How Risk Adjustment Advances Health Equity
Health equity is more than just a buzzword in US healthcare. More than 82% of healthcare professionals surveyed by the Rise to Health Coalition said health equity is a very or somewhat significant issue in our country.
Health risk, especially if unassessed or neglected in health records, can lead to avoidable health inequity. Maybe more than half of survey respondents said current industry practices are unable to address equity effectively because risk isn’t identified or managed appropriately.
Failure to carry over hierarchical condition category (HCC) codes from one year to the next, extract risk from health data and adjust risk scores not only threatens necessary care personalized for each patient or member, but it also puts significant revenue in jeopardy.
Risk capture is key to the success of value-based contracts. It helps define clinical and quality measure eligibility. When advanced analytics are applied to risk factors, payors and providers can quantify the money at stake for gaps in care, seeing potential incentive loss for providers and cost increase for payors on a continuum based on the risk score of each patient or member. Health equity becomes more than an ethical imperative and clinical ideal; it becomes a financial matter.
How risk adjustment works
Risk adjustment enables high-quality, cost-effective care, even for individuals with significant health challenges. A risk score incorporates demographics, clinical conditions and socioeconomic factors to calculate the relative measure of the predicted costs of an individual’s care compared to that of an average member.
If data is siloed — if health systems or plans cannot integrate data systems or aggregate and standardize data across sources — or if analytics solutions fall short — they’re not fully developed or perhaps rudimentary and poorly maintained — it is easy to under-report risk. The more data, the more trustworthy that data is and gathered near real-time, the better analytics can identify risk and find quality gaps.
Risk adjustment focuses on those most in need of frequent or costly care. Patients’ adherence to value-based care measures, starting with annual wellness visits, gives providers data to analyze for appropriate risk scoring. Add payor claims data, pharmacy data, social determinants of health, etc., and risk-adjusted factors (RAF) can define value-based reimbursement — per member, per month — that supports preventive care, chronic condition management and optimal vs. low-value, high-cost care utilization.
Tap into the power of data analytics
You can identify high-risk patients or members and amend RAF scores. Insights from Gray Matter’s advanced analytics can trigger interventions to fill care gaps, identify at-risk individuals to support improved health equity, as well as cost savings and revenue capture. Read “Finding the Way Back to Lost Revenue in Value-Based Contracts” to get started.
