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More payer/provider transparency at point of care improves risk, quality


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Increased data transparency between health plans and providers on care and coding gaps results in higher compliance, process improvement and positive behavior changes among network providers, according to a new report from information technology company IllumiCare.

The report demonstrates, across multiple plans, that placing previously unavailable information on quality gaps, HCC (Hierarchical Condition Categories) capture, HRA completion and other initiatives, within the provider’s workflow, is effective in closing more gaps.

WHAT’S THE IMPACT

Medicare Advantage and Accountable Care Organizations are leaving money on the table, according to the report. 

Providers also face lost revenue due to care and coding gaps in their member populations. 

For example, in 2021, Medicare Advantage plans with a 4-star or better rating received an average bonus of between $174-$521 per member, the report said. On the risk capture side, it has been estimated that for each 0.1 increase in risk score, a Medicare Advantage plan’s profits increase about 25%.

Providers can also receive cash incentives based on their composite quality star rating. The more care gaps closed, the higher the provider’s star rating, resulting in a higher quality bonus.

The common thread that runs through all incentive payments is the dependence of plans on primary care providers to close care and coding gaps in a timely and appropriate manner, the report said. 

THE LARGER TREND

The study focuses on a platform offered by Illumicare called Smart Ribbon, an EMR-agnostic platform of clinical apps.
The platform places care and coding requirements and information from the plan in front of primary care physicians during their normal workflow. It alerts them in their workflow to any care and coding gaps that may exist for the patient. 

Over the seven-month study period, a large Medicare Advantage plan used the Ribbon to focus on quality measures and saw a 342% net increase in users achieving a 4+ star rating, outpacing their peers, the report said. The Ribbon users went from 7% to 31%, achieving 4+ stars, while the non-users went from 10% to 20%.

ON THE RECORD

“Too many solutions are only focused on delivering the data, but that’s just the start,” said G.T. LaBorde, CEO of IllumiCare. “The most compelling insight from this data is the clear opportunity for behavior change and how plans can work alongside providers to enable it long-term. This opportunity to enact change through a complete feedback loop has not existed before.”
 

Twitter: @JELagasse
Email the writer: Jeff.Lagasse@himssmedia.com



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