Prospective Health Assessments and Best Practices for Risk and Quality

PHAs provide member information that helps health plans bolster care management, integrate financial and clinical information, and improve care quality.

In today’s healthcare environment, risk stratification has become a key focus for physicians and provider organizations—especially those that are entering Medicare Advantage (MA) plans or similar risk arrangements for managing defined patient populations.

Risk stratification enables providers to better understand their patient populations and manage their resources. This capability is particularly important for managing patients with chronic conditions or advanced illnesses and has become a central strategy for optimizing the quality of care in population health arrangements.

Effective implementation, however, requires actionable 360-degree insights into the health status of member populations using prospective health assessments (PHAs) and following best practices for quality outcomes. The ability to risk-stratify members allows health plan executives to fully understand their populations and provide optimal resources for integrating risk, quality, and clinical initiatives.

Finding the Right PHA Approach

Given the complexity of health care, the need for comprehensive and accurate patient data to monitor and manage chronic conditions is critical for effective population health management. PHAs have proven to be an effective tool for facilitating timely gap closure and improving care management initiatives. One key advantage is that PHAs can occur at any time during the year and be scheduled for MA, commercial, and Medicaid members who have been nonadherent in scheduling primary care appointments.

PHAs should be focused on identifying new conditions, recapturing and documenting previous chronic conditions, and closing care-quality gaps. A PHA should provide real-time visibility into assessments and documentation, integrating analytics, physician chart reviews, and peer-reviewed screenings to drive higher member engagement rates and optimal results.

Another important factor is flexibility regarding site selection for the assessment, with a goal of driving compliance and engagement. The assessment ideally should be performed by highly trained nurse practitioners and be conducted in the member’s home, a centralized clinic, or a primary care physician’s office.

To gather the most accurate data, the PHA should integrate quality measures, including Star measures, HEDIS®, and CAHPS®/HOS, and include a comprehensive assessment that focuses on member engagement and clinical profiles.

Furthermore, the PHA should allow physicians and the healthcare organization’s leadership team to view project dashboards and drill-down options, including member call metrics with detailed call comments, status on noncooperating members, and reason codes. All clinical data and Hierarchical Condition Categories (HCCs) should be hyperlinked within the assessment.

Offering tablet-based assessments that are exclusively electronic has generated impressive results, including a patient acceptance rate for in-home PHA visits that exceeds 35 percent.

Best Practices for Integrating Risk, Quality, and Care Programs

PHAs present a key opportunity to integrate financial and clinical information. Typically, risk programs are organized within the financial department of a health plan while the quality programs report to the clinical side. However, it’s vital that these two programs be integrated within the organization. The role of the risk program is to identify members who represent “high risk” and may need additional screening and care to ensure optimal health. The role of the quality program is to enable timely and thorough care that is well-documented.

Risk adjustment documentation encompasses a particular illness (or illnesses) and serves as an extension of the quality program. This aspect is especially important for patients over 65 who have three or more chronic conditions. The ability to correctly identify, document, and code allows for more accurate clinical monitoring and care management resource utilization, which is vital given the exponential cost curve related to each additional chronic illness.    

The benefits for health plans of integrating risk and quality include:

• Reduced administrative costs
• Interventions prioritized to impact risk and quality results
• Holistic and patient-centric population health initiatives that improve care and lower the cost of supporting a population

Health plan and provider leaders must begin thinking both independently and in terms of the system as a whole when it comes to delivering quality care, documenting outcomes, and accurately reporting outcomes. Integrating the comprehensive information from health plans and placing it in the hands of providers allows for better clinical decision-making.   

The most effective quality programs offer these advantages:

• Alignment of incentives and objectives across patients, providers, health plans, and the government
• Integration of risk assessment, care management, and quality reporting into a holistic care program that no longer functions in isolation
• Implementation of technology infrastructure that supports an integrated program from start to finish and year-round.

PHAs Prompt Adoption of Beneficial New Practices

PHAs act as a catalyst to drive improvement, with health plans tasked to fully comprehend and implement quality programs that satisfy government requirements while engaging providers and members alike. Ideally, providers will be trained and given financial incentives to adjust their practices in ways that deliver high-quality outcomes. At the same time, patients/plan members will be given adequate information and guidance to ensure active participation in their care.

The best quality programs utilize ongoing interventions that provide actionable information to providers and members at the point of care. For example, when providers have patients in the exam room during an office visit, pertinent clinical information is available. Effective programs also foster relationships and participation in care—involving the entire care team for a member, including spouses, parents, and/or children—and provide a complete care plan.

Achieving Improved Outcomes

Historically, many organizations have viewed risk and quality as projects that are initiated and completed throughout the year. Technology and processes are scheduled and operated on a project cadence.

Given that patient populations are in constant flux, this strategy could result in missed opportunities. Once a member is identified for an intervention, there may be other factors that should have been reviewed or a test ordered. At the same time, a project-based approach limits the timeliness of data at the point of service and allows care and data to fall through the cracks.

A better approach allows a plan to partner with a provider network and move to an ongoing program-oriented strategy that continually incorporates new data and utilizes tighter data integration between the health plan’s systems and the provider’s electronic health record. Constantly updated information is then used to stratify the population, identify gaps in risk, improve care quality, and provide actionable information to providers and members when they need it—at the point of care.

Nilay Shah is president of provider solutions, Advantmed, LLC.