According to CMS’ Office of the Actuary, healthcare spending is predicted to increase at an average annual rate of 5.5%, reaching $6 trillion by 2027. This projected growth doesn’t account for patient care implications or the economic impact stemming from the ongoing COVID-19 pandemic.
The unprecedented complications posed by a public health emergency, combined with the accelerated need to align new strategies for continuity of care, exemplifies why health plans must remain agile and proactive in their approaches to problem solving by constantly exploring and evaluating new innovative care delivery options. The most successful organizations are those that can quickly adapt to change and find new solutions.
COVID-19 has presented unimaginable challenges to the healthcare ecosystem, creating significant challenges to safely and proactively connect members with their providers. As health plans around the country amend their approach to care amid the coronavirus pandemic and social distancing measures remain in place, engaging members through a virtual care platform in a meaningful way is necessary for more than just safety and convenience – it plays a vital role in enabling the ability to reach the most vulnerable populations to support their health and well-being.
When care for at-risk members is disrupted, as it has been during the pandemic, Medicare Advantage plans face additional challenges to addressing and closing HCC documentation and quality gaps. Naturally, this has a direct impact on the overall health and wellness of a plan’s members. Unaddressed diagnoses lead to worsening conditions, which skew the patient profile and negatively affect reimbursement for the care and management of chronic conditions, essentially causing a domino effect.
In particular, the absence of annual risk assessments makes it difficult to identify changes in member risk profiles, which impacts the ability to ensure appropriate services are provided. Targeting the right intervention to the right member at the right time, allows health plans to address preventable or worsening health conditions and close patient quality and risk gaps. This allows the most accurate capture of diagnoses to avoid exacerbating health issues and to ensure health plan payments from CMS appropriately reflect the risk profile of their membership.
With the uncertainty as to when the COVID-19 pandemic may end, organizations need to focus on effectively keeping their member populations healthy by the safest means available. The continuity of care empowered by telehealth services allows organizations to adapt with a viable member intervention and risk adjustment accuracy strategy to effectively provide in-class quality of care. By doing so, they will ensure quality gap closure and alleviate a potential risk score shortfall for 2020 dates of service.
Health plans are expected to maintain a high quality of care while achieving clinical and quality outcomes as well as risk mitigation objectives. Given the current circumstances, this becomes a greater challenge.
Let’s explore a few areas where health plans should focus to meet member needs and performance expectations and maintain accurate HCC documentation and quality gap closure in the face of COVID-19.
Now that CMS has temporarily approved coverage of telehealth by Medicare during the COVID-19 health emergency, members can access remote health services in the safety of their home, at an expense comparable to that of an in-person visit. This may include preventative services, routine care and annual wellness visits. While the U.S. Department of Health and Human Services (HHS) would like to consider the extension of telemedicine coverage after the coronavirus is behind us, this cannot happen without the approval of government entities. The determination also needs to be made on whether telemedicine will increase healthcare costs before remote options are adopted permanently. Given the uncertainty of telemedicine coverage beyond COVID-19 for Medicare beneficiaries, health plans and their members should take advantage of these services while they can.
The advantages of telehealth services have never been more clear. Virtual health technology can be used as a collaborative tool for providers and health plans for effective member engagement and care management. Safely engaging members via telehealth minimizes the risk and spread of COVID-19 among both healthy and sick members by delivering real-time, high-quality virtual care. It is important that health plans recognize telehealth as a valuable long-term component of an integrated healthcare delivery model for payers, providers and members alike to circumvent any disproportional impact of COVID-19 on the most vulnerable populations.
Prioritizing preventive care for a patient population is critical to mitigating more serious and costly health conditions. Delayed or missed health visits create the possibility of major patient health lapses. On an operational level, these missed appointments mean fewer opportunities to document and close risk and quality gaps that are revealed during traditional member encounters. Existing barriers to care have been magnified in the wake of the COVID-19 crisis, with many healthcare consumers opting to cancel or postpone non-urgent health visits. Under these circumstances, it is critical for health plans to proactively engage their members to schedule telehealth visits with their primary care providers to support continuity of care, care coordination and to help ensure preventable adverse events are avoided.
Some of these preventive services include Medicare Annual Wellness Visits, recommended screenings and health monitoring. With CMS’ expansion of access to these services under telehealth, organizations should be sure to communicate how important preventative services are for optimal health and for monitoring and maintenance of existing conditions.
Given that seniors have an increased risk for many chronic conditions, health plans should proactively encourage members to seek preventive care via telehealth, which helps manage these conditions to decrease the risk of complications from COVID-19 and limits overall risk of exposure.
Many Medicare Advantage plans traditionally utilize in-home assessments as a component of their annual risk adjustment program to increase access to care for members, improve HCC documentation accuracy, address quality gaps and help attain member assessment completions rate performance goals. However, in-home assessments aren’t an option for many plans during the current healthcare crisis, leaving seniors vulnerable. This is yet another example of the value that telehealth services provide to health plans and members. For this reason, organizations should encourage and incentivize providers to use telehealth to perform annual member health visits so that care is appropriately being provided and accurate documentation simultaneously enabled.
Ultimately, to improve HCC coding accuracy, enhance quality of care and mitigate RADV audit risk, health plans should aim to take full advantage of virtual care technology as part of a successful care strategy. Telehealth should be viewed not only as a short-term social distancing mechanism, but also as a long-term approach to enable continuity of care to address risk gaps for member health and proper documentation.
If they haven’t already, health plans will need to start developing short and long-term strategies to support the health of their members through accurate HCC coding. Those who haven’t started this process may be running the risk of poor performance on quality measures and inaccurate risk scores and for the 2020 DOS year, resulting in inaccurate and reduced payment from CMS.