Reducing the impact of COVID-19 on risk adjustment and quality scores – Telehealth

Prospective risk scores used to pay Medicare Advantage (MA) health plans in 2021 are trending lower than forecasted because routine medical services have been canceled or postponed due to COVID-19. Payers should see an increase in demand for elective and routine care as time goes on, but pandemic precautions have limited capacity and may therefore continue to impact risk adjustment and quality scores.

With more limited face-to-face encounters, payers can leverage telehealth and remote care practices to help reduce the potential negative impact of the pandemic on risk adjustment and quality measurement programs.

MA plans can perform a year-over-year comparison of risk scores from 2019 to 2020 and look for variation to understand how this change in routine visits is impacting their risk adjustment scores. Payers may not see more patients on a routine basis for some time, even as the pandemic lessens or a vaccine is produced. And when face-to-face primary care does resurge, physicians and other health care providers with limited availability to deal with pent-up demand may prioritize seeing sicker patients, further impacting risk adjustment scores.

According to the latest data from FAIR Health’s Monthly Telehealth Regional Tracker, telehealth claim lines increased 3,552 percent nationally from August 2019 to August 2020, rising from 0.17 percent of medical claim lines in August 2019 to 6.07 percent in August 2020.

However, virtual care claims volume fell from a high of 13.0 percent in April 2020 to the 6.07 percent in August 2020 as states began to resume in-person treatment for non-emergency medical care, allowing patients to return to their doctor. Nonetheless, telehealth usage remains extremely high compared with pre-COVID-19 utilization.

According to CMS, in order to meet the risk adjustment face-to-face requirement, diagnoses resulting from telehealth services must be provided using an interactive audio and video telecommunications system that allows real-time interactive communication. On June 5, the National Committee for Quality Assurance (NCQA) announced permission for telehealth capture of 40 HEDIS® measures, allowing telehealth to address both risk adjustment and quality gaps.

Although telehealth is set up for success, providers do struggle with effective “face-to-face” telehealth delivery. Currently, audio-only (telephonic) telehealth visits cannot be used for risk adjustment consideration. NEJM Catalyst found that telephonic care is the current telehealth mainstay while video-based visits are taking time to ramp up. Ongoing barriers to video-based care include:

  • Training clinicians
  • Explaining arrival procedures to patients
  • Using interpreter services
  • Getting video equipment to clinicians’ homes

The publication also noted that some attempted video visits have had to be switched to the telephone or less HIPAA-compliant platforms such as FaceTime and Skype.

In review, payers should continue perfecting the telehealth model in the event of future COVID-19 waves and continue to treat sick members wherever they are. Having qualified nurse practitioners and physician assistants to reach members in their homes is critical to substantiate and round-out risk adjustment efforts, particularly during a pandemic, but this can be difficult to execute. That’s why Persivia offers telehealth functionality to our risk adjustment services. Learn how we support telehealth to improve prospective risk adjustment results and close care gaps.