MedCity Influencers, Payers

Mitigating the impact of Covid-19 on Medicare Advantage risk scores and payment

The impact of delayed care among MA members goes beyond lower-than-forecasted risk scores and decreased plan payments.

Delays in care due to Covid-19 will likely lead to reduced risk scores for Medicare Advantage (MA) patients, lowering plan payments in 2021. For now, the big questions facing MA plans are, “How much revenue could we lose—and can we close the gap by year-end?”

An analysis by PopHealthCare shows that health plans could see double-digit decreases in the disease portion of risk scores due to deferred care during Covid-19. Unless plans can encourage members to seek preventive care by the end of the year, the impact on 2021 payment could be substantial.

The clock is ticking. While the Centers for Medicare & Medicaid Services (CMS) bumped up the MA growth rate to 4.07% amid the coronavirus outbreak—significantly higher than the 2.99% rate proposed last February—health plans still need to make up for missed in-person appointments by the end of the year to take advantage of higher rates.

But plans face numerous obstacles getting MA members to providers for routine care. For one, many high-risk MA patients are uncomfortable with venturing to doctors’ offices during the pandemic. A recent survey shows 70% of consumers are worried they will contract Covid-19 if they seek care at a medical facility. They also have concerns about the cost of care, the wait time, and their ability to be seen by a physician. Further, even as some patients seek to return for care, providers dealing with pent-up demand may prioritize sicker patients.

With limited time remaining in 2020 to close gaps in risk scores and revenue, how can health plans mitigate the impact of Covid-19 on their members and results? Here are three approaches to consider.

Strengthen capabilities to treat sick patients where they are. This includes not just telehealth, but also home health resources. For example, investing in nurse practitioners and physician assistants to perform member assessments in the home could pair MA members with the expertise needed to evaluate members who have become disengaged from their wellness plan and fill in care gaps for chronic conditions. Plans might also consider partnering with community service centers, particularly in rural areas, to perform these assessments in alternative settings that are convenient for members to access and close to home.

Health plans also can use telehealth to recover missed face-to-face appointments so long as services are provided in real-time using an interactive audio and video communication system. But while CMS has loosened restrictions on the use of telehealth for MA members during Covid-19, there are barriers to engaging seniors in telehealth, from gaps in technology access and use among some patients to dropped calls and poor image quality resulting from insufficient internet capacity to lack of familiarity in engaging members via telehealth.

Health plans should assess whether members have the devices and broadband coverage needed to connect with healthcare professionals via telehealth. In instances where lack of technology is an issue, providing devices to members that could make telehealth visits possible, such as tablets and mobile hotspots, could empower plans not only to address members’ physical and mental health needs, but also assess and respond to social determinants of health. Plans also should pair clinicians with the right equipment for video communications and offer “web-side manner” training to successfully engage seniors in virtual care.

Focus on ways to break through members’ emotional resistance to seeking care. During Covid-19, when 72% of consumers have dramatically changed their use of traditional healthcare services, partnering with providers to communicate the safety measures undertaken to protect seniors’ health will be critical to bringing members back into physician offices for care. So will compassionate, culturally competent scripting that takes into account the members’ unique needs, perspectives, and values.

Develop training for care managers, social workers, and nurses around how to provide appropriate care and guidance for members, taking into account all of the factors that shape a member’s life experience—from culture to age, gender identity, economic status, housing situation, and more. Look for ways to strengthen relationships with members in partnership with primary care providers. Initiate communications in small doses, being careful not to bombard members with messaging at a time when many consumers are facing information overload.

It’s also important to provide members with the option to take action rather than a mandate. Empowering members to make the choice for health—and providing multiple options for care, from in-person visits to telehealth to in-home support—helps position the health plan as a trusted resource. It also avoids scenarios where the health plan may come across as aggressive, leading to breakdowns in communication and engagement.

Explore ways to accomplish multiple objectives during a single visit without overwhelming the patient
Now that the National Committee for Quality Assurance (NCQA) allows 40 HEDIS measures to be captured via telehealth, some plans are exploring ways for members to conduct screenings in the home prior to their appointment. These include sending fecal immunochemical test kits to members’ homes for colorectal cancer screenings or tests that identify diabetes through A1C levels in the blood or the presence of microalbumin in urine samples. Payers such as Blue Cross Blue Shield of Minnesota and Humana provide these kits at no cost to the member, expanding access to preventive care while maintaining or improving HEDIS scores and MA star ratings during the pandemic.

The key to implementing an approach such as this is to analyze plan data to identify at-risk members. These include not just MA members who have avoided care during the pandemic, but also members with chronic conditions who have been treated for Covid-19, those who experienced Covid-19 related complications, and those who have been treated in an intensive care unit since March. Share the data with primary care physicians, and collaborate with providers in communicating the need for preventive testing and one-to-one support to help reduce health risks.

By conducting coordinated outreach in partnership with the member’s primary care physician, health plans not only increase their chances for successful engagement but also reduce their administrative expense.

Developing a Proactive Approach
The impact of delayed care among MA members goes beyond lower-than-forecasted risk scores and decreased plan payments. Ultimately, delays in needed care also could lead to higher-than-necessary costs of care, especially when members are living with existing, complex chronic disease. Taking a proactive, highly collaborative approach to mitigating the impact of postponed care on risk scores and payments not only protects health plans’ bottom line but also improves long-term health outcomes for members.

Photo: JamesBrey, Getty Images

Rachael Jones is Senior Vice President, Performance Analytics and Quality for Cotiviti, a leading solutions and analytics company that leverages clinical and financial datasets to deliver deep insight into health system performance.

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