5 ways to set up your team for success in risk adjustment

Physician groups—driven by the move toward value-based care—must lay the groundwork to maximize outcomes by finding new processes and technologies in support of their teams in effectively serving their patient populations.

Most value-based payer contracts contain some variation on the formula: attribution times risk adjustment times quality performance equals reimbursement. Hierarchical Condition Categories (HCC), which is the most common Risk Adjustment Factor (RAF) score formula, are an important piece in this effort and have attained heightened visibility when Medicare Advantage Plans made them central to revenue.

When even a small increase in HCC-RAF scores can mean a significant revenue increase for practices, making the move to value-based care without that groundwork can mean at best leaving money on the table, and at worst actively losing money. With over 70,000 ICD-10 codes and 83 HCC categories, this is especially true, as making the shift can leave already overburdened physicians¹ suddenly facing an even greater deluge of administrative tasks. Physician groups that are new to risk contracts aren’t alone in the search for best practices; groups that are deeply engaged in value-based agreements often suffer from the same challenges—like burdening their teams without giving them the tools they need to succeed.

What, then, does the right groundwork require? How can physician groups ensure they’re doing all they can to best capture their patients’ health status and maximize value-based outcomes? Navina recently hosted two webinars that looked at exactly this topic, providing best practices for medical groups in setting their team up for success. We’ve pulled together those tips and are sharing them here, for groups that are just starting out in value and those that already have a large portion of risk contracts.^2,3

1. Educate, educate, educate

For the value-based model to work, your entire team needs to understand the ins and outs of risk adjustment, and why accurate assessment and diagnosis capture is necessary for success.

For teams that are in the beginning stages of moving to value, that means starting with the basics, including what value-based care means, why the group is making the shift, and how risk contracts change the way the practice brings in revenue.

In groups that already have a large number of risk contracts, that education looks different. If your team isn’t appropriately capturing risk, you need to start by understanding why. Are your physicians adding diagnoses that are too generic or simple when their patients actually have complications? If, for example, in a quest for speed a physician diagnoses a patient with diabetes without complications and is assigned the code E11.9, yet the patient has chronic kidney disease and should be assigned the code E11.22 for diabetes with CKD, then the coding is not appropriate for the risk. Or perhaps you work with a team of coders, and your physicians have a low acceptance rate on their coding suggestions. Here, the need for education becomes more specific, and requires a strong understanding of the problem: conveying to clinicians that  low engagement negatively impacts not only the group’s overall goals but also affecting the quality of patient care. Only by providing ongoing education for your team that’s tailored to the problems you’ve identified will you be able to ensure accurate risk adjustment across your patient population.

2. Find new paths to physician engagement

Your team may understand why the group has taken on risk contracts, but what if they’re not actively participating in achieving outcomes?

With physicians spending 45 percent of their time  at work looking at EHRs,⁴ already overtasked physicians and medical assistants may see adapting to value-based models as just one more administrative burden they now have to bear. Educating your team is one step, but they also need to be engaged in the process. This means making sure everyone, from medical assistants to coders to clinicians, knows how to achieve success—and that they want to.

One way to engage your team is to ensure everyone is working from the same playbook. Just like a sports team will practice a play for weeks before they execute it on the field, a physicians group should practice how they execute diabetic visits or annual wellness visits to make sure everybody knows their role. Everyone needs to know how to pass the ball so there are no fumbles.

Another path that many practices take is to incentivize the entire care team for positive value-based outcomes; when the practice finds financial success in value-based care, so does everyone else who has had a hand in it. The research supports this, with medical assistants reporting that even a small incentive would provide motivation, particularly around quality care.

3. Code prospectively, not retrospectively

When diagnosis suggestions are made retrospectively after the patient’s visit, they’re less impactful than when they’re made prospectively in a pre-visit review. That’s because retrospective coding doesn’t give the clinicians the knowledge to act on data at the point of care. To improve your outcomes, support your team with tools that allow them to act during an annual wellness visit, annual physical, or comprehensive wellness visit. By providing and receiving insights prior to the patient encounter, physicians will be more prepared for patient visits and will be able to make informed care decisions that will ultimately lead to better proactive and preventive care and a more accurate and timely reflection of the patient's health status and risk.

4. Utilize (the right) technology

One of the biggest challenges in the transition to value is that taking a proactive approach to care requires clinicians to remember and process more patient data than they can possibly handle. One answer is to use technology to fill the gaps. But these tools can only help you improve outcomes when they’re the right ones—that is, tools that both improve clinical outcomes and ease the burden on clinicians. When technology isn’t intuitive or comprehensive, the team won’t use it. What are some of the things you should look for when purchasing clinician-facing technology for your practice?

• Diagnosis insights based on multiple sources: If the purpose of the technology is to improve your value-based outcomes, make sure it achieves that purpose. It’s no secret that the patient data housed in EHRs is often a chaotic mess. Look for a tool that can make sense of your data—including unstructured data from scanned documents—and that can suggest potential diagnoses and HCC codes based on a variety of data sources such as the EHR and HIEs, and not just from claims.
• AI-powered prospective diagnosis suggestions: It’s not enough to show missed HCCs from last year or simply rely on claims data to suggest gaps. Use a platform whose algorithms will identify potential new clinical conditions, along with supporting evidence that are inferred from data such as lab results and imaging.
• Explained AI: For physicians to be engaged in technology, they must be able to trust it. To drive physician engagement, select a tool that goes back to the source and shows exactly where in the patient data the recommendations are pulling from and how the suggested diagnoses and HCC codes were determined.
• An intuitive clinician experience: A tool is only useful when it’s used. Look for tools that offer a simple user experience and interface, and which integrate with your EHR, allowing clinicians to reduce clicks.

5. Gain a better understanding of your results

Outcomes can’t be improved if they’re not understood. Reporting and performance management tools can help point out which areas your practice needs to work on. With the right visibility into your team’s performance, you’ll be able to track how many HCC codes were suggested for each patient visit, as well as what codes were accepted, allowing you to see whether your team is recommending codes with accurate complexity. Once you understand the data and where things need to be improved, you can go back to point number one and educate, educate, educate.

No matter where you are in your value-based journey—whether your physician group is still only thinking about value, or already has a significant number of risk-based contracts—there’s a good chance your outcomes can be improved. By laying the proper foundation for value and engaging your entire team, you can start representing your patients’ risk more accurately and positively impact their health and wellness.

References:

1. American Academy of Family Physicians Innovation Lab Report, May 2022, https://www.aafp.org/dam/AAFP/documents/practice_management/innovation_lab/report-navina-ai-clinical-review-phase-1.pdf
2. Webinar: Using AI in the Transition to Value - The CMO Perspective, Hosted by AAFP and Navina, https://www.navina.ai/webinars/post/aafp-webinar-822
3. Webinar: Winning Strategies in Value-Based Care and Risk Adjustment, Hosted by RISE and Navina, https://www.navina.ai/webinars/post/rise-webinar-on-demand-0722
4. 10 Ways to Reduce Your Administrative and Documentation Burden, AAFP FPM Journal, https://www.aafp.org/pubs/fpm/blogs/inpractice/entry/reduce-administrative-burden.html
5. Financial Incentives for Medical Assistants, Annals of Family Medicine, Sep-Oct 2021, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8437570/