Building Quality and Performance Models for Risk Contracting Success Part 3

As more and more provider organizations engage in risk-based contracts, including Medicare Advantage, understanding  quality and performance along with clinical workflow integration  is critical to contract success. On our third episode of our three-part series focusing on risk-based contract and performance, we invited two special guests from qrcAnalytics to join the show and dive deeper into Risk Adjustment Factor (RAF) scores and the impact of Hierarchical condition category codes (HCCs).  

Tune into the latest episode of Value-Based Care Insights, as our host Daniel J. Marino speaks with Gene Rondenet and Paula Gallagher on how data and information critical to proactively build a prospective risk model is key to to manage the potential risks of health care cost increases and prepare the organization for the future. 

KEY TAKEAWAYS: 

• A prospective model provides the organization with a forward look into actionable data to affect change in the organization for better care outcomes.
• All key stakeholders, including providers, must be aligned to attain the goals of better care, lower cost, and improved care outcomes.
• Provider organizations must prepare for new, evolving payment models and learn how to navigate the intersection of quality, risk, and cost.

LISTEN TO THE EPISODE:

 

 Transcript:

Daniel J. Marino: 

Welcome to Value-Based Care Insights. I'm your host, Daniel Marino. We are very excited about today's episode. If you've been listening to the last couple episodes this is a third part series where we've dove into discussions around risk-based contracting. The first episode was a replay that we did with my colleague, Cliff Frank. It was initially recorded last October, and we spent some time talking about the foundation of risk-based contracting. Episode two is where we brought Cliff back. And due to the fact that there's been a lot of changes with regards to risk contracting, particularly in the MA space CMS made some new announcements. Cliff and I spent a little bit of time talking about what some of those changes are and how providers need to reposition themselves for success within risk. And a big element coming out of that conversation was the need to really create sound models, really moving from retrospective to prospective models and understanding data, the performance outcomes, all of those things that are going to drive change for providers in the clinical setting.

Well, in today's episode, we're going to dive into what that data means, what the models really should look like, moving to a prospective risk model. At the end of our conversation today, I have a really exciting announcement to share with everybody that I am really looking forward to, to making some real changes and, and support with a lot of providers within the industry. So, with that being said I have great guests today. qrcAnalytics is an analytics firm. We at Lumina have done quite a bit of work with them over the years. They have lot of expertise in in extracting a lot of clinical data, claims data helping organizations prepare for risk monitoring, the performance of risk-based contract. Here today to talk with me is Gene Rondenet. Gene is the founder and president of qrcAnalytics and his partner in crime, Paula Gallagher, vice President of Sales and marketing. Paula and Gene, welcome to the program.

Paula Gallagher:

Thank you. Hey. Hi, Dan. We're excited to be on.

Daniel J. Marino:

Paula, let's start with you. You know as we've talked about, risk-based contracting has really changed. A lot of providers have started to really build their capabilities on understanding RAF scores, understanding quality, understanding HCCs, understanding where they need to, what their information needs to look like as they're optimizing some of these contracts. What are some of the things that you've seen as real challenges to providers to ensure their success as they've engaged in these risk-based contracts?

Paula Gallagher:

From my perspective, going into an organization, I'm kind of an early adopter into the organization when they're getting ready to move to more downside risk. And one of the challenges I have as I am prepping an organization to get ready to work with qrcAnalytics is letting the organization understand the data that is needed to take a full holistic look at the organization. We need administration buy-in, we need physician buy-in, we need revenue cycle buy-in, we need h i t buy-in. And working with organizations so that they understand this holistic view of data and how to apply it to the rest. Right.

Daniel J. Marino:

And really plotting that course, right. So exactly. If they're at risk, you know, and again, there's upside risk and there's downside risk. Nobody wants to payback a check. Everybody you're focusing on performing, you really do have to have that full buy-in. But I also feel like you have to have a clear understanding on what informs what, what the information that's needed. And in order to get the information, you have to have the right level of data. So, you know, Gene, I know you've spent a lot of time, you've worked with large health systems around the country. I'm building these models. In your opinion, are providers capturing the right level of either quality data, performance data, claims data or is it that they don't have it, or maybe they just can't extract it and make sense of it?

Gene Rondenet:

I think the biggest challenge is getting the providers to understand the difference between their clinical workflow and what the financial needs of the organization are as far as revenue. And understanding the connection between the two that the physicians are, you know, they're clinicians, so they're looking at things clinically, but they put things into the visit note that represent what they're doing accurately, but then making sure that there's a connection between what's in the visit note versus what is updated in the problem list, what diagnosis codes get captured, and making sure that those things all tie together and making sure the right level of specificity on the diagnosis codes. And that's becoming more and more important as the newer models are coming out, that the CMS is requiring that necessity. If you don't provide it, you won't get reimbursed. Right.

Daniel J. Marino:

And it needs to be presented in a way, I would think that it has to translate to the clinical workflow, right? So as you're getting this level of information, like I said, it needs to be incorporated into the problem is incorporated into the care plan in incorporate it into the conversation that these physicians are having with patients. So you can really make that change. But Gene, I immediately then go to the concept that we've talked about moving from this concept of retrospective information or modeling to being prospective, right? So understanding what we need to do going forward to drive that change. I think moving to that prospective model, that's a necessity in my mind of the success of these contracts,

Gene Rondenet:

Correct? Yeah. The pro prospective model is much more efficient for within the clinical workflow, and it's much more accurate. Everything just works much better. You know, like we said, it requires the entire organization to be bought into the process. And it's really, really important before you take that downside risk that you use a retrospective model to try to train the organization to what is coming. And so right when you look at the visit notes and you have your auditors look through the notes and say, what was missed? You know, what was documented, but not quite close enough that we can't capture properly and use the opportunity before you're taking that downside risk to kind of get the machine well lubricated and functioning properly. And then when you get to the, so when

Daniel J. Marino:

When organizations make this change from retrospective to prospective again, they're extracting their own data. I sort of think about retrospective and I had a conversation with a vice president managed care just not too long ago, and they were almost a hundred percent relying on the payers to give them this information and really understanding what their performances and then trying to apply it going forward. And I said, well by the time the payers give you this information, it's too late, right? Yeah. You need to have these models, you need to put them in place ahead of time. So you're able to drive some of the change in your opinion Gene, what's some of the data that's required, or what's the data that is required in order to build this prospective risk models?

Gene Rondenet:

Really the single most important one is having the ability to see what HCC diagnosis were previously captured for a particular patient. And if they're not acute, making sure that those get captured on an ongoing basis. You know, they have to be captured every year. And one of the best ways to manage that is using the problem with, and making sure the problem with is accurate as all the HCCs diagnoses that are appropriate, and then using that to drive as new visits come along. And then also using algorithms when a patient comes in to see if there's any clinical indicators that there's a potential HCC diagnosis that hasn't been captured yet. Then you also being more prospective if you will, using AWS as an opportunity to capture HCCs preparing for when a visit is scheduled and this about to happen, and making sure you have enough information to support that. But one of the biggest ones is identifying patients that have not been seen. Right?

A lot of times providers are more passive. A patient shows up, but the organization needs to be more active in looking forward and say, okay, I've got patients who were at risk for and we haven't even seen them. So, A. you're not capturing the diagnoses that you should be getting reimbursed for, and B, you're not managing those conditions. And so that is the big win on a on this kind of a contract. If you're managing the patient properly, you're getting paid for the risk. And so if you manage it properly, you're making money.

Daniel J. Marino:

Absolutely. Absolutely. And, and that's such an important point, but it's really comes down to making sure you're extracting that right level of information. And as you said Gene, it's the HCCs, the diagnosis, the problem list, and so forth. Paula thoughts?

Paula Gallagher:

Yeah. You know, the retro Gene is being awfully modest about that, that first step of making sure that the inform the data is accurate, because it can take our organization a while to verify that the information coming out of a health system is accurate. And when we look at the retrospective, it also gives us a little eye into possible training needs and into possible areas where the organization might be needing additional assistance to get where they need to be before they're taken downside risk. And this isn't an easy process by any stretch.

Daniel J. Marino:

Right.

Paula Gallagher:

And making sure that data is accurate.

Daniel J. Marino:

Well, that kind of brings me to my next point. As I was thinking, you were describing this Gene, there's been a lot of focus on the RAF score, right? I think early on a year and a half ago, folks spent a lot of time thinking about how to create accuracies of the RF score. And again, I think good, bad or indifferent, possibly some providers have maybe overemphasize the support or the calculation of the RF score, but it is an important driver as you are thinking about how to create that true care directed support to patients who need it. Paula, as you think about the RAF score, as you think about providing that right level of support, how do you position it appropriately so the AF score is accurate? So you're actually able to drive a lot of change to the patients within the clinical setting?

Paula Gallagher:

The first thing that we would do with an organization is we try to assess where the organization is, and we take a look more at the HCCs than the RF score. You can't really change a RF scores, you can really affect it by the HCC. So that's really where we really pay attention to. As Gene had mentioned, if they're being properly assigned to diagnosis, how they're working with their HCCs to really be able to affect the organization's overall scoring to make sure that it's compliant and that it's accurate and that they're getting the appropriate reimbursements for the population they're caring for.

Daniel J. Marino:

Yeah, absolutely. If you're just tuning in, I'm Daniel Marino, you're listening to Value-Based Insights. I'm having a great conversation today with Gene Rondenet, Paula Gallagher from qrcAnalytics, and we're talking about the data needs, the modeling requirements that are important on driving a lot of these risk-based contracts. So Paula, just kind of building on what you had just said, the capturing and recapturing of the HCCs is critical, having the data elements both I think in terms of the claims data and the quality data is really important. But at the end of the day, we have to create these level of reports, these insights, if you will, to really drive clinical operational change with the practices, right? Because if it can't translate well to the clinical workflow of the physicians, then I, I think many of these providers are going to be challenged in really performing well in these contracts. Would you agree Gene? thoughts?

Gene Rondenet:

Yeah, I think that what Paula mentioned is a really important point that from a clinical perspective, you know, as a clinician mindset, they don't think about RAF scores. It's just a number. It doesn't mean anything to them, but if you tell them they need to recapture diabetes, that makes perfect sense to them. And so we really try to focus more on the actual recapture of the diagnosis code that is the HCC.

Daniel J. Marino:

Right? Absolutely. So let's focus a little bit on some of these audits and things that are coming down from cms. There's been a lot of discussion lately related to the increase in the amount of audits, increase in amount of, of activity that that's going to occur from CMS and possibly OIG and so forth. How are you working with your clients right now on to support some of these audits to ensure that there's a level of compliance?

Gene Rondenet:

Yeah, we try to make sure that they have an internal audit process that predates any kind of RAV audits or any other kind of repair audits, or things like that so that they understand it where they will land if there is an audit, make sure that the organization is well trained to understand the accuracy of coding based on the clinical record. That’s the essence of what an audit is. It’s basically looking at the claim that was submitted and the diagnosis codes, and then the clinical documentation to support that. And so we have a process where they go through and do those, you know, mock audits, if you will. Even though they check type in our audits, because, you know, at the end of the year, you do have to attest that your claims are accurate. And so going through an auditing encounter is a sampling encounter for providers on a periodic basis. It is a really good idea to figure out who needs to be trained and how to code no code, how to write their notes so the coding is appropriate and making sure that the organization follows those guidelines.

Daniel J. Marino:

Well, and I'll tell you, this is a part that has always been important to me. You know, we've done a lot of revenue cycle work over the years and have helped many organizations with their compliance program. And I know you all have done a great job on building these risk model compliance. I'm looking forward to working with you and on really creating a strong risk model compliance program that kind of incorporates the right level of modeling with, as well as a lot of the policies and procedures and the elements that are going to be critical on supporting providers in the event that they are audited. Because I think it's always scary. And as we've talked about before, Gene, it was as long as they've been able to demonstrate that they have the ability to self-monitor and self-governance selves, that goes a long way towards, ensuring that level of compliance. Paula, let's kind of change the discussion a little bit. As we think about where contracting is going, Medicare advantage, some commercial risk-based contracts as hospitals are starting to consider taking on additional risk. Are there two or three things that are top of mind that are really critical that these providers need to think about or really give strong consideration to as they build the right level of modeling, the right level of data, and the right level of reports?

Paula Gallagher:

Absolutely. And when I talk to organizations that are still primarily fee for service moving to valued based contracting and eventually to downside risk, we encourage, the sooner they assess how they're capturing HCCs, the better. If you're not taking downside risk, it, you don't have the compliance issue and the deletes and the returns, you can still work pretty transparently with organizations to make sure you're doing it correctly and accurately. And then from there you can decide what are the best contracts to participate in based on the maturity of your organization and move along an appropriate path so that you have a sustainable model for caring for patients, and that you can continue to get the appropriate revenue again, to care for your patients because you're going to care for them regardless. Right?

Daniel J. Marino:

Right. And these contracts build on one another. As we've negotiated managed care contracts for many, many years, and the fee for service side and the fee for value side, I often say as you're negotiating the first this contract, right, you have to think about the next contract, even though you're not negotiating for it. But how is this contract going to impact the future contract? And typically, when you're managing this fee for value contracts and taking risk, you're only going to be asked to assume more risk. Yep. And, you know, Gene, I guess I'll throw this back to you. As we're thinking about the data, and as we're thinking about where these risk-based contracts are going, from your perspective, what do the payers really have to consider as they're negotiating these contracts that are critical elements on driving this success?

Gene Rondenet:

Well, one of the things the payers would like to get is more clinical information, but that's generally problematic. And that's why it's nice to have an organization that sits between the payer and the provider organization that can have access to the clinical data to run out. Yeah. So that there isn't the privacy issues and we can actually dig a lot deeper than the payer. But then getting the payer to give you the provider organization access to data that they have that you don't have is critically important and the time to do that. And when you're negotiating the contract, one of the things we love to see is if we can get the payer to say, these are the HCCs that we see that you have captured, so that we understand to make sure that everything's in alignment. That, you know, we thought an HTC was submitted, then they didn't recognize it, and we need to know why. And so it's very important to kind of close that loop, and they're generally a little reluctant to do that. And so it's been somewhat challenging, and that's the best time to do that is during contract negotiation.

Daniel J. Marino:

Well, some time ago, it reminds me Gene, of that comment that you just mentioned. I was part of a panel that we were working through manage care contracting, and one of the facilitators asked a question to me and said, when you're talking about collaboration and sharing of information with a payer, what are some of the key things that are important? And as I sat back and thought about it, in my mind it came down to three things. One, the provider has to have good sense of their data, right? They have to have a strong model, they have to believe in their data, and in some cases, the information, in most cases, the information that they get really has to be better than what the payer gives them.

And they should be able to get that because they have access to the clinical data. Correct. Second to that is you're going to get data from the payer. We have to use that data as we get from the payer as a tool to develop our under understanding and drive change, not really as a defense mechanism. And a lot of times, providers will jump to being defensive because oftentimes the information we get from the payers is sort of less in terms of the financial implications than what we as providers think we have. And then third to that, as you're thinking about either the financial reconciliation or the performance going forward, you need to take both the data that you're getting from the payers and your own model and really evolve that for future change, both in terms of the contract that's going to be important going forward, but also in your clinical setting. So really understanding the model, the payer data, operationalizing that, those are really the three key things that I found that have been absolutely critical to performance.

Gene Rondenet:

Agreed. Yeah, just following the entire life cycle of the data provider organizations collect it, they send it to the payers. The payers either deny or pay a claim or set the reimbursement. Then figure out why they set the level at what they set it at and making sure you're all in agreement.

Daniel J. Marino:

Absolutely. And I think if they do that, that's what's really going to allow providers to be successful on these risk-based contract plus allow them to again, mitigate some of their risks going forward. Well, at this time in the show, I'm really excited guys to make this announcement. I know Paula, Gene, this is something that, you know, we've been talking about for quite some time. We've been working alongside each other for quite some time. So to our audience, I'm really pleased to announce that Lumina Health Partners and qrcAnalytics are coming together as a program collaboration. The title of the program is going to be qrcIlluminate. It's an integrated program of data analytics, risk-based modeling combined with clinical and operational change, with the goal of driving true performance improvement and optimization, true success from a lot of these managed care contracts that providers are undertaking. I personally am really excited for this. You know, in Lumina we've done a lot of contract negotiations and have done a lot of clinical redesign. We've not had access to a data partner. Working with qrcAnalytics has been fantastic. And you know, Paula and Gene, I know you've sort of struggled with some of the operational things as well. So any thoughts that you can share? Paula,

Paula Gallagher:

We are super excited about this. I've been wanting to do this for a long time because I was very excited to be able to bring an organization data that they can use to drive change and operationalize, particularly the contracts. It's a tricky lift, and I think it ultimately having better outcomes and better care is of course, that is our goal for anybody working in healthcare for the most part. And I think this will be a really great partnership to be able to deliver on that.

Daniel J. Marino:

Well, and I think the exciting thing is that we're going to be taking a lot of the expertise and the knowledge that we have in, in value-based contracting and really pulling together a strong data engine around that, right? That's coming up. Yeah. You've been doing that for years, but now to really begin to operationalize some of those key elements, not only are going to help organizations really succeed and optimize their contracts, but it's going to help them to kind of think about what's it that they need to do next to ensure that they're going to achieve that success going forward. Gene, any thoughts?

Gene Rondenet:

No, we're very excited to do it too. And just to be able to take kind of our nerdiness and, and mix it with work with organizations is going to be very powerful.

Daniel J. Marino:

Yeah, I agree. I agree. Well, to our listeners, if you're interested in learning a little bit more about qrcAnalytics, their website is qrc-analytics.com. And of course, our website is luminahp.com. Stay tuned for even more information about what our combined integrated program is going to look like. And again, it's called qrcIlluminate. Really excited about this. And of course, if any of our listeners are interested in talking more about it, learning a little bit more, understanding what the value would be, feel free to contact me directly or Gene or Paula as well. Paula, I don't know, maybe if you want to give your email address, it might help some of our listeners.

Paula Gallagher:

Sure. It's Paula.Gallagher@qrc-analytics.com, if anybody has any

Daniel J. Marino:

Sure to our listeners, you're going to be hearing a lot more about this. You know, Gene, I think certainly given your expertise, you're a wealth of information. I think as we start to continue to work together, continue to support providers you know, I certainly want to continue our discussion and even talk about some of these other top of mind issues that will come out related to risk-based contracting.

Gene Rondenet:

Yes.

Daniel J. Marino:

So let me start again. I'm going to build off of that. Gene, I don't know if you have any final comments you want to put in. I was kind of tossing over to you.

Gene Rondenet:

Not really. Paula usually comes up at that <laugh>. Okay.

Daniel J. Marino:

All right. So I'm going to do a signing off then.

Paula Gallagher:

Yeah.

Daniel J. Marino:

To our listeners, I want to thank everybody for listening in today. Again, these three episodes, I think were just great conversations. I would encourage folks to go back and listen to them. And again, if anybody has specific questions on qrcLuminate, happy to answer them. Until the next insight, I am Daniel Marino, bringing you 30 minutes of value to your day. Thanks and take care.

About Value-Based Care Insights Podcast

Value-Based Care Insights is a podcast that explores how to optimize the performance of programs to meet the demands of an increasingly value-based care payment environment. Hosted by Daniel J. Marino, the VBCI podcast highlights recognized experts in the field and within Lumina Health Partners