Improving 2020:

Risk Adjustment Micro Strategies

Presented by:
Sujata Bajaj
SVP Product Development
Episource

Jason McDaniel
VP Risk Adjustment and Quality
HealthCare Partners Nevada
Micro Strategy Definition
Micro Strategies reflect smaller, laser-focused programs
that are intended to capture RAF that is typically missed.

Additionally, these programs are designed to account for

the intersection of cash-flow and sweeps deadlines.
Risk Adjustment Team

Medical Operations IT
RA & Quality VP IT
Medical Director RA & Quality VP Director IT
Affiliate Medical Director Operations Project Manager
APP Medical Director Operations Directors
RA & Quality AMDs Provider Relations

Analytics Coding
Manager Risk Coding Manager
Data Warehouse Director Affiliate Clinic Coding Educator
Decision Support Analyst
Point of Care Platform

Usability Suspecting Reporting

Provider Friendly Data Multi-Level
Document in Solution EMR Health Plan
Instant Feedback Claims Clinic
HCC logic Suspect Algorithms Provider
Patient
 DOS Impact on Reimbursement
Opportunity:
Target members with low DOS
or high HCC gaps from July
2019 to June 2020 and
perform telehealth visits
before June 30, 2020 to close
gaps in order to maintain 2021
revenue.
Solution:
Create a chase list of
target members and
enroll them in a
Telehealth campaign.
Value
Engage patients and complete
visits remotely via telehealth
due to COVID-19 and for those
patients that decline an in-home
assessment, but are willing to
utilize telehealth, resulting in a
higher completion rate.

Why in Q2?
January 2021 to June 2021 initial payments are based on RAF from July 2019 to June 2020 DOS
While 2021 payments will ultimately be trued-up to reflect RAF from full year 2020 DOS, if July 2019 to
June 2020 RAF is low, there could be a significant payment impact for the first 6 months of 2021
How a DOS Will Impact 2021 Payment
RAF for the 12-months ending June 2020 plays a significant role in determining 2021 payments

Initial Payments: First 6 monthly payments

based on Dx from Jul 2019 to Jun 2020 as
submitted before “September Sweep”

Mid-Year Payments: The next six, monthly

payments are based on FY2020 DOS submitted
before March Sweep; One one-time retro true-
up for Mid Year RAF vs Initial RAF

Final Payment: One-time retrospective true up

for Final RAF vs Mid Year RAF based on Dx
submitted by the final Jan Sweep (Generally
chart audit results)
How a DOS Will Impact 2021 Payment
Decrease in reimbursement due to HCC022 and HCC108 failing to be captured for a consecutive 12 -month period

1st Half 2019 2nd Half 2019 1st Half 2020 2nd Half 2020
HCCs Captured by DOS HCC022 HCC022
Period HCC108 HCC108
HCC019 HCC019

Payment Period: 2nd Half 2020 1st Half 2021 2nd Half 2021
2nd Half 2019 / 1st Half
HCCs From DOS: Full Year 2019 Full Year 2020
HCCs by Payment Period 2020
HCC022 HCC019 HCC022
HCC108 HCC108
HCC019 HCC019

2nd Half 2020 1st Half 2021 2nd Half 2021

Demo Score: 0.316 0.316 0.316
Risk Payment
HCC Score: 0.874 0.307 0.874
RAF Score: 1.190 0.623 1.190
$PMPM: $952 $498 $952
 Financial Example
If there are 1,600 members unaddressed, the PMPM reimbursement for these members will be
$425 on average in January 2021, a 15% reduction from 2020

[A] FY 2019 RAF vs. $ Impact per

# of Members
[B] 2H 2019 / 1H 2020 RAF Differential Month
[A] – [B] > 1 100 $100,000
[A] – [B] between 0.5 and 1 500 $300,000
[A] – [B] between 0.2 and 0.5 1,000 $280,000
Total Opportunity 1,600 $680,000
 Care Gaps Closed and RAF captured
during TH visit
Two members with recent telehealth visits in May 2020

Example 1. Example 2.
71y male patient w/ cancer 68y female patient w/ multiple sclerosis

Before Visit Telehealth Visit After Visit Before Visit Telehealth Visit After Visit
Demo Score: 0.390 0.390 Demo Score: 0.610 0.610
HCC Score: 0.716 3.539 4.255 HCC Score: 0.728 0.566 1.294
RAF Score: 1.106 4.645 RAF Score: 1.338 1.904
$PMPM: $885 + $2,831 $3,716 $PMPM: $1,070 + $453 $1,523

Before Visit Telehealth Visit After Visit Before Visit Telehealth Visit After Visit
HCC085 HCC085 HCC077 HCC077
HCC107 HCC107 HCC018 HCC018
HCC008 HCC008 HCC059 HCC059
HCC084 HCC084
HCC096 HCC096
HCC111 HCC111
Next Steps

Identify members who have Obtain contact

low DOS or high HCC gaps information for members
Risk Analytics should provide meeting chase list criteria
this stratification

(Optional) Establish mode of Launch telehealth

delivery for HCC gaps, Quality campaign during Q2
gaps and SDOH to be captured to
telehealth provider
Clinical Correlations
Angina Morbid Obesity
496 Patients 1,992 Patients
Nitrate without the BMI ≥ 35 with comorbidities
diagnosis of Angina BMI ≥ 40

Analytics
DM w/ Major
Complications Depression
Target for prospective 1,349 Patients
chart reviews F32.9 w/o HCC 59
HCCs 18 & 19
0.197 in RAF
60%
57% Diabetes - 18 - Diabetes
with Chronic

50%
Prevalence Rates Complications

Diabetes - 19 - Diabetes
without Complication

Heart - 85 - Congestive
Heart Failure
40%
Heart - 88 - Angina
34% Pectoris

30% 29%
Heart - 96 - Specified
27%
26% Heart Arrhythmias
24%
23%
Lung - 111 - Chronic
19% 19% Obstructive Pulmonary
20%
Disease
15% 15% Metabolic - 22 - Morbid
13% Obesity
12%
10%
10%
7% Psychiatric - 59 - Major
5% 5% Depressive, Bipolar, and
4% Paranoid Disorders

Vascular - 108 - Vascular

0% Disease
952 1467
Provider
GONZALEZ A S
MD,KAREN Provider
KALRA BB
MD,SUNITA
Screenings Lung Cancer
Current Smokers
Quit smoking within 15 years
PHQ2 & PHQ9 Potential ancillary findings:
PCP & Oncology • Atherosclerosis
Oncology rates are 2-4x greater • Emphysema
MG – 19% vs. Affiliate/IPA – 13%
Incentives
AAA
Men ages 65 – 75 who have ever smoked
Diabetic Peripheral Prevalence
Neuropathy • 3.9% - 7.2% in men over 50
All diabetic patients should be
assessed for polyneuropathy
starting at diagnosis of type 2 Peripheral Arterial
diabetes, 5 years after the diagnosis Disease
of type 1 diabetes, and at least Over age 65
annually thereafter. (ADA) Over age 50 with a history of smoking
Cardiology and PCP
Polling Question
What Screenings are you currently using?
A. PHQ 2 & PHQ 9
B. Lung Cancer
C. AAA
D.Peripheral Arterial Disease
 Peripheral Arterial Disease Initiative
80.00%

70.00%
67.70% PAD Result Total Percentage

60.00% Negative 12,952 67.7%

50.00% Positive 6,179 32.3%
40.00%

30.00%

20.00% 15.27%
9.64%
10.00% 5.28% 2.11%
0.00%
Normal Mild Moderate Significant Severe
Negative PAD Positive PAD
COVID-19 Impact on 2020 RAF Scores
Plans Performing 9.2% better year-over-year in February slipped to -4.8% by May

Monthly RAF Trend

1.6 1.383 1.464
1.322 1.357
1.213 1.251 1.288
Average RAF Score

1.4 1.156
1.2 1.071 1.092
0.971
1.0 0.790
0.8 1.009 1.0861.100
0.6 0.7420.890
0.4
0.2
0.0

2019 2020

Total Members
2019: 282,843
2020: 260,279
Member Engagement and Gap
Closure Solutions
• Identify members with no DOS or current year gaps
1. Member Scheduling • Engage members via 3-way call to schedule a visit with their PCP, or
arrange for an in-home or telehealth visit

+ • Build the member’s gap report and generate a gap letter for the
provider
2. Gap Letters
• Send the gap letter to their provider prior to the scheduled patient
visit
• Remind clinician to capture Quality, and SDOH (with COVID, more
seniors are experiencing food insecurity, housing, loss of work etc.)
+
• Provider returns the gap letter and progress note after the patient
3. Retrieval and Coding visit
• Medical coders review documentation to ensure gaps have been
addressed
• Make referrals for SDOH that are captured
Sample Gap Letter
Gap letters can increase the quality of care
and improve documentation.

Effectively addressing each of a patient’s

active and suspected conditions becomes
even more important among populations
that are less likely to see their provider on
a regular basis.

Providers will have insights that enable

them to provide the highest level of care.

Post COVID, gap letters can also be used to

capture SDOH to refer members to more
resources available to them.
Data Requirements
If an epiAnalyst Client

• Member/PCP contact information

• Gap letters generated using epiAnalyst with the following options:
- No PCP DOS
- Gaps and no annual wellness visit

If a Non-epiAnalyst Client (No provider letter)

• Member/PCP contact information

• Gap letter or gap list can be provided by the client
Polling Question
What was your biggest Telehealth difficulty?
A. No Telehealth platform
B. Patient with no Smartphone
C. Lack of technological ability
D. Concern over scams
Social Distancing Visit Type
Telephonic

25000 Virtual

In Clinic

20000

15000

10000

5000

0
January February March April May
“New Normal” Scheduling
RED
75% Virtual Visits
<5% Telephonic Visits

ORANGE 20% In Clinic Visits

45% Virtual Visits

<2% Telephonic Visits
50% In Clinic Visits YELLOW
30% Virtual Visits
<1% Telephonic
Visits
70% In Clinic Visits

Green
20% Virtual Visits
Telephonic Follow-Ups
80% In Clinic Visits
 Preemptive Scheduling Interventions
Opportunity: Target members who have no DOS by Q2 or have HCC suspects not yet captured

Solution: Outreach target members to offer multiple solutions for completing a visit (3-way scheduling call with
provider, IHA, or telehealth visit)
• Working with providers to target members and schedule visits can minimize member abrasion
• A gap letter with HCC suspects and SDOH is sent to the provider should be sent in advance of a visit
• Member scheduling provides alternatives to maximize conversions (in-office, in-home, or telehealth)

Why in Q3
• Without a visit by June, there is approximately a 57% chance that they will not complete a visit by year
end
• Expect demand for office visits to return as the stay-at-home order is eased, but there are fewer months
remaining to complete visits
• Unemployment rates in the 65+ population has gone from 4.4% to 14%, this means that a vulnerable
population has become more vulnerable. Might not have access to care, medications etc.
• Q4 is generally the high season. Targeting Q3 can flatten the utilization of provider resources
 Use Cases and Target Result
Use Cases / Program Applications
• Target members who have no visit by Q2
• Target members who have suspected SDOH that will be exacerbated by COVID (Duals or members likely to be dual)
• Target members with uncaptured HCC suspects
• RA analytics should help you to create a refined cohort of members/patients
• Promoting Action:
• Prioritize providers by the number of members / HCC suspects/likelihood of being dual/dual
• Possible incentive program for members complete an AWV (Annual Wellness Visit)

Target Result (historical performance)

• On average, 2 HCCs captured per visit -> $320 pmpm increase (estimation)
• Significant decrease in the number of members with no DOS
• Capture SDOH, discuss with member and make referrals (food banks, etc.)
• Enroll members who are likely dual eligible
Financial Impact
Assume 30% of membership has no visit yet, 30% of target successfully
led to office visit

MA Plan with 20,000 members

Target Members x 40% 8,000 members
Successful Conversion x 20% 1,600 conversions
x $320
Monthly Revenue Lift $ 512,000
pmpm
Annual Revenue Lift x 12 months ≈ $ 6.1 million
Polling Question
What will you do through the rest of this year to help get RAF
back up?
A. Utilize Telehealth to increase member engagement
B. In-home assessments
C. Encouraging members to see PCPs/Specialists and
coordinating with doctors on gaps to close
Next Steps

Identify members who have no DOS Obtain contact

or high HCC gaps. Leverage claims, information for members
Rx, MMR/MOR, CCLF data set for meeting chase list criteria
ACOs, provider data to create list

Launch Member Scheduling campaign Re-route members who

during Q3 showed preferences on In-
• Confirm which route to take – from Home or Telehealth visit to the
members or from providers applicable program
Managed Care Operations
Social Distancing

Telehealth Technology
Capability Application Evaluation
Security Concerns Internet-based Platform
Provider Adoption Download Assistance
Point of Care Solution

Scheduling Education
Stratification Provider Education
Risk and Quality Gaps “The Perfect Visit”
SDOH
Follow-up Appointment
Vendor Partnerships

Retrospective Audit
In-Home Virtual Visits
Increase patient options Chart Retrieval
Remote access
Less burdensome

Prospective Chart Reviews Telehealth Platform

Patient Volume Robust application
Face-to-face education Simple website
 Risk Adjustment Operations
Team Building Idea oriented Accountability

Expand the Denominator

Data Prospective Chart Reviews
Claims Data
Suspect algorithms
Retrospective Audit Results

Vendor Partners
Enhanced Specific Expertise
Operations Efficient Implementation
Monitor ROI
 Smarter Risk Analytics Engine
Enhanced slicing to create micro strategies
Targeting for each cohort of member/patient

Engage Members and Providers

Program Empower providers with gap information before
the patient is in office
Execution Coordinate visits
Identify SDOH and conduct referrals

Risk Analytics Engine

Measure and Course Improved care
Correct ROI on interventions
Better tactics to close gaps (more effective)
Focus on failure and how to course correct)
Q&A