Prospective Health Assessments Give Providers Actionable Insights into Individual Member Health Status

Scott Howell, MD, Chief Medical Officer, Advantmed, LLC

Scott Howell, MD

As healthcare shifts toward value-based care and reimbursement, risk stratification becomes a key focus for physicians and provider organizations that may be entering risk arrangements for managing defined patient populations under Medicare Advantage plans or other health payer arrangements.

This requires a multi-pronged approach that includes rigorous analysis using statistical monitoring, electronic medical record (EMR) data and nonclinical data. Frequently, this approach includes health risk assessment information gathered internally to encompass demographic data on financial status and other social determinants.

Risk stratification enables providers to better understand their patient populations and manage their resources. This is particularly important in the management of patients with chronic conditions or advanced illness and has become a central strategy in population health as a way to optimize the quality of care. Doing this effectively, however, requires actionable 360-degree insights into the health status of member populations.

This is precisely the intent of Prospective Health Assessments (PHAs) which play a vital role in the process. PHAs have proven to be an effective tool for facilitating timely gap closure and improving care management initiatives. One key advantage is that PHAs can occur at any time during the year and be scheduled for Medicare Advantage (MA) — Commercial and Medicaid members that have been non-adherent in scheduling primary care appointments.

Finding the Right PHA Solution

The search for a PHA program or partner that meets organizational needs can be a daunting task. The simplest approach is to choose a PHA partner with a focus on identifying new conditions, re-capturing and documenting previous chronic conditions and closing quality care gaps. What’s more, the PHA solution should provide real-time visibility into assessments and documentation, integrating analytics, physician chart reviews and evidence-based screenings to drive higher engagement rates and optimal results.

Flexibility regarding site selection for the PHA is also a factor in driving patient compliance and engagement. It is important to look for a solution that is performed by highly-trained nurse practitioners that can be conducted in the patient’s home, a centralized clinic or a primary care physician’s office.

The optimal PHA solution offers key advantages:

• Patient acceptance rate for in-home visits of greater than 35 percent
• 100 percent electronic (tablet-based) assessments
• 100 percent quality audits of all assessments
• An average revenue increase to over $1,500 per assessment

To gather the most accurate data, the solution should integrate quality measures, including Star measures, HEDIS and CAHPS/HOS, and offer a process that involves a comprehensive assessment that focuses on member engagement and clinical profiles.

Furthermore, the PHA solution should allow physicians and the organization’s leadership team to view project dashboards and drill-down options, including call metrics and detailed call comments, status on non-cooperating members and reason codes. All clinical data and Hierarchical Condition Categories (HCCs) should be hyperlinked within the assessment.

In today’s environment, the need for comprehensive, accurate patient data to monitor and manage chronic conditions is critical for effective population health management. The right PHA partner is one of the first steps and complements capabilities to integrate technology-enabled solutions that lead to improved care quality and care coordination, better patient outcomes and improved financial results.

Scott Howell, MD, is the Chief Medical Officer of Advantmed, LLC, a healthcare solutions company dedicated to partnering with health plans, provider groups and risk-bearing entities to optimize risk adjustment and quality improvement programs. Our integrated and technology-enabled solutions improve health plan financial results and offer insights on health plan members. For more information on Advantmed’s solutions visit www.advantmed.com.