Unlocking the Potential of Risk Adjustment: A Strategic Approach

CMS compensates 10X more in annual per-MAPD member risk adjustment payments to UnitedHealthcare versus Kaiser Permanente¹. How can there be so much payment fluctuation between two of the nation’s leading payers? An analysis of publicly available data from CMS suggests that the variance probably does not lie in underlying differences in the plan’s populations. Across the FFS population in the counties served by the two plans, there is only a 0.03 difference in risk adjustment factor. So, what is the driver? 

Risk adjustment represents a crucial lever for ensuring financial sustainability and equitable resource allocation within health plans. The key to getting a code on a claim is getting a member to a provider. Ideally, this happens by getting the members to their own PCP. But, using in-home assessment vendors to round out the effort needs to be part of the plan. 

Get members to the PCP  

Success hinges on the Annual Wellness Visit (AWV) done by the member’s PCP. Connecting the member with a PCP in a meaningful way leads to a host of benefits²:  

• 35% greater retention 
• 40% lower readmission rate 
• 5-10x more likely to get preventive care 
• 45% higher risk adjustment 

However, assuming a PCP has more than 2,000 patients, and each AWV takes 45 minutes, over the course of the year there would be little time left for anything else. Shifting the burden away from the provider and towards others in the office keeps everyone at the top of their licenses (G0439 can be billed under direct supervision) which means nurses need to take the lead.  

Supporting offices 

CMS data suggests that 45% of beneficiaries are getting AWVs, but this varies dramatically across providers.³ Health plans need to:  

• Identify providers not completing AWVs 
• Support them with coaching related to billing and workflow 
• Offer templates for their front office staff such as call scripts, FAQs, and letter templates encouraging members to come into the office  

Expanding Horizons with In-Home Assessments 

While PCP engagement remains the gold standard for risk adjustment, in-home assessments play a complementary role, particularly for harder-to-reach populations. Think of the pandemic-era analogies to Swiss cheese and multiple layers of protection. Engagys recommends a focused strategy for in-home assessments that plugs the holes left by PCPs: 

• Targeting High-ROI Members: Prioritize members with likely undocumented HCCs using claims and pharmacy data. Frankly, in-home assessments cost the plan about 3x more than a claim for an AWV, so focusing them where there is likely more value is the key. 
• Customized Messaging: Tailor communication based on member history and preferences, addressing specific barriers to engagement. Our experience suggests that in-home assessment vendors can double the number of AWVs completed by leveraging segment-specific messaging. 
• Vendor Collaboration: Establish guardrails to balance vendor practices, member satisfaction, and plan-wide goals. Members rarely distinguish between vendors and plans. In one case, members described vendors as “relentless”. One member was called more than 20 times in just three weeks. By reducing the number of attempts, member satisfaction and the number of visits scheduled increased – sometimes more is indeed less. 

Conclusion 

Succeeding at risk adjustment demands that plans develop a tiered strategy that supports different approaches to various segments of their populations. While the starting point is getting the most out of the PCP and office-based visits, the next step is to use in-home assessments to catch remaining opportunities. Engagys can help you optimize your strategy and execute the processes and communications needed at any point. Our deep experience is focused on delivering tangible results – not another report that will sit on a shelf.  

Ready to engage? Jack Newsom, ScD is a Partner and the Risk Adjustment Lead at Engagys