Mitigating the impact of COVID-19 on Risk Adjustment


Since routine medical care is delayed or canceled because of COVID-19, the risk scores that will be used to pay Medicare Advantage (MA) health plans in 2021 are decreasing than previously forecasted. In addition, the risk score for that Health and Human Services (HHS) model that is used in health plans under the Affordable Health Care Act (ACA) for commercial plans are also decreasing than in previous years, as per health plan data collected by Guhilot’s risk-adjustment solution partner. As the pandemic eases health plans will witness an increase in the demand for routine and elective treatment, however, the insufficient capacity and re-strategizing needed to meet these demands could impact the risk adjustment scores as well as revenue-generating opportunities.

Despite these challenges health plans are able to use preemptive telehealth or remote healthcare strategies to reduce the negative effects caused by the virus on quality and risk adjustment programs.

Monitoring the impact

“Health policies across the nation are reporting double-digit reductions in the portion for diseases to score for risk adjustments” reported Arturo Diaz, chief operations officer for risk analytics at Guhilot. “While the number of telehealth visits has been increasing to levels that are historically high, however, overall face-to-face interactions with providers are declining.”

To determine how this shift in routine visits affects their risk adjustment scores MA plans are able to conduct an annual comparison of risk scores between 2019 and 2020, and then look for variations. Health plans shouldn’t assume they will “catch up” when the pandemic is less severe but. When primary care is regaining its popularity the providers who are dealing with high demand and limited availability could be more inclined to treat patients who are sicker, which could impact risk adjustment scores.

“Medicare Advantage plans to file 2021 bids with minimal impact on the revenue from risk adjustment must carry out remediation actions to correct the reported drop in face-to-face interactions to make sense of the decline in their bids submitted,” Diaz added.

Utilizing telehealth to make up for less in-person appointments

As we discussed in an earlier blog article, we reported that the Centers for Medicare & Medicaid Services (CMS) has increased the MA increase in payments by 4.07 percent in 2021. This could reduce revenue losses due to the gripe. However, to benefit from these rates, health plans must cover absences from in-person appointments. According to data from Guhilot’s plans might be able to take advantage of more than 95 percent of hierarchy category categories (HCCs) through Telehealth instead of in-person visits.

The results of telehealth-related diagnoses are able to satisfy the face-to-face requirement for risk adjustment in the event that services are delivered with an audio or video telecommunications system that allows live-time interactive communication, as per CMS. Furthermore, the National Committee for Quality Assurance (NCQA) issued guidance on June 5 that permits telehealth-based capture from the 40 HEDIS (r) measurements, meaning that telehealth can be utilized to fill in risks and quality gaps.

Health plans, for instance, could incorporate fecal tests for immunochemical into their telehealth programs to meet the demands of the Colorectal Cancer Screening (COL) HEDIS measure. These tests are able to be mailed out and may improve satisfaction since multiple goals can be attained in one telehealth appointment which can reduce contact with members.

A further benefit of telehealth is its possibility of reaching members living in rural areas who be unable to access a healthcare center. Some members might be reluctant to seek out care in bigger cities or to travel to areas that are experiencing an outbreak, which makes traveling risky. In such a case, at-home assessments for members are possible online via the use of telehealth visits. In keeping both the members and healthcare professionals safe and secure, Telehealth can solve a variety of problems and remains an option as the healthcare system continues to move towards recuperation.

Telehealth issues for healthcare providers

Except for large medical facilities, Most providers have difficulty implementing the effectiveness of “face-to-face” health care delivery via telemedicine, Diaz noted. Presently only audio-only (telephonic) visits to the doctor cannot be considered to assess risk in spite of opposition from organizations like The Better Medicare Alliance (BMA) and the fact that many of the provider organizations are relying on the telephonic assessment.

In actual fact, NEJM Catalyst found that telephonic healthcare is currently the most popular telehealth option and video-based visits take some time to get going. Barriers to video-based care are:

  • Training clinicians
  • Informing patients on the arrival procedure
  • Using interpreter services
  • Transferring video equipment into clinicians at their homes

The publication also mentioned that some video visits have required switching to the telephone or to less HIPAA-compliant devices like FaceTime or Skype.

Blockades on the way towards 2021 for those who pay

In the review, Diaz offered seven challenges health plans could face when dealing with risk adjustment solutions and quality gap before 2020’s end:

  • Orders to stay at home that banned routine care and closed several offices of providers during the first quarter of the year.
  • Only a short amount of time in 2020 to fill in gaps
  • Provider offices struggle to stay open
  • Patients at high risk are uncomfortable going to doctors’ offices for routine treatment
  • Patients taking annual assessments via telephonic communication (thus not eligible to be considered for risk adjustment)
  • The possibility of a new COVID-19 wave
  • Influenza season is not well-known.

He also stressed that health plans that cover both MA and commercial, need to continue to improve the telehealth model to be able to handle any future COVID-19 waves. Additionally, they should remain able to provide treatment for sick members no matter where they are.

“Plans must enhance telehealth technology in order to help members’ well-being and mental aspects of wellbeing,” Diaz said. “These essential needs of members can’t be addressed with a vaccine.”