Health plans today want greater internal control of their Affordable Care Act (ACA) and Medicare Advantage risk adjustment programs and increased visibility into the risk adjustment process. No longer content to rely on broad-brush chart reviews, provider engagement, and in-home assessments, health plans instead want greater accuracy, efficiency, and transparency in how members are selected and which interventions are deployed.
Answering this need, Blue Health Intelligence’s (BHI®) Population Advyzer platform unbundles analytics from interventions. This allows the company to recommend what actions to take and what to avoid based solely on data-driven insights. Care and coding gaps are being closed more efficiently; health risks are being more accurately captured; and reimbursement is reflecting the actual risks within a member population. Through a fully transparent methodology, BHI has helped plans realize as much as a twelve-fold ROI on medical chart reviews alone. The Population Advyzer risk adjustment and stratification solution follows a playbook built on best practices and informed by the right analytics. The playbook is designed around proven principles for better targeting the most impactful risk adjustment interventions:
- Capture the right data to enable efficiency Strive for high-quality provider data and capture appropriate feedback from intervention vendors.
- Take time up front to let analytics inform the best intervention
- Take aim with predictive analytics to accurately target providers and guide when – and when not – to take Every unnecessary action wastes money.
- Engage providers with meaningful information on members, gaps, and incentive programs by using tools that integrate into existing workflows.
- Measure to improve, because – in the words of the pioneering scientist Lord Kelvin, “If you cannot measure it, you cannot improve ”
“Unlike other solutions BHI’s fully transparent information helps plans decide which actions to take and which actions not to take – resulting in reimbursement that better reflects the actual health status of their populations.” – Alan Spiro, MD, MBA – VP Strategy & Growth, Chief Medical Officer at Blue Health Intelligence
Three Health Plans Get Results
Population Advyzer was employed to improve the efficiency of three health plans’ risk adjustment programs while helping them reach or surpass previous years’ results. While each plan faced unique market dynamics, geographic considerations, and provider affiliations, the Population Advyzer playbook was effective in every case.
A mid-sized regional plan completes a thorough chart review
- Challenge: This plan had historically invested significant resources into risk adjustment, casting a wide net on chart reviews and using multiple vendors to perform both in- and out-of-area reviews. Plan leaders sought a way to reduce program costs while maximizing risk capture results.
- Action: By taking time up front to let analytics inform its intervention strategy, the plan executed a well-thought out, multifaceted approach that maximized results.
- Result: Plan leaders credited their team’s efforts and Population Advyzer for a twelve- fold return on investment for medical record reviews alone and a six-fold overall return, including vendor and internal staffing
A smaller regional plan supports a tight, targeted approach
- Challenge: A small nonprofit plan with a large share of the state’s ACA population took a conservative approach to risk adjustment, with one in-house coder and a defined budget. This plan needed to target the members with the greatest potential for improving risk score accuracy, informed by the knowledge of the best time and method with which to engage them to ensure the greatest return within their budget.
- Action: The plan focused first on its large, high-impact provider affiliations, which included the largest health system in its Because members typically stayed within the single system for all their medical needs, this approach eliminated the need for multiple chart reviews. Further, the plan’s relationship allowed it to access the system’s electronic health record, a less costly and burdensome approach than conducting manual chart reviews. Armed with the right predictive analytics, the plan could then zero in on the members in whom it saw the greatest opportunity for closing gaps.
- Result: By leveraging Population Advyzer, the plan achieved a three-fold return on its medical records review
A large regional plan saves more than $1 million in its pilot year
- Challenge: A third regional health plan chose Population Advyzer to be the centerpiece of its risk adjustment efforts as it brought the program in-house. This plan needed to get started quickly with a platform that employed the right analytics and workflow programs, and minimized learning curve downtime and errors.
- Action: The plan approached its first year as a pilot year – with a new staff, processes, and a limited scope of interventions.
- Result: By relying on Population Advyzer to inform the best intervention strategies, the plan realized more than $1 million in payment transfer
Different Plans, A Consistent Approach
Every plan is unique, but the principles within the Population Advyzer playbook work equally well in any circumstance. As an analytics company, BHI’s only goal is to provide insights to optimize results and pinpoint where improvements are needed. As data scientists, BHI’s consultants are firmly committed to measurement, transparency, and accuracy. As a company, BHI is proud to say that it has built a strong partnership with every client, delivering them a solid program and return on their investment.Download PDF