed the before-and-after results of a retrospective risk adjustment approach that adds analytic rules to traditional clinical rules. Presbyterian found that the addition of analytic rules exposed a potential gap in appropriate funding of $4 million in undocumented or under-documented conditions.
How do you solve the challenge of risk stratifying newly enrolled Affordable Care Act (ACA) plan members with no prior health history? The answer: the practical application of technology-enabled clinical laboratory results, according to Cigna in their Tuesday afternoon session. The session presenters highlighted that while lab data informs some 70 percent of medical decisions, payers underutilize this data in risk stratification and adjustment despite the accuracy and availability. Results are timely too, as they are typically delivered well before treatment decisions are made. This allows Cigna to also use the data for proactive and collaborative member/provider outreach.
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