Finding Value in Value-Based Healthcare

It’s hard to argue with the concept of value-based healthcare.  Achieving better outcomes at a lower cost is a pretty non-controversial goal, no matter where you find yourself in the healthcare ecosystem.  The hard part is actually making it happen.

Let’s say you’re a health plan administering a Medicare Advantage plan.  How do you make sure that reimbursement from Medicare truly reflects the medical complexity of your members? How do you communicate with healthcare systems and individual providers to help close gaps in care? How can you identify the most at-risk members to facilitate timely intervention? And how do you ultimately put the whole picture together to improve quality and maximize value-based payments from CMS?

Each step is critical in actually finding the value in value-based healthcare.

First and foremost, you need to ensure that your starting point is correct.  If you’re managing a complex group of members, your reimbursement needs to reflect this reality.  Obviously, the focus needs to be on HCC (Hierarchical Condition Category) coding, which if done correctly, can lead to the proper RAF (Risk Adjustment Factor) score.

But how exactly is this accomplished? Traditionally, somewhat random chart reviews have been used to find HCC codes.  Aside from being a bit haphazard, such reviews are also rather time consuming.  To compound matters further, human coding error is an accepted fact of life.  Such error can lead to either missed opportunities or unsupported HCC codes that translate into hefty fines.  Finally, given the retrospective nature of these reviews, the real-time application is nearly impossible.

So is the playing field really level? Good question.

The next focus needs to be on helping the rest of the team.  HCC coding typically falls under the domain of providers and coders.  Placing this burden on already overworked personnel may not only be unfair, but it can also be ineffective.  Providing assistance in the process is clearly reasonable.  But if your EHR is different from theirs, how can you even communicate? And even if incompatibility is not a concern, what exactly should you communicate about?

In an ideal world, proper communication would, of course, help in the coding process.  In an even more ideal world, it could identify gaps in care that, if closed, could improve overall quality.  And in a dream world, such communication could convey the results of predictive modeling that identifies the most at-risk members, allowing for timely intervention to avoid adverse outcomes.

Stated in another way, this world would increase not only RAF scores but also HEDIS (Healthcare Effectiveness Data and Information Set) scores and CMS value-based payments.

A manual approach to all of the above can be a patchwork and onerous undertaking.  Even worse, it can be fruitless.  That’s where the world of software enters the picture.  What if just one tool could help you put the entire puzzle together? What if this one tool could improve RAF scores, HEDIS scores, and CMS value-based payments?

Clair360™ integrates seamlessly with all major EHRs, serving as the glue that connects your system with the system of your providers.  Once this step is accomplished, our AI-based platform really starts working for you.  Existing HCC codes are identified, as are members for whom HCC codes would be warranted.  Care gaps are noted, with provider notifications helping to close these gaps and improve quality.  Finally, predictive algorithms identify high-risk members for whom intervention is warranted.

And to top it off, the cloud-based, pay as you go system requires no up-front investment and no specialized IT talent.