Latest / Becker’s Payer Issues Podcast / Rethinking Risk Adjustment and Payer Provider Alignment in Value-Based Care

Transcript

Rethinking Risk Adjustment and Payer Provider Alignment in Value-Based Care · Becker’s Payer Issues Podcast

• 0:00
  - Hello, everyone. This is Erica Spicer Mason with
• 0:02
  - Becker's Healthcare. Thank you so much for tuning
• 0:05
  - in to the Becker's Healthcare podcast series today.
• 0:08
  - So today, we're going to talk about how
• 0:10
  - healthcare organizations
• 0:11
  - are rethinking risk adjustment in value based care.
• 0:15
  - And joining me for this conversation is Carrie
• 0:17
  - Kettleson, the president of Vertex Health.
• 0:20
  - Carrie, so glad to have you with us
• 0:22
  - on the podcast. Appreciate you being here today.
• 0:25
  - And and before we get into the conversation,
• 0:27
  - wanted to just give you the opportunity to
• 0:29
  - introduce yourself and share whatever you think would
• 0:31
  - be helpful for our listeners to know.
• 0:34
  - Thank you, Erica, so much for having me.
• 0:37
  - It's my pleasure, and thank you listeners
• 0:39
  - for being present.
• 0:42
  - So my background,
• 0:43
  - I've been in health care for over twenty
• 0:45
  - years, and and that that says
• 0:48
  - my background says a lot about why I
• 0:50
  - love health care and love what I do.
• 0:53
  - I have worked in large management consulting firms,
• 0:57
  - also
• 0:58
  - several years managed care on the payer side,
• 1:01
  - integrated health systems,
• 1:03
  - also in the vendor and the technology space.
• 1:06
  - And and the breadth is is not just,
• 1:08
  - you know, my resume, but it really shapes
• 1:12
  - how I think about health care and why
• 1:13
  - I love it so much. And I love
• 1:15
  - to use
• 1:16
  - my experience
• 1:17
  - to really solve tough problems. And and really
• 1:20
  - as we talk about, you know, today, the
• 1:23
  - topic we're on, really, how do we get
• 1:25
  - payers and providers
• 1:27
  - to think about things the same way? They're
• 1:29
  - seeing the same patient. They speak the same
• 1:31
  - language,
• 1:33
  - shared data, work towards the same outcome, and
• 1:36
  - that's I'm very fortunate to be able to
• 1:38
  - lead at Vertex Health, and that's what we're
• 1:40
  - building.
• 1:41
  - The technology, the processes, and the people that
• 1:44
  - make that alignment real and also at scale.
• 1:47
  - Carrie, I love your intro and also this
• 1:50
  - concept that you're already touching on, which is
• 1:52
  - this need for payers and providers
• 1:54
  - to, you know, get aligned, get on the
• 1:56
  - same page, whatever you'd like to call it.
• 1:59
  - But it's something that we hear as a
• 2:00
  - through line at Becker's throughout leadership conversations all
• 2:03
  - of the time on both sides of the
• 2:05
  - house.
• 2:06
  - And I know you work closely with both
• 2:07
  - payers and providers
• 2:09
  - across the country.
• 2:10
  - And as more organizations are moving risk adjustment
• 2:13
  - upstream,
• 2:14
  - what changes
• 2:15
  - are improving risk capture accuracy and documentation integrity?
• 2:19
  - I'd love to learn a little bit more
• 2:20
  - about what you're seeing there.
• 2:22
  - The the honest answer is that the organizations
• 2:26
  - that are getting this right,
• 2:27
  - they've really stopped treating risk adjustment like a
• 2:30
  - coding exercise
• 2:32
  - and they've started treating it and and operating
• 2:35
  - it like it's a clinical
• 2:37
  - program.
• 2:38
  - And that that may sound like a subtle
• 2:40
  - distinction,
• 2:41
  - but it it really changes everything. When you
• 2:44
  - think about who owns it, when it happens,
• 2:47
  - what tools you put in front of the
• 2:49
  - people doing the work,
• 2:51
  - that that's where you start to see the
• 2:53
  - real
• 2:54
  - difference.
• 2:55
  - And
• 2:56
  - what we're seeing really drive the real improvement
• 2:58
  - is is three things that that work together.
• 3:01
  - So first, it's prospective outreach
• 3:04
  - that's actually grounded in data. So meaning you're
• 3:07
  - not just sending a list of open gaps
• 3:09
  - to a provider,
• 3:10
  - you're surfacing clinically relevant,
• 3:13
  - patient specific insights before the encounter happens, so
• 3:17
  - before the patient walks into the office.
• 3:19
  - So the physician
• 3:21
  - comes into
• 3:22
  - the encounter,
• 3:24
  - they're already primed, they're ready to assess, document,
• 3:27
  - and close
• 3:28
  - what gaps need to be closed.
• 3:30
  - Second
• 3:31
  - is concurrent review.
• 3:33
  - So the days of pure retrospective coding when
• 3:36
  - when you're chasing those diagnoses,
• 3:38
  - you know,
• 3:39
  - retrospectively
• 3:40
  - six to twelve months after the visits,
• 3:43
  - those days have a ceiling.
• 3:45
  - Very important still, and you can still capture
• 3:47
  - a lot of value retrospectively, and that will
• 3:49
  - still continue to be a meaningful
• 3:52
  - source of information.
• 3:54
  - The real lift, though, comes from intervening when
• 3:57
  - the encounter is live or immediately post visit,
• 4:00
  - when that documentation can still be corrected
• 4:03
  - or completed without a lot of pain. And
• 4:05
  - our our goal is really going for all
• 4:07
  - of the accuracy and completeness and looking both
• 4:10
  - ways. We wanna make sure the documentation supports
• 4:13
  - everything we're saying, but we're also
• 4:16
  - deleting anything that is not supported
• 4:18
  - at the same time.
• 4:20
  - And then third and and final point I
• 4:22
  - would make is,
• 4:24
  - you know, the use of technology,
• 4:26
  - and this is where we're heavily focused
• 4:28
  - at Vertex Health and really using an AI
• 4:31
  - enabled
• 4:32
  - platform,
• 4:33
  - it's not just surfacing
• 4:35
  - codes. It's giving coders and providers
• 4:37
  - the right context. So clinical evidence,
• 4:40
  - the confidence scoring,
• 4:42
  - audit ready documentation
• 4:43
  - support, so the work is both faster and
• 4:46
  - more defensible.
• 4:48
  - Yeah. Carrie, appreciate how you outlined those so
• 4:50
  - nicely into those three buckets.
• 4:53
  - So when organizations
• 4:54
  - are able to give coders the right context,
• 4:57
  - when there's more accuracy and completeness in both
• 5:00
  - directions
• 5:01
  - and gaps can be
• 5:03
  - addressed and assessed and closed sooner.
• 5:06
  - You know, within that shift, where are you
• 5:08
  - seeing the biggest return on investment?
• 5:11
  - I think when, you know, we what we're
• 5:13
  - seeing on the biggest, you know, ROI is
• 5:16
  - when
• 5:17
  - both the prospective and the retrospective
• 5:19
  - programs work together as a system
• 5:22
  - rather than competing with each other or or
• 5:25
  - feeling like you just have to do one
• 5:27
  - or the other,
• 5:29
  - and put your eggs in one basket.
• 5:31
  - When you're able to close those gaps prospectively
• 5:34
  - during the encounter and you have a strong
• 5:36
  - retrospective review to catch anything that may be
• 5:38
  - missed, you're capturing that full picture of the
• 5:41
  - patient complexity.
• 5:43
  - And that's really where you stop leaving money
• 5:45
  - on the table and more importantly, where you
• 5:48
  - actually reflect the true burden of care your
• 5:50
  - providers are delivering.
• 5:52
  - And and that's what everyone's really after.
• 5:55
  - Yeah. Carrie, thanks for for clarifying that for
• 5:58
  - us.
• 5:59
  - And I know that bending the cost curve
• 6:01
  - is is ultimately
• 6:03
  - a a significant goal, but a mismatch between
• 6:06
  - clinical complexity
• 6:08
  - and RAF scores
• 6:09
  - or for those listening, risk adjustment factor scores,
• 6:13
  - it means that organizations may not even be
• 6:15
  - starting from the right baseline from what I
• 6:17
  - understand.
• 6:18
  - So from your point of view, what does
• 6:20
  - it take for organizations to close that gap
• 6:22
  - and actually move the needle?
• 6:25
  - This is a, foundational tension in in value
• 6:28
  - based
• 6:29
  - care. I I don't think people say it
• 6:32
  - plainly enough.
• 6:34
  - If your if your RAP score doesn't reflect
• 6:37
  - your patient's
• 6:39
  - population,
• 6:40
  - the the true clinical complexity,
• 6:42
  - you're not playing the game on a level
• 6:44
  - field. You're either
• 6:46
  - leaving revenue on the table or you're taking
• 6:48
  - on risk that you haven't been paid to
• 6:50
  - manage.
• 6:51
  - Neither of those is sustainable.
• 6:53
  - So closing those gaps starts with data integrity,
• 6:57
  - making sure that every chronic condition is being
• 6:59
  - actively monitored, evaluated,
• 7:01
  - assessed, or treated is actually captured and coded
• 7:04
  - to the highest level specificity.
• 7:07
  - It sounds basic, but when you look across
• 7:09
  - the populations that we work with, and I
• 7:11
  - mean, we're supporting
• 7:12
  - millions
• 7:13
  - of of lives and and records
• 7:16
  - with over 13,000
• 7:18
  - dedicated resources to this work,
• 7:20
  - you see we we see every day how
• 7:23
  - consistently
• 7:24
  - clinical
• 7:25
  - complexity is actually under coded. And it's not
• 7:29
  - because providers don't care.
• 7:31
  - It's because the systems and the workflows that
• 7:33
  - we're operating in aren't designed to catch it.
• 7:36
  - And we're not
• 7:37
  - complementing
• 7:38
  - the physician so they can take the best
• 7:40
  - care of the patients.
• 7:41
  - So what really moves the needle is that
• 7:43
  - alignment across three dimensions. So the the clinical
• 7:47
  - aspect where physicians
• 7:49
  - need to understand the accurate documentation, it's not
• 7:51
  - a billing function, it's a care function.
• 7:54
  - The RAF score is how the system funds
• 7:57
  - the care of the sickest patients.
• 7:59
  - The technology alignment, so you need tools that
• 8:01
  - translate the clinical data into
• 8:04
  - actual insights at the point of care where
• 8:06
  - decisions are made. Not in a back office
• 8:09
  - report that no one reads, not after the
• 8:11
  - fact.
• 8:12
  - And then third, you want that operational alignment
• 8:14
  - where the workflows,
• 8:16
  - the outreach, the feedback loops between
• 8:19
  - coders, nurses, clinicians, they have to be tight,
• 8:22
  - consistent, and measured. And when you get those
• 8:24
  - three in sync, you stop starting from a
• 8:27
  - wrong baseline,
• 8:28
  - you start from a reality,
• 8:30
  - and then you can actually start to bend
• 8:32
  - the curve.
• 8:34
  - I love that. I love that reframe of
• 8:36
  - starting from reality.
• 8:38
  - Appreciate you elaborating on that, Carrie.
• 8:41
  - I wanna make sure we dig in to
• 8:42
  - the provider side a little bit more as
• 8:44
  - well.
• 8:45
  - In that realm, what type of risk data
• 8:47
  - are you seeing help clinicians most at the
• 8:50
  - point of care, and
• 8:51
  - what tends to create friction or maybe even
• 8:53
  - get in the way of accurate and complete
• 8:55
  - documentation for them?
• 8:58
  - Clinicians
• 8:59
  - want
• 9:00
  - a signal,
• 9:02
  - not noise.
• 9:03
  - That's really the most important thing I can
• 9:05
  - say here. When you put risk data in
• 9:08
  - front of a physician, the question is not
• 9:11
  - how much can we surface.
• 9:13
  - It's does this make their job easier or
• 9:15
  - harder in that moment?
• 9:17
  - Is it accurate? Is it complete? Is it
• 9:19
  - helping the patient?
• 9:20
  - And what really helps them is patient specific
• 9:24
  - encounter relevant insights that are riff arrive before
• 9:28
  - or at the time in the visit.
• 9:30
  - So, for example, like, things like this patient
• 9:32
  - has a history of congestive heart failure.
• 9:34
  - It hasn't been coded or reported this year.
• 9:38
  - Or if a patient's diabetes documentation doesn't reflect
• 9:41
  - the level of severity that their lab support,
• 9:44
  - that's actionable.
• 9:46
  - A physician can do something
• 9:48
  - with that in the room. Obviously, in a,
• 9:50
  - you know, compliant, clear, concise way, but that's
• 9:53
  - what really is helpful to them.
• 9:56
  - What creates friction, and I see this across
• 9:59
  - the market constantly,
• 10:00
  - is information overload.
• 10:02
  - So long list of potential HCC gaps with
• 10:05
  - no clinical context, no prioritization,
• 10:08
  - no indication of whether this is highly probable
• 10:11
  - or if it's just speculative.
• 10:13
  - It puts a burden of clinical judgment back
• 10:15
  - on the physician, and they're already managing 15
• 10:18
  - other things in a fifteen minute visit.
• 10:21
  - They'll ignore it, and and you can't blame
• 10:24
  - them.
• 10:25
  - The other big friction point is the integration
• 10:28
  - with tools and technology in the EHR or
• 10:31
  - frankly, the lack of it. So if a
• 10:33
  - coder or a clinical team has to toggle
• 10:36
  - between three different systems to verify diagnosis or
• 10:38
  - pull a clinical lab or a different result,
• 10:41
  - then document a code, that workflow is going
• 10:44
  - to break down at scale. And it it's
• 10:46
  - going to have a a ton of burden
• 10:48
  - tied to it. The platforms that are winning
• 10:50
  - right now are the ones that are deeply
• 10:52
  - embedded in an existing clinical workflows,
• 10:55
  - not bolted on as a separate program.
• 10:57
  - And that's something that we spend a lot
• 11:00
  - of time on with the philosophy here at
• 11:02
  - Vertex, and it's it's really our philosophy is
• 11:05
  - right insight
• 11:06
  - delivered at the in the right workflow at
• 11:08
  - the right moment,
• 11:10
  - and what drives all of that is it
• 11:12
  - it drives the adoption.
• 11:14
  - So because at the end of the day,
• 11:15
  - even the best risk adjustment technology fails, a
• 11:18
  - foot clinician does not engage with it.
• 11:21
  - Adoption is everything.
• 11:24
  - Yeah. And, Carrie, it really aligns with what
• 11:26
  - we're hearing at Becker's. Becker's. I I was
• 11:28
  - just revisiting a a piece that we wrote
• 11:30
  - earlier this year about,
• 11:32
  - this trend among hospital health system leadership, especially
• 11:35
  - of craving, you know, tools that are integrated
• 11:38
  - already. You know, it's not so much about
• 11:40
  - the flashiness of the technology itself, what kind
• 11:43
  - of AI it might be, or some other,
• 11:46
  - tool, but rather just
• 11:48
  - the workability of it and the integration. So,
• 11:51
  - everything you're saying certainly resonates.
• 11:54
  - But I wanted to bring our conversation full
• 11:56
  - circle here. I know we started off by
• 11:58
  - talking about the importance of aligning both providers
• 12:01
  - and payers. And, of course, shared KPIs and
• 12:05
  - aligned incentives are meant to bring those two
• 12:07
  - parties together, but that doesn't always play out
• 12:09
  - in practice. So I'd love to know the
• 12:12
  - metrics and incentives that you've seen genuinely change
• 12:15
  - behavior around risk capture
• 12:17
  - and gap closure and which at the same
• 12:19
  - time are falling short.
• 12:21
  - This one is is personal for me. I
• 12:24
  - I've said on both sides of this table.
• 12:26
  - So working with payers, designing programs, and also
• 12:29
  - with providers trying to execute them.
• 12:32
  - And I'll tell you what I've seen. The
• 12:35
  - the metrics that change behavior are the ones
• 12:37
  - that are transparent,
• 12:39
  - timely, and tied to something the provider actually
• 12:42
  - cares about.
• 12:43
  - So what actually works is a performance scorecard
• 12:46
  - that's updated frequently.
• 12:49
  - Not an annual scorecard, not even quarterly,
• 12:52
  - but almost close to real time. So providers
• 12:54
  - can see their gap closure rates and their
• 12:56
  - risk capture performance and actually adjust.
• 13:00
  - They're looking at that data.
• 13:01
  - They can pivot. They understand what is happening
• 13:04
  - in the moment and how their actions are
• 13:07
  - impacting
• 13:08
  - the the metrics in those KPIs.
• 13:11
  - You pair that with a shared savings model
• 13:13
  - that are actually designed so the provider sees
• 13:15
  - a meaningful financial return is is when the
• 13:18
  - program works.
• 13:19
  - When a primary care physician looks at their
• 13:22
  - panel and says, okay. My patients are being
• 13:24
  - managed better. My documentation
• 13:27
  - reflects their true complexity,
• 13:29
  - and I'm receiving the resources to take care
• 13:31
  - of them appropriately.
• 13:32
  - That's when the behavior starts to change.
• 13:36
  - It it falls short when there's just a
• 13:38
  - one time incentive payment tied to participation rather
• 13:41
  - than performance.
• 13:42
  - We we see a lot of programs that
• 13:44
  - essentially pay providers to show up
• 13:47
  - to complete maybe an HCC training, to open
• 13:50
  - a portal,
• 13:51
  - to answer an assessment,
• 13:52
  - and that generates activity,
• 13:54
  - but it doesn't generate sustainable change.
• 13:58
  - And I I would say one other thing
• 14:00
  - that consistently falls short is vague quality targets
• 14:03
  - with no connection to the risk adjustment workflow.
• 14:07
  - STARS measures and HEDIS gaps matter enormously.
• 14:11
  - But if they're managed in a separate program
• 14:13
  - from risk capture, you're you're missing the integration.
• 14:16
  - The providers
• 14:17
  - and and the groups that are winning in
• 14:19
  - value based care are the ones where quality
• 14:22
  - risk and care management are all running from
• 14:24
  - the same playbook.
• 14:26
  - Yeah. Important sentiment you're you're,
• 14:29
  - bringing up here, Carrie, especially as we're seeing
• 14:31
  - value based care gain traction across
• 14:34
  - the industry.
• 14:35
  - And on that note, you know, before I
• 14:37
  - let you go, I wanna make sure that
• 14:38
  - I get your perspective on the next few
• 14:41
  - years ahead. So as you look to the
• 14:43
  - future and as we know the regulatory landscape
• 14:46
  - will continue to evolve,
• 14:48
  - what do you think a defensible
• 14:50
  - patient centered risk adjustment program looks like? And
• 14:53
  - where do payers and providers need to better
• 14:55
  - align to get there?
• 14:57
  - So let's start by reframing the word defensible.
• 15:01
  - I I think sometimes that word makes people
• 15:03
  - think about audit protection first and patient care
• 15:06
  - second.
• 15:07
  - And and when that happens, we've got the
• 15:09
  - priority order backwards.
• 15:11
  - So a truly defensible risk adjustment program is
• 15:14
  - defensible
• 15:15
  - precisely because it is patient centered.
• 15:17
  - Every code is supported by clinical evidence.
• 15:21
  - Every diagnosis reflects a condition that's being actively
• 15:24
  - managed.
• 15:25
  - So there's a clear documented clinical rationale behind
• 15:28
  - every risk adjusting diagnosis.
• 15:31
  - And that's not a compliance posture. That's just
• 15:33
  - good medicine and it's captured accurately.
• 15:36
  - And that defensibility will flow through. It supports
• 15:39
  - everything a provider is doing, a payer is
• 15:41
  - doing, whether it's Radb or
• 15:43
  - or something else.
• 15:45
  - In practice, when we say, okay. What does
• 15:48
  - that actually look like?
• 15:50
  - It it means that prospective programs that engage
• 15:52
  - the patients before they're in crisis. It means
• 15:55
  - concurrent documentation
• 15:57
  - support that helps clinicians
• 15:59
  - capture complexity in real time, not reconstruct it
• 16:02
  - months later. And it means technology
• 16:05
  - that provides confident scoring and audit ready evidence
• 16:08
  - at the point of coding. So when CMS
• 16:10
  - or a payer audits a claim,
• 16:12
  - the supporting documentation is already there.
• 16:15
  - So I and when we think about on
• 16:17
  - the alignment piece where where payer and providers
• 16:20
  - need to get better, it's really around that
• 16:22
  - data sharing. So payers are sitting on they've
• 16:25
  - got claims history, utilization patterns,
• 16:28
  - population health data
• 16:29
  - that most providers have never seen in a
• 16:32
  - usable form,
• 16:33
  - and providers have clinical context that payers desperately
• 16:37
  - need to understand their members' true complexity.
• 16:40
  - When you take those two datasets and they
• 16:42
  - come together in a shared workflow,
• 16:44
  - both parties are working through the same picture
• 16:46
  - of the patient,
• 16:47
  - and that's when
• 16:49
  - data becomes actionable. That's when risk adjustment stops
• 16:51
  - being adversarial and starts being a genuine partnership.
• 16:55
  - The organizations
• 16:57
  - that are going to lead in value based
• 16:58
  - care of their next five years are the
• 17:00
  - ones building those partnerships now.
• 17:02
  - Not waiting for a regulatory mandate, not reacting
• 17:05
  - to a CMS model change, but proactively
• 17:08
  - aligning around the patient.
• 17:10
  - And that's what we're here to help make
• 17:12
  - happen.
• 17:13
  - Well, Carrie, I I so appreciate you sharing
• 17:16
  - your vision of what success and value based
• 17:18
  - care looks like on both sides for payers
• 17:21
  - and providers.
• 17:22
  - You've shared so many great insights with our
• 17:24
  - audience today, and I just wanna thank you
• 17:26
  - for the time and for sharing your expertise
• 17:28
  - here.
• 17:29
  - My pleasure. Thank you. I enjoyed being here.
• 17:33
  - Well, it's great having you. And, of course,
• 17:35
  - we also wanna thank the sponsor for today's
• 17:37
  - podcast, Vertex Health.
• 17:39
  - Listeners, be sure to tune in to more
• 17:41
  - podcasts from Becker's by visiting our podcast page
• 17:44
  - at beckershospitalreview.com.