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Challenging the Status Quo: Quality and Risk Program Integration

By now, most health plans are well aware of the benefits of quality and risk program integration – from improving the member experience and reducing provider abrasion to accelerating quality and risk adjustment gap closure with a complete, holistic patient view. The potential advantages of integration are clear, so why aren’t we seeing more of it?

Challenge: It’s hard to move the needle on the status quo

Looking back to the inception and goals of quality rating and risk adjustment programs, it is no surprise that siloed quality and risk programs have long been the standard for health plans.

    • Risk adjustment has been in place in its current form – with diagnoses mapped to risk adjusted categories called HCCs (Hierarchical Condition Categories) – since the early 2000s and is used in various forms across all government programs (Medicare Advantage, Commercial ACA, and managed Medicaid).
    • Conversely, the first federal quality ratings program wasn’t launched until 2007 for Medicare Advantage plans and wasn’t expanded to Commercial ACA until 2020 (with no financial incentive for health plans).

Additionally, risk adjustment is primarily focused on the financial aspect of member care – ensuring health plans receive appropriate funding to care for their members based on the accurate documentation of member conditions. Meanwhile, quality rating programs focus on the clinical aspect of member care – measuring health plan performance on a wide range of quality measures and incentivizing accountability and care quality improvement through consumer transparency and financial bonus arrangements (for some programs).

The distinct purpose and goals of these programs – and the different areas of expertise required to manage such programs – lend to the siloed organizational structure frequently seen today. Different objectives result in separate and unique data needs to drive these programs, with different annual timelines tied to data collection to support federal reporting requirements. Add in ongoing challenges tied to organizational culture, healthcare interoperability, regulatory hurdles, health information exchange (HIE) data limitations, and provider hesitancy around data sharing – and it’s no wonder most health plans continue to operate separate and distinct quality and risk programs.

Opportunity: Healthcare technology innovation is enabling quality and risk program integration

Amid what remains a lengthy list of obstacles, there is growing opportunity for health plans to take steps toward removing the silos separating quality and risk adjustment programs and taking advantage of the myriad benefits that can result.

At RISE National 2022, Inovalon facilitated a Think Tank of quality and risk program leaders representing a dozen health plans with the goal of examining the challenges and opportunities related to aligning program goals and resources through integration. The discussion offered fresh perspective on the top health plan needs to support the journey toward true program integration, alignment – and ultimately, success – including:

  1. Access to a complete, holistic view of the member journey through a single, integrated data analytics platform.

Most health plans have separate analytical systems to measure the care quality and risk profile of their membership. Data sharing among quality and risk teams is often limited and is most likely to occur informally rather than via a standardized process. This all-too-common reality means many health plans are not getting as much value out of their data as they could be, and may be at risk of lower clinical quality, less accurate risk scores, and reduced member satisfaction.

A unified analytics platform providing access to a complete, holistic dataset – including the underlying clinical member data – is instrumental to enabling quality and risk program integration. Armed with a comprehensive view of each patient and their unique care needs, health plans can act earlier to support the delivery of appropriate care, improve health outcomes, and reflect an industry-leading compliance posture. And the value doesn’t stop there. From claims and finance to operations and compliance, nearly all health plan departments can benefit from access to a single, integrated data source.

  1. Enhanced care delivery and efficiency stemming from integrated intervention provider management capabilities.

One of the main advantages for health plans operating an integrated quality and risk program is the ability to streamline the member and provider engagement experience. Coordinating outreach and capturing data for both quality and risk adjustment purposes within a single member encounter can go a long way toward achieving this goal. Replacing multiple, disjointed member touches with a single, comprehensive outreach reduces abrasion and improves the member’s experience while lessening operational burdens and costs for the health plan.

However, health plans often rely on a range of member and provider intervention providers to meet the diverse needs of their membership – from identifying and communicating the need for services (as well as the supporting data) directly to health plan members and provider networks, to facilitating follow-up actions. This significantly adds to the cost and complexity from a management perspective for the health plan, making integrated intervention provider management capabilities an important contributor to increase efficiency. The ability to manage, coordinate, and track the performance of multiple intervention partners within the same platform may further improve the member and provider experience and reduce the number of missed, mis-timed, or unnecessary interventions.

Integration: the catalyst to advancing healthcare efficiency and outcomes

Health plans with integrated systems to support both data processing/analytics and member and provider outreach are better equipped with the information needed to drive continuous program improvement, including:

    • Return-on-investment (ROI) analyses across all program initiatives
    • Tracking member and provider outreaches over time to better understand their experience
    • Benchmarking and trending information at the member level and across programs
    • Provider incentive analytics to determine optimal engagement methods
    • More accurate forecasting and prioritization to drive speed to market

Ultimately, quality and risk program integration equips health plans with more than a comprehensive, 360˚ member view spanning clinical and documentation needs – it opens the door to achieving new and enhanced data insights that were previously inaccessible.

By Courtney Breece, Associate Vice President, Product