Save Money and Lives with Population Health Management Platform (PHM)

Twenty years back, there was a very little dependency on advanced technology to manage the healthcare sector. However, during the previous decade, healthcare providers, and policymakers started to depend on the Population Health Management platform (PHM) for value-based care. The PHM platform focuses on devising interventions, incentives, and other measures to improve health outcomes.

Many healthcare leaders think that saving money and lives can be achieved by fostering multi-sector collaboration, community integration, and non-clinical initiatives. The common perception revolves around a successful PHM, that can lead to a healthier population, reduced healthcare utilization, and huge financial savings. For this purpose, they have been concentrating on social determinants of health (SDoH), boosting wellness, and managing chronic diseases.

Population health management assists in sustaining and enhancing people's physiological and psychosocial health. It resolves healthcare disparities and provides cost-effective personalized health solutions.

The Reimbursement Connection

The Medicare and Medicaid Services Centers (CMS) have started four initial value-based programs to improve the quality of medical services delivered to enrollees. These include Hospital Value-Based Purchasing (HVBP), Physician Value-Based Modifier (PVBM), the Hospital-Acquired Conditions (HAC) Program, and the Hospital Readmission Reduction (HRR) Program.

CMS has also developed other value-based payment mechanisms for different programs such as the End-Stage Renal Disease (ESRD) Quality Initiative Program, the Skilled Nursing Facility Value-Based Program (SNFVBP), and the Home Health Value-Based Program (HHVBP). The objective of all these payment models is to correlate the improved medical service quality and provider reimbursements for pop health.

Population Health Management for Payers

The Center for Medicare and Medicaid Innovation has endorsed models of multi-payer delivery and payment reforms with a focus on population health and SDoH. Several payers have promoted virtual access to care providers and telemedicine because they consider the virtual healthcare system as the key element of population health management software.

Payers are now concentrating on better management of pop health and data analysis. The payers are developing strategies to improve care coordination, disease management, and patient outreach to reduce unnecessary healthcare costs. The payers are adopting new hiring practices by signing the members of the vulnerable communities as the workforce. These workers will benefit from employer-sponsored health plan coverage.

Robust Population Health Management Software

A robust Population Health Management Software can assist in predicting the requirements of healthcare practitioners. It selects cost-effective interventions to reduce unnecessary and expensive treatments, thus helping in cost savings. It helps to manage chronic diseases and in obtaining preventative care. The PHM analytics convert healthcare data into real-time insights that show an accurate overview of health conditions.

 

 

Understanding The Basics Of Population Health Management (PHM)

Several healthcare organizations have set population health management (PHM) as a priority for formulating value-based reimbursement and risk adjustment. It has been noted that many caregiver-led accountable care organizations that are not supported by a hospital or health system, have also started to utilize population health management platforms.

 

Population health management refers to an improvement in the outcomes of clinical health of a specified group of people by greater coordination of healthcare as well as patient involvement supported by suitable models of cost and treatment. The analytical tools of the Population Health Management Platform help to enhance the quality and cost-effectiveness of care by using comprehensive data.

Components of Population Health Management

The optimal population health management approach includes high-risk care management and therapeutic procedures that help to lower the risk level. It contributes to diagnosis along with the assessment of the health of moderately risked individuals.

The basic components of PHM include:

1.    Data-driven clinical decision-making

2.    Primary care-led clinical care-managers

3.    Patient involvement along with community integration

4.    Trends of health determinants

5.    Policies and timely interventions

How Does Population Health Management Work?

With the help of population health management solutions, health organizations and clinicians can understand and formulate better care plans, monitor patient outcomes, and improve the healthcare outcomes of a community quantitatively. The PHM enables care providers to use reliable patient data to support effective and efficient care proactively. It also helps to mobilize community people to expand the reach of a primary care team. The PHM also plays its role in linking patients with vital resources by coordinating with community players.

Population Health Management Software

Healthcare organizations are acquiring population health management software to manage public health. Information technology helps to analyze patient population data to devise a future strategy. The healthcare providers gain data insights to deliver value-based care by utilizing PHM software that offers:

·         Tools to coordinate care

·         Help to evaluate patient participation

·         Help to diagnose, track, intervene for appropriate care

·         Analyze health information for a group of individuals

·         Facilitate data exchange among electronic health records and other databases

Goals of Population Health Management 

One of the goals of the PHM is to use patient risk scores to divide patient populations into subpopulations based on health, lifestyle, and medical history. This technique assists providers to understand their requirements in healthcare. 

It helps to determine how resources in healthcare may be used to improve management efforts at reduced cost. Apart from providing clinical data, PHM also includes the payers for providing care teams, claim data and risk-adjustment. 

 

Effective Ways of Tracking & Reporting Risk Adjustment Solution for ACOs

 The risk adjustment solution enables Accountable Care Organizations (ACOs) to cost-effectively highlight high-risk patient groups. It calculates reimbursement levels and correctly determines costs under a value-based payment model. 

Effective risk adjustment means improved patient care, lower costs, and higher incomes. It serves as a tool for ACOs to assess their performance, and understand patients’ risk adjustment scores. Organizations are delivering a better quality of care through different risk adjustment solutions and payment models including Merit-based Incentive Payment System (MIPS), Quality Payment Program (QPP), risk adjustment factor (RAF) used by the Centers for Medicare and Medicaid Services (CMS) and insurance providers. 

Role of HCC Coding in Anticipating Future Costs

Effective tracking and reporting are crucial for Accountable Care Organizations to estimate future costs due to high-risk patient groups. The risk adjustment model named Hierarchical Condition Category (HCC Coding) focuses on proper documentation and offers higher payments for sicker patients and lower reimbursements of healthier individuals.

For every patient of Accountable Care Organization, the HCC model assigns a risk score or Risk Adjustment Factor (RAF). Retrospective patient data and clinical diagnoses are used for the calculation of the RAF. ACOs can predict future costs to manage the patient population based on effective tracking reporting and patient RAF.  

Effectively Managing Risk Adjustment within ACOs

Risk adjustment contributes to appropriate health plan payments for beneficiaries with varied estimations of medical costs. To manage beneficiary payments effectively, you have to track diagnostic codes for HCC coding-related claims correctly.

There are some steps that ACOs must take to enhance their tracking and reporting risk adjustment operations. These include diagnosis plans, coding expertise, and advanced technology.

1)       Implementation of Strategies for Diagnosis

The caregiver must document all active chronic conditions along with those illnesses that are related to the patient's recent care. Proper documentation minimizes discrepancies in medical records and ensures better diagnosis. Rather than focusing on risk scores, caregivers must deliver accurate diagnoses. It is important to educate them about the monetary value of diagnosis coding precision.

2)      Hire a Coding Team

Hiring an experienced certified risk adjustment coder is essential to get accurate risk adjustment results. The coding team must understand the ACO’s internal coding standards and risk management of healthcare plans. Technically equipped coding teams can carry out the risk adjustment process effectively.

3)      Utilizing Advanced Technology

Integration of advanced technology such as automation tools, rule-based configuration helps to track RAF scores of patients and high-risk groups. It sets up a smoother workflow and sends customizable notifications to swiftly detect high-risk patients and HCC diagnosis codes. It also helps in managing records by retrieving built-in auditing and tracking tools.

Adaptation of HCC Coding, Latest Risk Adjustment Solution & Model

The Risk Adjustment Solution forecasts risk scores based on a patient’s demographics and diagnoses. Because a healthy enrollee has a lower-than-average risk adjustment factor score, the insurance premium is shifted from a healthy individual to that enrollee with higher-than-average risk adjustment factor scores.

What are Hierarchical Condition Categories (HCCs)?

Hierarchical Condition Categories (HCCs) are groups of diagnostic codes associated with a specific clinical diagnosis. The risk adjustment model has gained considerable attention in recent times since Medicare Advantage Plans have begun to demand risk adjustment scores for reimbursement. 

As per risk adjustment factors and Affordable Care Act reforms, the health insurers are committed to delivering high-quality, low-cost health plans regardless of the patient's health condition. It is more or less the same method by which patients are awarded a risk adjustment factor score, which is partly based on HCCs.

What is Risk Adjustment Solution & HCC Coding?

Risk adjustment is a technique for predicting healthcare expenditures by equating a patient's health condition to a risk score. The risk adjustment factor (RAF) scores are designed to forecast enrollees' costs of healthcare.

HCC coding is a risk adjustment prediction model that insurance providers utilize to give patients a risk adjustment factor score, in addition to demographic characteristics. Insurance companies can use algorithms to estimate costs based on an enrollees' risk adjustment factor score.

Importance of HCC & Risk Adjustment Solution

As HCCs take advantage of changes from Medicare capitation payments to Medicare Advantage healthcare plans, caregivers who fail to describe pertinent conditions of the patient precisely may reduce Medicare reimbursements.

HCCs decide payment for providers, as per the Centers for Medicare and Medicaid Services' Quality Payment Program. Complex patient incentives under the Merit-based Incentive Payment System (MIPS) and risk adjustments cost component of MIPS are examples of this system.

Modern Coder’s Task

The primary objective of HCC is to provide improved health management and correct reimbursements as per the Medicare Advantage Plan. Medical coders must be aware of the latest rules and informed about HCC to attain this aim. The competent coders will ensure that accurate diagnostic codes are provided together with comprehensive clinical data.

HCC coding, when implemented correctly, simplifies the process, resulting in clean claims and prompt payments.

Conclusion

The latest risk adjustment solution & model has opened a new universe of opportunities for coders and healthcare providers for quick reimbursements.

HCC coding is indeed an integral feature of the healthcare revenue cycle. It must be precise, safe, and efficient to ensure consistent revenue and compliance. 

 

Best Risk Adjustment Solutions For Better Savings & Improved Care

 Risk adjustment platform is a modern payment technique that uses demographics and diagnoses to create a risk rating that indicates how much a patient's treatment will cost in the upcoming year.

Risk adjustment solutions are a rising source of latent profit potential, but satisfying Centers for Medicare & Medicaid Services’ payment standards involves a significant investment of time and money. For the risk score of patients, the rules linked with risk recordkeeping requirements demand the submission of precisely picked and validated data consisting of risk profiles for patients' health.

It is the payer's obligation to submit Centers for Medicare & Medicaid Services with the risk rating data. As a result, the population health payers rely on practitioners to diagnose and appropriately correlate every high-risk patient's record by a rigorous procedure of required information for coverage.

Furthermore, the regulatory landscape is always changing, and audits are now more prevalent. So, to ensure timely and regular revenue payments, recognizing which risk adjustment solutions to employ as well as when and how to use them, is important.

To keep up with the new burdens on the health service amid pandemics, healthcare plans will have to adapt innovative risk-adjustment techniques. These may include;

• ·         Innovative approaches to managing at-risk groups, with a focus on innovation and telehealth as a major resource
• ·         Utilize risk analytics to improve individual focusing for both retrospective chart chasing and potential meetings.
• ·         Before claims settlement, involve caregivers in possible risk adjustment to ensure more comprehensive and detailed reporting.
• ·         Recognize effects of electronic health records accessibility, NLP aided source code tools, and new pattern searching methods.

NLP Enabled Risk Adjustment Solution

By using NLP-enabled processing application functionalities, customers may improve profits and resources against a variety of risk adjustment organizational objectives and targets.

As a consequence, every risk-adjusted patient group may get an end-to-end approach for detecting and reporting appropriate Hierarchical condition category codes.

Risk Adjustment & Unstructured Data NLP

As unstructured data accounts for 80% of current statistical patient data, it must be included for proper coding and care gap analyses. Once integrated into the system, NLP helps caregivers to record quicker and more correctly, saving time and money. Providers gain the most accurate perspective of patient risk by digging this unstructured data with sophisticated analytics.

What can be done for care improvement by using risk adjustment?

For an improved care system, these points must be followed;

1. Having a comprehensive list of problems

2. Making sure that patients are seen yearly

3. Increasing approval and optimizing electronic medical reports

4. Widely accessible communication

5. Keeping track of progress and recognizing chances

 

Population Health Management Platform Is Helpful For Value-Based Care

 In recent times, the healthcare industry has adopted a more focused approach to the concerns related to population health service. For that reason, they are slowly but surely shifting to a population health management platform, to ensure a more reliable and stable way to deliver value-based care.

How Does the Population Health Management Platform Work? 

 In 2010, with the advent of the Affordable Care Act, the significance of population health management platforms came to the surface. The population health management seeks to boost the healthcare results by bringing together the medical, financial, operational, and analytical data from the organization and provides triable analytics for providers to assist improve efficiency and patient care such as,

•          Through its inbuilt monitoring, tracing, and reporting competencies, population health analytics help enhance patient care by allowing timelier care delivery.

•          Through business intelligence tools, it maintains data collection, data control, and the process of examining data.

•         It relates the community health notions to chronic ailment management with wide-ranging data scrutiny.

•          It enables healthcare providers to have data to administer each patient’s record.

It has been observed that in the United States, population health management is attached to incentives that need a provider to verify a rise in a specified population's health through data analysis.

Role Of Population Health Management Solutions

The population health management platform not only provides population health management solutions but also offers resolutions for the vulnerable aspects by delivering a new course of action from the qualified clinical decision support mechanisms.

•          The population health management solutions play a significant role in assisting both the providers and payers to meet the objectives of the healthcare system.

•          By using insights, it helps to evade untoward medical events and assist to accomplish the goal of value-based care.

•          It facilitates healthcare providers in managing different aspects before involving payers in a value-based population health management plan.

 How Population Health Management For Payers Is Helpful?

There is no doubt that value-based compensation is gradually increasing its influence in the healthcare industry as population health management for payers helps to control costs while recompensing providers for better quality prevention and supervision of prolonged ailments that require persistent medical attention.

The population health management for payers is intended to ease costs by concentrating on the proper application of services to administer and align care resourcefully and cost-effectively.

 Why Is Population Health Management Software Necessary?

The population health management software prepares insights to recognize who in the health scheme needs instant action. It offers flexibility to build patient data to predict patient health conditions, community health trends. and find out areas of improvement in care delivery with higher accuracy through backend data.

Conclusion

Overall, the population health management platform delivers prompt insights, letting providers categorize any care gaps in the recipients of health care services. It maintains robust healthcare management for value-based care.