Advanced analytics are pivotal in unveiling hidden health influencers, improving member engagement, and strengthening provider relationships. By addressing data challenges and leveraging analytics, health care providers can enhance care quality and optimize resource use, ultimately benefiting both patients and the health care system as a whole.
In today's complex health care landscape, understanding member population analytics is crucial for improving patient care and optimizing resource allocation. By defining member population analytics and emphasizing its importance, we can address the common data challenges faced by health care providers.
Common data challenges
Our work with clients reveals two main challenges that surface again and again:
Incomplete health histories: Members transitioning from commercial to Medicare Advantage (MA) often come with no prior health history. It can take up to two years to get a full health picture, impacting risk payments and care management. The solution: Utilize predictive algorithms (AI/ML) to highlight gaps in care early, driving patient care and impacting costs positively. Robust suspecting analytics, which are timely and accurate, are essential.
Impact of Part D changes: The 2025 changes to Part D represent the most significant shift since the program's inception, with costs estimated to be four times higher than in 2023. The solution: Accurate suspecting and reassessment of chronic conditions are crucial to ensure comprehensive health reporting and correct risk payments. This involves educating members and providers, particularly primary care providers (PCPs) and specialists.
Implementing an advanced analytics platform capable of integrating diverse data sources (procedure, pharmacy, ACA analytics) to build a comprehensive patient history is key as analytics help facilitate meaningful data use, impacting care and cost management effectively.
Leverage analytics
To enhance member understanding with analytics, take the following steps:
- Identify conditions and education needs
Analytics can pinpoint conditions that have not been re-evaluated but were captured in the past two years, guiding education efforts for both PCPs and specialists. This helps focus resources on areas that need immediate attention.
- Conduct a retrospective analysis for improved actions
Retro coding must entail far more than basic validation of documentation and simply capturing missed diagnosis codes. For the enhancement of provider education, improved patient outcomes, and proactive compliance, it is crucial to have a coding alliance with your analytics. This promotes accurate historical reference and anticipates the needs of both providers and the health plan in the future. Retro coding that feeds your analytics helps you to make informed decisions now, in the current year, rather than retrospectively.
Moving to concurrent coding is also essential, as it provides real-time feedback to providers and addresses issues before the close of Centers for Medicare & Medicaid Services reporting periods. This proactive approach ensures timely corrections and optimizes compliance, ultimately leading to better patient care and more accurate risk adjustment
The shift from v24 to v28
The impact of transitioning from v24 to v28 coding models cannot be overstated. Understanding these changes helps in evaluating and adjusting program strategies effectively.
Education about these changes is crucial for all roles within the health care ecosystem. Everyone needs to understand what is changing, especially regarding specific diseases like diabetes and cancer, and the importance of coding re-education. As an analytics vendor, we had to make an immediate shift and released a blended model to address these changes
The average risk score decrease expected with this blended model is 3.56 percent in CY 2024, presenting a pressing need for clients to adapt to the latest coding methodologies for risk adjustment and revenue forecasting. With a limited timeline, MA, direct contract entities, and accountable care organization clients urgently sought visibility into 2023 risk scores for accurate revenue forecasting and gap identification. Rapid and effective education is essential for health care providers to adapt to the new coding system.
The altered mapping of diagnostic codes to HCCs necessitates proactive strategies to manage anticipated revenue decreases. Additionally, understanding the immediate and future impacts, tracking disease prevalence, and aligning with evolving value-based care requirements to reduce the cost of care add complexity to this dynamic landscape. Therefore, comprehensive education efforts or partnering with an analytics vendor are vital to ensure all stakeholders are well-informed and prepared for these changes.
Case study: Enhancing member engagement and provider relationships
A client required assistance with population analytics primarily to tackle the challenge of identifying the prevalence of conditions such as depression and schizophrenia among their member population. This posed a significant challenge as they needed precise data to understand the distribution of these conditions within specific geographic areas.
To address this, the client decided to partner with us to access comprehensive data analytics capabilities that could provide deeper insights into the suspected and known cases of depression and schizophrenia across different ZIP codes. This partnership enabled them to gather crucial information necessary for reassessment and better understanding of the prevalence of these conditions.
Furthermore, the collaboration facilitated the sharing of data across relevant stakeholders, including health care providers. This enabled the enrollment of providers in targeted intervention programs based on the specific needs identified through the data analytics. Ultimately, this approach aimed to improve compliance with treatment protocols and enhance the effectiveness of interventions tailored to the needs of different populations. This strategic collaboration allowed them to leverage advanced analytics to support informed decision-making and improve mental health outcomes.
About the author
Episource is a leading provider of risk adjustment services, software, and solutions for health plans and provider groups. As an integrated platform, Episource empowers commercial, Medicare, and Medicaid payers and providers with end-to-end risk adjustment solutions, including risk adjustment analytics, medical record retrieval, medical chart coding, and encounter submissions. Episource is at the forefront of member population analytics. Our analytics solution, Episource Analyst, helps health plans navigate the shift from v24 to v28 of the CMS-HCC model.