When we formed DeltaSigma in 2006, our intent was to form a healthcare consulting practice that would offer dramatic results for our clients. Oftentimes, these dramatic results are an outcome of helping clients take “IT” to the next level. In this Insight, we offer our perspectives on how to do just that with a tool that has been around for years, the health risk assessment (HRA).
While a great deal of focus has been placed on the important task of gathering member health data in a form that is both useful to the health plan and the member, HRAs and care plans are often overlooked as a source of actionable data. HRAs and care plans are easily implemented and can be extremely valuable tools for gathering this information.
Health Risk Assessment Requirements
During the past few years, CMS and state Medicaid agencies have defined a required model of care for individuals with specific needs or those presenting with disabilities. These requirements included HRAs and care plans as described below:
Health Risk Assessment (HRA): An initial comprehensive health risk assessment and comprehensive annual reassessments that comprise a medical, psychosocial, cognitive and functional assessment that guides care management and accounts for health status changes;
Individualized Care Plan (care plan): A care plan for each member that describes and addresses goals and objectives, services and benefits provided and measurable outcomes;
Interdisciplinary Care Team: The interdisciplinary team used in the care management of each qualified member; and,
Evaluation of Care Effectiveness: Performance measurement and improvement activities including data collection and reporting using HEDIS and structure and process measures.
In addition, as part of the 2009 healthcare reform bill, HRAs and care plans will be required to become part of the annual preventive exams for all Medicare beneficiaries beginning in 2011.
For Medicare Advantage health plans, and for Medicaid health plans in the 22 states that receive risk adjusted payments, health risk assessments are just the first step to ensuring that the proper care plans are put in place. HRAs and the information they supply should be utilized to stratify and prioritize which members should receive a full risk coding, provider-administered assessment.
These intense assessments are more robust than the general health HRA and require the services of a physician or nurse practitioner. These assessments will often provide valuable information to the health plan on the member’s health status and provide a significant increase in the monthly payment the health plan receives for that member. This increase in premium can be utilized to help manage that member’s health and well-being by providing additional services specific to the member’s needs.
Going the Extra Mile
We strongly encourage health plans to go beyond simply complying with the standard HRA and care management requirements for their members and seek creative ways to maximize the value and impact of efforts including:
An easy-to-read HRA that will yield the most meaningful information;
Multi-modal approaches for gathering the information, including telephonic, print and web-based methodologies;
Iterative attempts and mechanisms to reach difficult to contact members including on-the-ground capability;
Multi-language support and differentiated messaging that is culturally sensitive; and,
Collection of data beyond the minimum requirements that includes claims, pharmacy, self and clinician-reported information.
Taking this information and using it to develop an Enhanced Individualized Care Plan can set the stage for a meaningful engagement between the member and their provider and health coach that can maximize the opportunity to truly improve the quality of a member's health. The Enhanced ICP can include the member's:
Current health status and known medical issues;
Health age and chronological age;
Specific concerns, goals and objectives;
List of medications (prescribed and OTC);
Home health needs/DME
At the health plan level, Enhanced Individualized Care Plans can be aggregated and stratified based on health status and resource requirements to assure that appropriate medical, behavioral and social resources are available and assigned to each member based on their stratified level. The stratification and care planning should be supported by clinical staff who review results on a regular basis, re-stratify members and update care plans to reflect and report changes and improvements at the plan level.
Reaping the benefits of the Extra Mile
In combination, the HRA and the full risk assessments will provide the health plan with an outstanding opportunity to locate and engage those members that can benefit most from more intensive services and assist in determining other benefits that should be delivered to better meet the members’ needs. At this point, you are reaching those members that can truly benefit most from high quality managed care
Dedicating the time, expense and effort to identifying and better managing the needs of these high cost/high need members will have a positive impact on member health outcomes and satisfaction, plan medical spend, quality scores and plan ratings.
What if you need help in making IT happen?
While many health plan clinical teams believe they can meet the increased requirements, our experience is that these teams are often overwhelmed, under-resourced and "one or two minor clinical or IT enhancements" away from achieving their optimum program. Since this very small percentage of a health plan‘s membership consumes a significant share of the total plan’s medical spend, every day that passes waiting for these enhancements to be realized is money lost to the plan.
We encourage the leadership of health plans to identify a vendor willing to partner on the development and management of the kind of robust and high touch programs necessary to make the greatest impact. There are several vendors that go beyond the norm and deliver programs that can make a game-changing impact -- for the plan and the member.
It’s time to do more than just check the box for HRAs and care plans and that can make a real difference in the member’s health outcomes and the health plan’s bottom line.