How an end-to-end risk adjustment strategy helps direct contracting entities grow with confidence

By Brian Flower, Vice President of Client Solutions

Value-based care (VBC) is truly a team sport—especially when it comes to direct contracting entities (DCE) that include healthcare providers and suppliers sharing the common goal of improving healthcare delivery. DCEs operate under the Global and Professional Direct Contracting Model (GPDC), one of the Centers for Medicare & Medicaid’s (CMS) latest innovations to right-size costs and improve outcomes for patients with traditional fee-for-service Medicare coverage.

According to CMS, the goal of the GPDC is to transform risk-sharing arrangements in Medicare fee-for-service, empower beneficiaries to personally engage in their own care delivery, and reduce provider burden to meet healthcare needs effectively. There are 53 DCEs participating in the first Performance Year (PY2021) running from April 1, 2021 through December 31, 2021.

Here’s how it works. DCEs contract directly with Medicare under a risk-adjusted payment model similar to that of other alternative payment models. This means they accept financial accountability for the overall quality and cost of medical care furnished to Medicare fee-for-service beneficiaries aligned to them. While CMS has provided various participation options, all options are aligned the same. They measure DCE performance against annual medical cost benchmarks while ensuring quality metrics are met and reported.

DCEs represent a big win for CMS in the drive to expand value-based care and the vertical alignment of incentives in healthcare. However, for DCEs to be successful, these entities must educate and promote the shift to from FFS to VBC at the provider level, employing strategies to manage patient populations for whom preventive care and risk adjustment accuracy weren’t necessarily a priority in the past. While CMS has structured the financial equation to mitigate increases in RAF scores overall, targeted patient engagement, risk adjustment, and quality capture interventions are critical to ensuring predictable and reasonable benchmarks for each DCE. DCEs need each PCP’s help and buy-in to accomplish this. PCPs who don’t accurately capture hierarchical condition categories (HCC) can drag down a DCE’s benchmarks, negatively impact revenue, and stall overall growth. Again, VBC is a team sport.

The challenge: Achieving controlled growth without compromising data integrity

DCEs want—and need—to grow quickly. However, growth without a strategic plan can easily backfire. They can’t afford to onboard PCPs who have little or no experience in value-based care if they don’t have an onboarding process in place to drive documentation and coding compliance. This process shouldn’t put the onus on PCPs to take on more work. There simply aren’t enough hours in the day, and many PCPs are already facing burnout. Adding another task to their to-do list would cause unnecessary friction.

In GPDC, CMS has set up a financial structure to recognize the importance of quality care and allocating resources based on the needs of specific populations. For the majority, RAF growth will be capped at +/- 3% to ensure that risk adjustment accuracy is a priority instead of the priority. However, those with VBC experience know that the potential 6% window in med-expense benchmark is no small thing—potentially $3M+ on a population of 5,000 beneficiaries in Atlanta, Georgia.

DCEs need a risk adjustment strategy that promotes patient engagement, improves quality reporting, and prioritizes accuracy and compliance.

The solution: An end-to-end prospective approach to risk adjustment

Leveraging an end-to-end, prospective risk adjustment partner helps DCEs ensure risk and quality accuracy without having to worry about each PCP’s experience with HCC capture and risk adjustment. Even practices that are new to the world of value-based care can quickly be brought up to speed with custom workflows and education as well as clinical and administrative support. The goal is to yield maximum accuracy with minimum physician effort. Mitigating burnout is key. And promoting early detection and effective management of chronic conditions are cornerstones of effective prospective risk adjustment.

Following are five priorities for DCEs as they continue to expand:

  1. Understand current state of documentation and coding accuracy, patient engagement, and quality performance on provider panels.
  2. Understand options for ensuring risk adjustment accuracy and quality performance to drive better patient outcomes.
  3. Empower providers with the right tools to improve the accuracy of population-specific medical expense benchmarks.
  4. Identify and measure key indicators at the PCP level to align organization value-based outcomes with provider performance and incentives.
  5. Maintain compliance and focus on the quadruple aim.

Each of these priorities is equally as important, and collectively, they lay the foundation for a DCE’s long-term success.

How Vatica Health can help

Vatica takes the pressure off DCEs by supporting the VBC onboarding process for all PCPs regardless of their experience with risk adjustment and quality capture. It does this by pairing expert clinical teams, including licensed registered nurses, with cutting-edge technology to work with physicians at the point of care. By synthesizing EMR and health plan data to create the most complete view of each patient and applying a rigorous clinical documentation improvement process, Vatica improves data accuracy and reduces compliance risk. It also provides comprehensive PCP training as well as 100% clinical coding validation. When coupled with PCP engagement, prospective risk adjustment enables comprehensive insight into the disease burden of a member population. In addition, prospective programs actually drive higher return on investment due more accurate and complete coding and documentation. It’s about engaging patients when they’re directly in front of their provider. This is where real change can occur. This is how to move the needle on value-based care. To learn more, visit https://vaticaprod.wpengine.com/.