Partnerships and Value

Exploring Health-Plan-Provider Partnerships

November 30, 2017 11:12 am

A joint effort between a provider organization and a health plan to collect and analyze data can result in mutual benefit.

The Centers for Medicare & Medicaid Services (CMS) is placing increasing emphasis on technical solutions for healthcare quality and cost. As it does, risk adjustment promises to be a central element of an ever-advancing, holistic approach to healthcare analytics. Health plans and providers alike will benefit by coming together to take advantage of the power that lies in the data they collect and report. Such partnerships hold great promise for creating opportunities that encompass financial performance, streamlined operations, increased competitive advantage, and improvements in the quality of care.

A primary advantage of health plan-provider partnerships is in easing the burden of increasing data reporting regulatory requirements. Greater collaboration between providers and health plans, in and of itself, would go far to help meet the nation’s essential goal of improving the quality of health care while reducing its cost. But collaboration around data sharing, in particular, could profoundly contribute to both improved efficiencies in health care and improved morale among physicians reeling under the administrative burden of data reporting requirements and other demands that take their attention away from their primary purpose of delivering health care.

Before discussing what such a collaborative approach might entail, let’s first consider the extent of the problems it would address.

The Challenge of Increasing Reporting Requirements: MACRA

Consider the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which went into full swing at the beginning of the year, and its implications for risk-adjustment and healthcare analytics. MACRA’s Quality Payment Program (QPP) consists of two tracks—the Merit-based Incentive Program (MIPS), and advanced alternative payment models (APMs).

Both MIPS and the APMs focus on performance and outcomes. APM participants may earn an incentive payment for participating in an innovative payment model. Those who decide to participate in MIPS will earn a performance-based payment adjustment.

The most effective risk adjustment strategies include a fully integrated risk-adjustment and quality program, because such a program would not only streamline collection processes for risk adjustment measures related to hierarchical condition categories and Healthcare Effectiveness Data and Information Set (HEDIS) quality measures, but also support more robust analytics that can cross strategic business lines. These processes become critical for QPP participants who are facing payment adjustments starting at plus or minus 4 percent in 2019  (2017 performance year) and rising to plus or minus 9 percent in 2022.

During 2017, QPP participants have been recording quality data and how they used technology to support their practice. To potentially earn a positive payment adjustment beginning on Jan. 1, 2019, under either MIPS or an APM, participants have until March 31, 2018, to send in data about the care they provided and how their practices used technology in 2017. MIPS participants who submit no 2017 data to Medicare will receive a negative 4 percent payment adjustment. Those who submit a minimum amount of 2017 data can avoid a negative payment adjustment. Those who submit at least 90 days of 2017 data may earn a neutral or small positive payment adjustment. Those who send a full year of 2017 data may earn a moderately positive payment adjustment. APM participants, too, must submit quality data and may earn a 5 percent incentive payment in 2019 based on 2017 data.

For 2017, participants must report in the following three categories for MIPS:

  • Quality (60 percent)
  • Advancing care information (25 percent)
  • Clinical improvement activities (15 percent)

A fourth category—Cost—is not assessed in performance year 2017, but it will begin to be considered in 2018.

To succeed in the MACRA QPP, participating providers must demonstrate that they can control costs, improve quality, use electronic health records (EHRs) and other healthcare IT in patient care, and improve and streamline clinical processes. Such reporting must occur while providers maintain their other reporting responsibilities. For health plans, which need to acquire and report their own risk-adjustment data, the increasing reporting burden for providers creates opportunities to cut across risk-adjustment and quality processes, and foster greater provider engagement.

A Role for Health Plans

If health plans can find ways to streamline collection and analysis of data and relieve their reporting burdens while also relieving some of the burdens for providers, mutually beneficial healthcare analytics partnerships can be achieved.

One effective tactic for health plans is to provide greater assistance in the area of health record accuracy. For Medicare Advantage plans, CMS requires annual documentation of chronic conditions for members/patients. Health plans can assist providers by reviewing member charts retrospectively to identify both historical chronic conditions and by ensuring all undocumented or poorly documented conditions are correctly tracked for risk and quality purposes. These same members/patients may have HEDIS measures that also need to be tracked. Similar measures are being tracked by providers for reporting on QPP categories.

This review effort often involves a massive volume of information, requiring a team that is proficient in a thorough retrospective process, with the ultimate goal of establishing a prospective plan to close care gaps, address HEDIS measures, and provide QPP documentation for providers. Because all of this documentation occurs at the point of care, success and provider trust is predicated on a great deal of effort behind the scenes by the health plan or its surrogate for the benefit of the provider. The work must not task the provider staff or interfere with the clinical flow, but the initial review effort and team should involve anyone in the provider organization with responsibility for entering information into the EHR or extracting information from it.

The success of this type of coordination requires a deep understanding of provider habits and friction points. For these reasons, it is important that the outside work be supervised by a provider so that the important interaction is conducted at a peer-to-peer level, provider to provider. This interaction is best accomplished when the liaison between the health plan and provider office works to establish trust and can clearly articulate the value brought to the individual provider and his or her patients.

These reviews should sensitize the medical record to become a more easily utilized tool for the clinician at the point of care. The tool within the medical record must allow a quick (60- to 90-second) review by the provider to encourage actions at the provider’s discretion. These actions should then be captured compliantly in the medical record.

When providers are then engaged prospectively for member outreach so that these previously uncaptured conditions are addressed at the point of care, some positive things occur:

  • Patient care, outcomes, and satisfaction improve.
  • Risk-adjustment care gaps are closed for accurate payment on the health plan side.
  • HEDIS/quality measures are coordinated so there is less member or provider abrasion.
  • Providers spend less time interacting with the EHR and more time in face-to-face interaction with patients.
  • Providers more easily and accurately collect information needed for QPP reporting categories of advancing care information, improvement activities, and quality.

Another benefit for providers is that this team effort between them and the health plan gives them concrete, reportable examples of active measures they have taken to improve meaningful use of EHR technology, healthcare quality, and practice efficiencies. So the collaborative process itself as described here can conceivably be used as an example of improvement in all three of the CMS reporting categories mentioned above.

Again, the potential for positive results is greatly increased when trust is established with providers as a result of successful peer-to-peer interactions focused on clinical outcomes—not code or measure capture—and when the work does not interfere with patient care.

By supporting the provider retrospectively at the point of care and prospectively for risk-adjustment, quality, and MACRA documentation requirements, a collaborative process allows providers to devote more time to what they do best and value most—caring for patients. And the result of this process is more accurate payment.

Effect of Increased Administrative Burden on Provider Morale

Such a sharing arrangement also could have a positive effect on physician morale. A 2016 survey of more than 17,000 physicians across the United States has found that many physicians are unhappy, burned out, and frustrated that they don’t have the time for the most important part of their jobs—their patients. a Many are considering quitting clinical work and recommending that family members not join the profession. These physicians cite regulatory and paperwork burdens and loss of clinical autonomy as the main sources of their dissatisfaction, and many specifically cite the ICD-10 system as a barrier to practice improvement. Only 14 percent of physicians responding to the survey said they have the time they need to deliver the highest standards of care. And just over 89 percent said that EHRs have offered little or no improvement to the quality of their patient interactions or have detracted from that quality.

How a Health Plan-Provider Collaboration Can Help

These factors and others reinforce the need for a team approach among health plans and providers for adjusting risk, conducting prospective and retrospective review, complying with regulatory requirements, and acquiring and managing data more efficiently. The reality is that, among the various healthcare entities, much of the same information is collected and distilled in different ways to suit the needs of the user. It would seem only logical, then, to work on ways to combine resources for mutual benefit. An effective health plan-provider collaboration could help to streamline both analytics and operations.

Streamlining analytics. From the perspective of health plans, the goal of effective risk-adjustment systems is to ensure that the insurers receive accurate and full payment to cover the risk inherent in their populations. In their effort to ensure their risk adjustments are accurate, health plans often fall short in two ways: not properly identifying the illness burden of the population, and not closely monitoring and managing their data submissions. Clinical practices face those same challenges as they view risk adjustment. And the two groups could benefit from finding mutually beneficial solutions.

Many healthcare organizations may assume the best solution is a bigger and better system for collecting and processing data. And this assumption is correct in that well-functioning data management systems are vital to a healthcare organization’s success. In the case of efficient risk adjustment, however, such a system has not only strengths but also weaknesses. Bigger is better only if an organization is collecting large amounts of the right information. All the data in the world won’t amount to positive outcomes if an organization is not able to efficiently identify and apply the most relevant information to its objectives.

As in any quality improvement project in health care, the most important component is the people—particularly getting the right people at the table. Every person who should be involved, but who is left out of the process, becomes a lost opportunity to substantially improve risk-adjustment efficiency and effectiveness.

The opportunities to improve efforts to properly identify the illness burden of the population and to closely monitor and manage data submissions come from all angles: clinical, financial, administrative, IT, and leadership. These opportunities and their potential benefits also cross business lines and organizational boundaries among providers, plans, and regulators. There is no one viewpoint from which to initiate improvement.

Streamlining operations. For health plans, creating and executing an annual risk-adjustment strategy that takes aim at two important issues—properly identifying the illness burden, and closely monitoring and managing their data submissions—are essential steps to improving their risk scores and payments. But strategic partnerships also are essential to success. A team approach among health plans and care providers could involve conducting prospective and retrospective reviews, complying with regulatory requirements, and acquiring and managing data more efficiently.

Obviously, partnering to improve processes related to these issues can provide direct financial benefits to both types of organizations. Working together to integrate timing and processes to streamline data collection for purposes of both clinical quality reporting and encounter data reporting can create opportunities for eliminating significant redundancies.

Because of the QPP, Star ratings, and other current value-based reporting guidance from CMS, health plans must operate with a value-based perspective. They also need to understand the relationship between what they are reporting to CMS for risk adjustment and what their associated providers are reporting to CMS for quality purposes. The mechanics of all this data collection and reporting also need to be well understood so that the partnerships between health plans and providers truly help to streamline these increasing burdens for both parties.

With such a strategy, health plans would dive deeply into their member/patient profiles, provider performance, and condition-specific analysis to identify opportunities and tailor outcomes. Such opportunities can include better and more complete capture of condition codes and encounter data, along with better timing within both organizations on collecting data that are used for both clinical-quality and risk-adjustment purposes. Through these efforts, health plans can use their partnership with providers to cross traditional lines to increase provider engagement, fostering best practices among the providers and using the relationship with providers to improve member/patient contact.

Streamlining the Future Starts at the Point of Care

According to the latest numbers from CMS, national health spending is projected to grow at an average rate of 5.6 percent per year from 2016 through 2025, and 4.7 percent per year on a per capita basis. b The figures project that healthcare spending will grow 1.2 percentage points faster per year than gross domestic product (GDP) over this same period. As a result, the healthcare share of GDP is expected to rise from 17.8 percent in 2015 to 19.9 percent by 2025.

These numbers show why health care in the United States must continue to evolve toward a value-based system, and there is not much room for error when such a large national financial burden is associated with it. There will be high stakes over the next decade for those involved in and affected by risk adjustment.

As providers and health plans throughout the country continue to transition from volume- to value-based payment arrangements and money gets increasingly tighter, predictability is becoming precious. In risk adjustment, as in other quality improvement activities, variation can be the enemy, but it can also provide significant opportunities.

Tackling Variation at the Point of Care

One key area in which variation can be harnessed and made useful is at the place where the most valuable information originates—the point where care is delivered. There is an old saying in healthcare quality improvement circles: “Garbage in, garbage out”—an organization must use high-quality data that are collected, retrieved, and organized in the right way. Better data will yield a better product.

Thus, provider engagement, sometimes called physician engagement, has become a critical focus in the full cycle of management of information used in risk adjustment on the health plan side and healthcare quality improvement on the provider end. It is essential to collect high-quality data and organize the data in a way that informs optimal and meaningful analysis—and that process begins with physicians. If there is no buy-in from clinicians, every part of the cycle is at risk.

If, however, physicians can see a collaboration with health plans as a means to improve quality and reduce the costs to our nation’s healthcare system, they are more likely to see the value in making a commitment to consistently provide the high-quality data that are needed to understand risk and variation.

Health plans and provider organizations around the country are finding that provider/physician engagement is becoming critical to any financial or clinical quality improvement effort they undertake. Remember that physicians, at their core, are scientists. Most are not fond of additional burdens in clinical documentation, but they enjoy seeing data that provide clear evidence of measurable clinical and financial success.

The goals of effective provider engagement are many, but for health plans, the following are examples of key areas where engaged providers can make a meaningful contribution to improved quality and lower costs:

  • Supporting the physician’s capture and documentation of patients’ chronic conditions in compliance with CMS documentation guidelines
  • Facilitating accurate diagnosis and management of member/patient conditions
  • Improving the accuracy of medical record documentation to supplement patient encounters and increase coding guideline compliance
  • Addressing HEDIS measures affecting Star ratings at the point of encounter

Physician engagement can provide health plans with more accurate and complete documentation, resulting in improved member risk scores, higher Star ratings, and higher quality of care.

To this end, a provider organization and a health plan could collaborate to establish a prospective provider engagement coordination program. Under the two parties’ shared oversight, provider engagement coordinators would assist providers in performing complete and accurate documentation, in a way that would be fully deferential to the physician’s insight and decision-making authority. These individuals would be responsible for designing, implementing, coordinating, controlling, and completing activities aimed at medical practice documentation improvement activities. They also would serve as educators and process-improvement specialists, always on the lookout for opportunities to improve efficiency and the quality of the final output, while relieving caregivers of documentation and administrative burdens when possible.

Provider engagement is the starting point for improvement in risk-adjustment processes for both provider organizations and health plans, no matter what the organization’s business perspective might be.

For health plans, in particular, there is no longer a question of how deeply interconnected all the data used in clinical quality, healthcare process improvement, disease management, wellness, and risk adjustment have become. There also is no disputing that there is a significant amount of redundancy in the way information is managed for healthcare organizations’ activities, which generally focus on two areas: improving care processes and getting paid fairly.

A holistic approach is needed to improve care, maintain a high-quality workforce, keep costs from spiraling further out of control, and give clinicians more time to spend on the most important part of their jobs—hands-on, one-on-one patient care.

Will Stabler 
is a risk adjustment and quality program professional who has worked in various industries, including hospitals and health plans, and a member of HFMA’s New Jersey Chapter.


 a. The Physicians Foundation, “2016 Survey of America’s Physicians: Practice Patters & Perspectives,” September 2016.

 b. Centers for Medicare & Medicaid Services, “National Health Expenditure Projections 2016-2025,” February 2017.


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