What health plans must know about telehealth’s immediate impact on risk adjustment

What health plans must know about telehealth’s immediate impact on risk adjustment

The coronavirus pandemic has disrupted so many parts of our healthcare system that it is hard to appreciate all of the second- and third-order consequences. One area being hit particularly hard is risk adjustment since traditional retrospective and in-home programs are not viable in the current environment.


In the early innings of the Covid-19 crisis, CMS implemented many initiatives in response to the national emergency declaration, but risk adjustment was notably left unaddressed. This created a lot of anxiety among health plans and other at-risk entities given the importance of accurately risk adjusting a plan’s membership. The industry’s hope, at the time, was that CMS would build on its series of telehealth waivers from March to allow health plans to gather risk adjustment data through telehealth visits.


That became a reality in April when CMS approved telehealth as a means for health plans to gather risk adjustment data. CMS made the right move, as it is critical for Medicare Advantage (MA) plans—which insure many of the oldest and sickest patients—to stay on track with risk adjustment. Additionally, to the extent that the risk adjustment solution is provider-centric, it enables primary care physicians (PCPs) to uphold quality and address care gaps through preventive and routine care.


However, rolling out a telehealth risk adjustment solution isn’t as simple as flipping a switch. While telehealth has seen explosive growth for younger users, many PCPs and seniors still face obstacles in adopting and integrating new technology and workflows. These challenges are compounded by ever-changing regulatory requirements and unprecedented financial stress threatening the ongoing viability of PCP practices.


Fortunately, there is a path forward. There are a couple of challenges that health plans can address which will enable them to implement successful risk-adjustment initiatives during Covid-19.


Solving for disjointed telehealth strategies


Telehealth usage is increasing but maybe disjointed between audio and video methods and external telehealth solutions. In order to capitalize on the telehealth risk adjustment waiver, visits via telephone only will not be enough. CMS has stated that PCPs can only gather encounter data for risk adjustment via real-time interactive audio-video telecommunication systems.


Additionally, many outsourced telehealth solutions use clinicians with no relationship to patients or connectivity to a PCP’s EMR. While such solutions may be effective to treat acute needs when a patient’s PCP is unavailable, they should not be a substitute for a PCP-centric telehealth solution for risk adjustment and care coordination. Outsourced telehealth solutions will likely be ineffective and cause significant provider abrasion at a time when PCPs are struggling to keep their practices open.


During this time, PCPs need solutions that keep them productive and engaged with their patients, rather than creating more work picking up the pieces of an outsourced telehealth solution. PCPs also need support implementing this new care delivery model into their workflow.


Helping strained and under-staffed PCPs by driving member engagement


As coronavirus care impacts all aspects of our business and personal lives, PCPs are under considerable stress, and their financial viability is being threatened. A survey of physicians in mid-April revealed that patient volumes are down 65% compared to pre-pandemic volumes, and the effects are beginning to catch up to the PCP practices. Some practices have already decreased their workforce, and others think they’ll have to temporarily shutter their doors.


Even though telehealth is now an option, practices still need help getting patients to participate. PCPs need easy-to-use member engagement tools with administrative and clinical support to secure patient participation. To optimize participation, health plans can promote PCP-centric telehealth to the members. Not only can this help maintain risk adjustment programs, but it also helps PCPs to generate reimbursable revenue at a time when it’s needed most.


While facing these two challenges will help MA plans in the near term, the real question is, “Where do we go from here?” While it’s hard to imagine that telehealth will ever fully replace in-person care, we expect that it will be our “new normal” for quite some time. This is especially true for seniors who are at the greatest risk of complications from Covid-19. I am cautiously optimistic that telehealth will remain in place for routine and preventive care and, if it does, we would expect CMS’ new guidance on risk adjustment via telehealth to also be extended.


In the meantime, health plans should help their PCPs integrate telehealth into their practice to take full advantage of the new rules and flexibility relating to telehealth and risk adjustment during Covid-19.





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