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How to Address Provider Challenges in Risk Adjustment and Quality Gaps

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How to Address Provider Challenges in Risk Adjustment and Quality Gaps

Many physicians are feeling challenged by risk adjustment and quality gaps. Many feel fatigue and burnout because they are spending more time on documentation and administrative work than ever before. Risk adjustment and quality gaps have dictated their day-to-day work, especially for physicians who see Medicare Advantage members. These challenges impact how much time physicians have and also their engagement with cumbersome documentation tools.

Physicians want to spend their time caring for patients but are struggling with burnout and low morale. A recent study completed by almost 9,000 physicians showed 8 out of 10 physicians are at full capacity or overextended. Overextension and burnout are being caused by a series of challenges, from the tools used or lack thereof to a shift to value-based contracting. When working with physicians on risk adjustment and quality gaps in the Medicare Advantage (or value-based) space, it’s important to use ease as a currency so you and your network can work together to properly document conditions and treat patients to address gaps in care and improve outcomes.

A Physician’s Perspective

So why are risk adjustment and quality a challenge in the office for PCPs? There isn’t just one thing. It’s a mix of:

  1. Limited time with patients
  2. Engagement challenges
  3. Billing
  4. EMR differences
  5. Too many prospective programs
  6. Lack of EMR integration
  7. Workflow abrasion

These challenges go against what many doctors gave up their 20’s to do, which is to help patients. They love spending time with them; the burden created by the system means they don’t receive this satisfaction.

A Mix of EMR Challenges

The electronic medical records (EMRs) or electronic health records (EHRs) weren’t built for physicians. The EMR and EHR were never meant to boost productivity or physician satisfaction. These systems were developed for data aggregation and billing; the rest was shoehorned into practices to help their day. The end result has been more challenging instead.

Often each EMR or EHR is built differently, and each health plan has different specific requirements for data formatting. Many physicians are then relegated to a lot of back office and administrative work to keep everything organized.

Extra Burdens in Medicare

The shift to value-based contracting and working with Medicare patients has been a challenge for many physicians. Today, 43% of physicians have their compensation directly tied to quality or value, where this number was about half of that 10-15 years ago. The extra documentation requirements for elderly and value-based patients is putting a strain on time for physicians. 22% are limiting their number of Medicare patients, or don’t see any at all.

Returning to the fact that 80% of physicians are at or above capacity, they don’t have the availability to fit these patients into their schedule unless something changes.

Fragmentation of Data Access

The lack of a cohesive space to access patient data is also a frustration for PCPs who don’t have an easy way to get specialist visit data, such as claims data from a cardiologist visit. This lack of a central hub for patient data opens up the patient, health plan, and provider to a higher chance of gaps in care forming. This has a lot to do with the EMR system because they all store and sort data differently, making handshakes between systems difficult.

Challenges Aside, Solutions are Coming.

Consider all of this together and you can understand why morale can often be low. Fewer physicians are recommending that others join the industry than ever before. We just aren’t creating enough doctors, which is its own problem.

We need to come up with solutions that can enable physicians and reduce their challenges and frustrations. It’s not just about efficiency; it will also lead to higher morale across the industry.

The Health Plan Perspective

The question, to begin with, is what do you as the health plan need your physicians to do around risk adjustment? Often these are the five steps health plans are looking for from physicians:

  1. Adopt or transition to value-based contracts
  2. Participate in prospective programs
  3. Complete annual wellness evaluations for full coding
  4. Improve documentation completeness
  5. Provide charts for retrospective chart review or audits

Many of these things are part of the challenges physicians are facing. It’s possible to reduce the challenges if you take a step back and focus on the problem. There are solutions that benefit both physicians and the patient population.

Overcoming Challenges - Using Ease as a Currency

There are opportunities to overcome the challenges faced by physicians, patient populations, and payers. By focusing on physician challenges and your goals together you can begin to achieve cooperatively. These are some of the first steps you can take to begin overcoming challenges.

We recommend when looking over best practices and strategies on how to position your programs, discuss current initiatives for provider risk evaluation programs to find out what’s worked and what hasn’t.

Identify key physician groups with low average documentation scores. Focus on the ones that can improve the most and those with large volumes of retrospective chart reviews, and take some of the work off their plate.

Use ease as a currency for physicians and you’ll get a lot of attention on what you want them to do.

Find physicians are willing to transition from fee-for-service to value-based contracting. It works well in certain geographies and that’s a great way to approach the problem. Another important point is to align incentives to the physicians who are doing what they need to be doing, and ensure they are rewarded for the work that expands care and improves outcomes. Putting physician groups at risk means adding incentives on quality metrics. Aligning on incentives is critical to success.

Build engagement strategies for members to help physicians. Engage members so they want to go in for their annual wellness visit, instead of chasing risk codes. In-home providers can fill in gaps within a network to improve risk scores and gaps in care.

Creating Tools

Create and utilize tools for in-office settings that are focused on quality metrics and documentation around risk adjustment and gaps in care. The most important objective is to provide a user-centric solution. Make life easier for your physicians and their entire staff. Using ease as a currency can go a long way. Focus on health risk evaluations and the ability to complete annual wellness exams using clinical decision support tools. When you make it easier for physicians to document, the results become obvious.

Signify Office - By Physicians for Physicians

Focus on reducing burdens with tools and you’ll see a rise in participation and accurate data capture. Once again, this goes back to the idea of using ease as a currency.

These are all factors we considered when building Signify Office, a tool that was built by physicians, for physicians. We utilize a similar tool in our own clinical network for health risk evaluations and care management solutions and then developed and released this tool for physician networks. We want to reduce the reliance on retrospective chart reviews and provide a tool that’s actionable at the point of care.

Signify Office brings data to the forefront so physicians can use and leverage the documentation accordingly. It creates a fully compliant medical record, and this is different than an EMR.

All of these factors together work to raise clinician participation by directly answering their challenges. In our test launch, adoption and satisfaction rates were very high. The tool itself maintains the consistency for physicians and does not allow for conflicting or duplicate information. The goals were to reduce the challenges physicians are facing, and to get them back to seeing more patients while improving engagement and results.

Ease as a Currency to Improve Outcomes

By using ease as a currency you can create a smoother and quicker process for physicians.  It’s important to allow your physician network to feel confident in the tools you choose. Focusing on physician challenges and working to provide tools that fit within their needs will help improve outcomes and documentation, and will help reduce gaps in care. Those are all goals we can agree on across health plans, health systems, and physicians.

By focusing on these challenges and using ease as a currency you will set your health plan apart for your physician networks. If you would like to learn more about implementing Signify Office in your physician network, schedule a meeting us to learn more.

Capture more accurate diagnostic data, reduce costs for your highest-risk members, and improve quality of care.

Joseph Jasser, M.D.
Joseph Jasser, M.D.
As Chief Medical Officer and EVP of Complex Care Management, Dr. Joseph Jasser is responsible for overseeing the complex care management program at Signify Health.