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Healthcare Analytics | Health Plans

How Payors and Providers can Partner to Improve Risk Assessment

June 18th, 2024 | 7 min. read

Carol Helton

Carol Helton

Chief Revenue Officer, ThoroughCare

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So much of a health plan’s business and operational structure revolves around risk and revenue. 

Whether through underwriting, risk modeling, risk adjustments, risk stratification or scoring, and risk assessments, payors want to reimburse for right-sized care via accurate risk-adjusted payments.  

As value-based care arrangements become more commonplace, partnering with providers to enhance the accuracy of risk assessment is critical to achieving the health plan’s vision. But how can payors and providers collaborate more to ensure they base risk modeling and scoring on the most timely, relevant, and impactful member data? 

Why are risk assessments critical for success?

Payor-provider collaboration around risk assessment is foundational to aligning incentives, revenue, and care acuity. This is especially true as payors continue to move more deeply into: 

  • Population health management
  • Care quality performance
  • Bi-directionally sharing data with providers to drive efficiencies and lower costs 

Risk assessments, such as a health risk assessment or a Medicare Annual Wellness Visit, can uncover important information about an individual’s medical history, functional status, lifestyle, home and personal safety, social barriers to health, and mental health status. 

When providers share this information with payors and, likewise, payors share population and performance data and analytics, this risk-related collaboration creates a strategic advantage, providing many benefits, including:

  • Discovering risks for specific conditions or issues, including genetic or lifestyle
  • Addressing care gaps and quality care standards with individual members
  • Stratifying risk for population health or Chronic Care Management eligibility and enrollment
  • Determining if the member has unmet social needs that are creating barriers to care 
  • Complying with regulatory and billing requirements
  • Probabilistic analysis of future events or care needs for early intervention and prevention

A primary reason timely and accurate risk assessments are more important today is the increasing focus on value-based care (VBC) arrangements between payors and providers.

Medicare Advantage plans, for example, make risk-adjusted payments for members with a higher risk score. From a value-over-volume perspective, many healthcare goals and programs are driving the need for shared risk assessments, including: 

  • Alternative payment models
  • High-risk population management
  • Accurate coding and payment
  • Quality-payment performance scores
  • Improving risk management or avoidance
  • Care management early intervention and risk mitigation
  • Enhancing engagement, experience, and satisfaction
  • Care gaps and meeting preventive care standards
  • Social determinants of health and equity

Case studies show that health plans, hospitals, and providers are increasingly sharing claims and clinical data to coordinate better care, reduce costs, and manage population health. This also helps improve member experience and outcomes via risk-oriented approaches.

How can shared data improve risk assessments?

When payors and providers collaborate on risk assessments and share their findings, value-based care participants are better equipped to understand a member or population comprehensively. 

This can lead to valuable and timely insights that spur early intervention and reduce risk, making care more effective and efficient while avoiding duplicate or conflicting treatments.

Through a shared software platform, payor and provider teams can achieve seven goals:

  1. Collect more timely and comprehensive member risk data
  2. Include more data sources in robust individual and population analytics
  3. Accurately risk stratify members for follow-up care management
  4. Identify high-risk members and implement personalized interventions earlier
  5. Uncover gaps in and barriers to care sooner
  6. Identify and reward high-performing providers to include in narrow networks
  7. Enhance quality measures like HEDIS and CMS Star Ratings

For health plans, collaboration and shared risk assessment data can help overcome the limited claims-based view they rely upon. 

ThoroughCare enables shared risk assessment, data, and analytics 

ThoroughCare's care coordination platform can be shared between health plans and their provider networks to provide seamless, coordinated care and capture more standardized and usable risk assessment data.

Collecting risk data through ThoroughCare

The platform collects risk-related information in several ways; however, the health risk assessment and Annual Wellness Visit are used most often. 

The health risk assessment module covers numerous categories of topics, including:

  • Medical history
  • Hospitalizations and surgical history
  • Providers and suppliers
  • Medications and allergies
  • Social history
  • Mental health
  • Lifestyle
  • Functional status and support
  • Home safety
  • Life planning
  • Preventive services

The Annual Wellness Visit module offers a variety of assessments that have been informed by recommendations from the American Academy of Family Physicians. These could include:

  • CAGE (Cut, Annoyed, Guilty, and Eye) evaluates for substance dependency
  • DAST-10 (Drug Abuse Screening Test) provides a quantitative index of the degree of consequences related to drug abuse
  • MDQ (Mood Disorder Questionnaire) screens for Bipolar Spectrum Disorder
  • PAC (Post-acute care assessment) measures general functional status after an inpatient stay
  • PHQ-2 or PHQ-9 (Patient Health Questionnaire) inquires about the frequency of depressed mood and anhedonia over the past two weeks
  • GAD-7 (Generalized Anxiety Disorder Assessment) provides a seven-item instrument to measure the severity of generalized anxiety disorder symptoms over the past two weeks
  • The mini-cognitive assessment tests memory and recall, using a three-word list of unrelated words and drawing a circle clock
  • An Activities of Daily Living assessment measures a person’s functional status and ability to perform self-care activities independently

Also, through the platform’s group functionality, different care teams and roles can have full access to all risk data or, where appropriate, limited access. 

Leveraging member risk data 

Once data is collected through a health risk assessment, Annual Wellness Visit, or direct member touchpoint, ThoroughCare provides various dashboards and reports that deliver analytics and actionable insights. 

Health plan and provider leaders will find the following six reports and dashboards of particular interest:

  • Health risk assessment report
  • Annual Wellness Visit dashboard and report
  • Gaps in care report
  • Barriers report
  • Patient stratification report
  • Population health dashboard 

For example, the patient stratification report provides a wealth of information across a member’s clinical profile. Identifying high-risk members across several categories helps providers view data to optimize care delivery, improve outcomes, and ensure the efficient use of resources. 

Key stratification data include:

  • Highly comorbid: Members managing three or more chronic health conditions simultaneously
  • Chronic future risk: Members older than 65 with one chronic condition and additional associated risk factors, volume of medications, or number of primary care visits in the last 12 months
  • Frequent ER: Members that have visited the emergency room three or more times in the past year
  • Frequent inpatient: Members admitted to the hospital two or more times in the past year with at least one chronic health condition
  • Smoking cessation: Members who are currently active smokers and wish to quit
  • Risk for readmission: Members recently discharged from the hospital within the last 90 days who have a high risk of being readmitted
  • Long-term services and support: Members older than 65 who require assistance with Activities of Daily Living or Instrumental Activities of Daily Living 
  • Behavioral health: Members dealing with behavioral health conditions
  • Weight management: Members with a body mass index indicating obesity or being underweight

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