CARES Act Examinations: What You Should Know
HealthMay 24, 2021

Risk adjustment challenges brought on by COVID-19

The COVID-19 pandemic has created major challenges for health care, foremost the need to stretch existing resources to manage a massive influx of COVID-19 patients, and secondarily managing patients with non-COVID conditions. Even when health care resources were available, many patients, as high as 40%, chose to avoid care for acute and chronic conditions during the pandemic. Limitations in health care resources combined with patient concerns with seeking care resulted in patients not receiving adequate care to avoid otherwise preventable adverse outcomes.  

The impact of the reductions in care can be analyzed from the perspective of US-based shared-risk program models such as Medicare Advantage, the Affordable Care Act Commercial Insurance Marketplace, Accountable Care Organizations, the Merit-based Incentive Payment System (MIPS), CMS Innovation programs, and several Medicaid programs. These initiatives all share the need for accurate and up-to-date coding of conditions, which allows costs of care to be projected. 

Assessing the gaps in care caused by COVID-19

While the primary reason patients avoided medical care in 2020 and 2021 was due to concerns related to COVID-19 virus transmission, patients also avoided care due to the “Stay at Home” orders, reductions in services provided by stressed provider organizations, loss of employment and consequently health care insurance, patients deferring elective procedures, and concerns over hospital staff resources being diverted to treat COVID-19 patients. Many patients decided that they would wait until they were fully immunized or until the public health emergence ended before seeking care.  Further, a lack of access to care as well as other social determinants of health (SDoH) have led to insufficient care in disadvantaged and vulnerable patient populations.

There are a number of disease states which are especially sensitive to gaps in care including: diabetes, refractory hypertension, congestive heart failure, chronic kidney disease, ischemic heart disease, bipolar disorder, obesity, hypertensive cardiomyopathy, vascular disease, cancer, seizure disorders, HIV infection, cirrhosis, inflammatory bowel disease, rheumatoid arthritis, hypercoagulable states, substance use disorders, myasthenia gravis, Parkinson’s disease, peripheral vascular disease, pressure ulcers, venous ulcers, and others. Individuals who have one or more of these conditions are at risk of experiencing progression of their disease(s), including complications that could negatively impact their overall health and the need for healthcare services.

The full impact of the pandemic on chronic conditions has yet to determined, although some reports have started to illuminate the scope of the problem. One such study looked at the impact of a pandemic lockdown on a cohort of diabetic patients in Italy. They reported significant increases in key diabetic parameters including body weight, waist circumference, BMI, fasting blood glucose, and HbA1c percentages. The more fragile patients, including those with CKD and insulin dependence tended to have worse outcomes. Another report found a significant deterioration in diabetic glycemic control during the pandemic despite the absence of a lockdown. Other studies have found negative care impacts on the management of patients at risk for venous thromboembolism, Parkinson’s Disease, chronic kidney disease, myocardial infarction, stroke, and cancer.

What does this mean for quality-based care initiatives?

From a risk adjustment perspective, this will result in inaccurate assessments of the patient health statuses, projected health care needs, and predicted cost of care. For example, a Medicare Advantage patient with borderline diabetes mellitus type 2 and hypertensive heart disease, who does not receive adequate care is at risk of progressing to more severe forms of these diseases such as, diabetic retinal complications and chronic kidney disease. This has amplified the need to engage patients quickly and efficiently to fully assess their current health status, optimize management, and determine their risk status.

Most quality-based healthcare initiatives also feature a component of risk adjustment. For example, the MIPS Cost category uses a model akin the one used by Medicare Advantage for determining risk adjusted performance scores on a growing number of cost measures. The cost category is set to have a MIPS final score weighting of 30% in 2022 (from 20% in 2021). With over one million providers participating in the MIPS program the pressure to accurately determine the severity of illness levels through proper diagnosis, documentation, and coding now has even greater significance. Accurate coding and risk adjustment may be a significant determining factor as to whether a provider organization receives a positive or negative MIPS payment adjustment.

Medicare Accountable Care Organization performance is also risk-adjusted to identity high-risk patients, determine reimbursement levels, and to accurately predict the costs of care per enrollee. The Affordable Care Act Commercial Insurance Marketplace uses a model that is similar to Medicare Advantage, although the Marketplace program is a prospective vs. retrospective model, uses a different set of HCC codes, and includes pediatric, obstetrical, and other conditions. The majority of state Medicaid programs and initiatives developed by the CMS Centers of Innovation, such as the Oncology Care Model, also factor in risk adjustment to determine performance.

All roads lead to risk adjustment

Given the broad range of shared-risk programs one might say that in healthcare, “all roads lead to risk adjustment.” This places significant pressure on organizations to optimize proper documentation and coding to ensure the most accurate patient severity of illness levels can be assessed and used to determine performance in a growing number of health care models. This rend will increasingly impact providers, payers, and emerging "payvider" models.

As discussed in a recent webinar with Wolters Kluwer and Fierce Health, organizations not already doing so need to identify and focus on providing optimal care to patients who have not received adequate primary and specialist care throughout the duration of the pandemic, including those impacted by social determinants of health. This will allow for gaps in care to be addressed and for the patient’s current healthcare status to be fully assessed. Care for patients with conditions and combinations of conditions that tend to deteriorate more quickly without ongoing management may need to be prioritized.

Wolters Kluwer Health Language provides tools and services that help provider and payer organizations identify at risk patient populations and assist with determining severity of illness scores, such as the Risk Adjustment Factor (RAF) score used by CMS in Medicare Advantage. Contact us to learn more about how these tools support targeted interventions and ongoing performance in health care models that include risk adjustment.

Speak To An Expert
Michael Stearns
Specialized Consulting Director - Medical Informatics, Health Language
Michael Stearns, MD, CPC, CRC, CFPC is a physician informaticist, health information technology (HIT), and healthcare compliance professional. He has 20+ years of experience in the areas of electronic health records (EHRs), telehealth, virtual services, quality reporting, risk adjustment, health information exchange, clinical terminology development, standards, and billing and coding compliance.
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