360-Degree Risk Adjustment: Our Framework for Optimization

Steve WhitehurstOver the last year, members of the Health Fidelity team have offered posts outlining ways to incorporate risk adjustment best practices into your overall program. From our vantage point as partner to dozens of organizations looking to optimize their risk adjustment programs, we’ve continued to distill the strategies that drive success in this constantly evolving healthcare environment.  To that end, as 2016 draws to a close, I’d like to introduce our innovative new framework to address pervasive challenges across the industry: 360-Degree Risk Adjustment.

 

What is 360-Degree Risk Adjustment?

Risk adjustment as you’ve always done it is no longer viable; going forward, you must operate with a full 360° view of risk adjustment:

Component visual of the Health Fidelity 360-Degree Risk Adjustment Framework

360-Degree Risk Adjustment Defined

The comprehensive set of ongoing activities which project, detect, and capture all commensurate member risk, and thereby risk-adjusted payments, to cover healthcare expenditures for a member population.

A 360° approach considers risk adjustment optimization from all angles, including how to modernize technology, enhance provider collaboration, integrate with multiple departments, and obtain performance control and transparency.

Now let’s unpack the various components that comprise the 360° View:

  1. Organizational Alignment – Organizations should ensure they have the appropriate team structure, goals, and incentives in place. Clear communication of priorities from leadership and breaking down departmental silos will help to set up a foundation for performance improvements.
  2. Data and Performance Management – Organizations should leverage the various data sources at their disposal in a sophisticated manner in order to gain a more complete understanding of members’ health, increase the ability to carry out targeted interventions, and obtain a greater ROI. Accessibility to data and performance transparency are critical to achieving a culture of continuous improvement.
  3. Prospective Review – Organizations should conduct prospective review as effectively as possible to ensure that provider partners are equipped to deliver the right care to the right patients at the right time; doing so will improve both clinical and financial performance. Coordinated efforts in provider engagement, member outreach, and data-driven prioritization are key to optimizing results.
  4. Provider Engagement – Organizations must ensure the appropriate alignment, incentives, education, and tools are in place to increase providers’ engagement with payer-led initiatives.
  5. Data Acquisition – Organizations should enable access to the fullest breadth of up-to-date clinical data from medical records. The key is to invest in scalable solutions that enable multiple departments to leverage a common set of records and reduce redundant and costly chart retrievals.
  6. Retrospective Review – Organizations should implement technology-enabled workflows that allow risk conditions to be captured more accurately and more efficiently. When many of the tedious manual processes are augmented with technology, coders can better utilize their skills to focus on accurate coding of diagnoses.
  7. Compliance – Organizations should adopt modern approaches to compliance to ensure maximal adherence to regulations and protect against possible penalties. Small enhancements with coding processes can help to ensure proper validation of codes and better audit preparedness.

 

Why Approach Risk Adjustment Challenges Holistically?

Several industry trends are putting pressure on risk adjustment – including risk-based model enrollment growth, increasingly complex data submission requirements, scrutiny from regulators, and downward reimbursement pressures – signaling the waning utility of traditional approaches. There is a significant opportunity for risk-bearing entities to leapfrog their peers by taking a comprehensive approach to risk adjustment and aligning the function with the objectives of their overall core strategy.

 

Stay Tuned…

In the coming months, we will release a series of eBooks addressing each of these topics in greater detail. Each eBook will outline common challenges that organizations face along with our proven methodology for success.

Until then, I wish you a healthy and happy holiday season!