The following is a guest post from Rodrigo Martinez, MD, Senior Vice President, Consulting at Advisory Board Company.
As the shift toward value-based care and risk-based contracting progresses, it will become even more important for health plans and those who deliver care to collaborate.
Yet health plans and providers often fail to take advantage of the ample opportunities to operationalize "win-win" programs that offer financial, operational, and quality gains for both organizations, which are also wins for their patients. Why? One major factor is that, historically, payers and providers have had a challenging relationship based on mistrust, misunderstanding, and perceived differences in goals.
But when you dive deeper into one major opportunity to align approaches on chronic care management — for conditions such as diabetes, morbid obesity, and congestive heart failure — you see there are other key obstacles to overcome.
A major opportunity
One of the fundamentals of best-practice disease management is to have patients with chronic conditions regularly check in with the appropriate provider to discuss their treatment plans and health. In 2004, CMS launched a program to encourage regular contact between providers and patients with chronic conditions. The appropriate encounter, coding, and documentation of Hierarchical Condition Category (HCC) codes were instituted to predict costs and, ultimately, improve care quality, but there are two key challenges to overcome:
- It can be difficult to accurately document the patient encounter, particularly when a patient might be in the habit of seeing his or her provider only during acute events or for a medication refill; and
- If providers feel they don't have time to address the chronic condition during a visit for an unrelated complaint, the condition may easily be ignored, which can lead to worst-case scenarios of expensive emergency department visits or hospital admissions for exacerbated conditions.
Without documentation and coding to prove the provider has addressed the chronic condition at the appropriate interval and, thus, is providing best-practice disease management, you get a "care gap." The care gap in this context is the difference between the full care a patient could receive and that which is delivered (or at least documented as having been delivered). Sustained care gaps can negatively impact the patient's long-term outcomes, as poorly-controlled chronic conditions often lead to gradual deterioration along with intermittent acute exacerbations.
This missed opportunity to close the care gap doesn't just hurt care management, it also hurts the health system's bottom line. CMS uses HCC codes to help determine how much care funding it will allocate for patients each year under Medicare Advantage (MA). If ambulatory providers do not document each calendar year that a patient still has the chronic condition and that they have addressed it, CMS will assume the patient got better and will not set aside enough care funding for that patient under MA. However, if organizations get the patient into the office, and if providers code and document correctly, the associated activities comply with a number of broadly accepted quality metrics. Therefore, a well-designed HCC program benefits not only the patient but also the provider organization.
Health plans are also interested in the success of this type of program because they, too, are incentivized to keep patients healthy and out of the hospital. Furthermore, a patient's positive care experience is an important metric of success to the payer, as health plans also rely on positive patient satisfaction scores for their own incentive payments and rankings.
There are clearly many positives that can come from improving HCC coding and documentation, and there are obvious incentives in place to benefit providers, healthcare organizations, and payers. So why do many patients persist with chronic care gaps, and what can be done about it? Here are two things payers and providers should do to align, collaborate, build trust, and deliver better patient care:
1. Don't let the HCC process be a paper-filled hassle and administrative burden.
The HCC risk adjustment model has been around since 2004, and even in recent years, it has typically been a paper-based process, with insurers asking providers to do extra documentation outside the EHR. This manual process becomes a huge hassle that clinicians end up avoiding or skimping on because it appears to be a "coding game" divorced from clinical care that creates more work for the provider. Additionally, identifying the right patients has also been an administrative burden, requiring additional time and effort from ambulatory staff who are already overwhelmed.
Providers need to be able to use available data — from lab results, vital signs, problem lists, and billing information—to understand a patient's medical complexity and easily identify HCC coding opportunities. Furthermore, these opportunities should be flagged for clinicians within the EHR at the appropriate time in the clinical workflow in a format that allows for immediate and easy-to-execute action that is compliant with CMS guidelines.
2. Make sure clinicians know the potential clinical and financial implications
Without staff education, providers often do not realize how using HCC codes can improve chronic condition management and payment accuracy under MA. Insurers that have poor relationships with providers can also sometimes fail to break through without a third party to act as an intermediary.
Use peer-to-peer support and education to ensure providers understand how accurate HCC coding and documentation can improve care funding and care quality. Support your providers with at-the-elbow guidance during the roll-out of any new clinical workflows, particularly ones that require new steps in the EHR, as classroom and online education is quickly forgotten.