Medical care, though crucial, represents only a fraction of the contributors to healthy outcomes—10%-20%. The remaining 80%-90%, often tied to social determinants of health (SDoH), holds the key to comprehensive healthcare. Primary care physicians (PCPs) are central figures uniquely positioned to capture and address SDoH due to their established trust with members and the ability to connect on a personal level.

The Core of Health Plan Efficiency: PCP Interactions

At the heart of a health plan's ability to ensure accurate charting and HCC coding lies the critical interactions with primary care physicians (PCPs). This webinar emphasized a team-based approach that established a multitude of benefits for Health Plans:

Enhanced Care and Vigilant Monitoring:

Collaborative, bi-directional, relationships between PCPs and health plan Risk Adjustment (RA) teams enhances care by ensuring more vigilant monitoring and documentation of members. For instance, with the investment in health data management platforms like Centaur Data Platform, Health Plans gain more accurate insights into members' health status, allowing for proactive identification and sharing of risk gaps directly in providers’ EMR workflows. Operating from universal member records facilitates seamless communication and coordination among healthcare stakeholders. Payers and PCPs can work together to establish care plans that ensure continuity of care. Care coordination helps prevent unnecessary duplication of tests, reduces medical errors, and ensures that members receive appropriate follow-up care after hospitalizations or specialist visits – ultimately reducing the overall cost of care.

Thorough Documentation for Risk Adjustment:

Thorough documentation is essential for accurate risk adjustment. Products like HC RiskRevPro facilitate this by automating and optimizing the code review process. For example, Health Plans can leverage the platform’s NLP model to identify gaps in documentation between the clinical data they have access to and the claims submitted by providers, ensuring a comprehensive and accurate reflection of members' health status. Any gaps in risk coding identified by the health plan’s risk adjustment team can be pushed back into the provider’s workflow to drive correction, intervention and improvement of outcomes. Payers can also work with PCPs to implement advanced risk stratification models. These models leverage predictive analytics to identify members at high risk for specific conditions, again enabling proactive interventions and accurate risk adjustment.

Fostering Active Engagement:

Active engagement between members, Payers and Providers is foundational to a collaborative approach in healthcare delivery. Analytics solutions like HC SQLAI come into play, allowing Health Plans to pull insights from enterprise databases in real-time, without the need for writing complex SQL queries. For instance, Health Plans can use this tool to analyze member engagement data, understand communication preferences and tailor engagement strategies accordingly. Collaborative efforts can support the development and implementation of preventive care and wellness initiatives. With access to the right data, Payers can provide incentives for PCPs to focus on preventive measures and health promotion. Preventive care interventions not only improve member health but also contribute to cost savings by avoiding more expensive treatments for preventable conditions.

Conclusion:

As the webinar "RADV Final Rule: Focus on PCP-RA Team Collaboration" concluded, Health Chain left attendees equipped not only with insights into the power of collaborative efforts between PCPs and health plan Risk Adjustment teams, but also with practical examples of how technology solutions can drive actionable insights. These insights, powered by products like Centaur Data Platform, HC RiskRevPro, and HC SQLAI, pave the way for Health Plans to navigate the complexities of accurate medical coding, RAF scoring and risk stratification, ultimately driving improved outcomes in the ever-evolving landscape of healthcare. Click here to book a one-on-one demonstration.