To maximize shared savings, mastering risk adjustment is a critical factor for Accountable Care Organizations (ACOs) participating in MSSP, ACO REACH, and other alternative payment models. Unfortunately, however, many ACOs that participate in MSSP and ACO REACH don’t have a risk adjustment program in place that’s set up for success—or they may not have one at all.

And without the right people, process, and technology in place, it’s nearly impossible for ACOs to accurately assess the population’s disease burden, take informed steps to reduce it, and measure their progress in driving better outcomes. As a result, both new entrants and existing ACOs are challenged with understanding what it takes to holistically support a scalable risk adjustment program and, more urgently, where to start when bringing it to fruition.

3 Steps To Risk Adjustment Scoring

Apixio is here to guide you on addressing these challenges and have leveraged our industry knowledge and years of risk adjustment success to comprise a list of strategies on what you need to maximize your risk adjustment scoring:

1. Leverage interoperability to capture data
2. Introduce prospective risk adjustment process to scale data
3. Improve HCC coding with an approach that looks both ways

Leverage interoperability to capture data

Sourcing, gathering, and seamlessly accessing the siloed patient data that exists across multiple EHRs is key to the foundation of your organization’s risk adjustment program. NAACOS survey conducted this year, 39% of ACOs have more than 10 EHRs and only 17% have one EHR. However, many organizations lack the infrastructure and workflows to organize and efficiently aggregate this data, let alone use it to support their risk adjustment initiatives. However, by utilizing bi-directional interoperability across multiple EHRs, your organization will have one of the key building blocks with data access.

Pro tip: In order to begin capturing this data, your organization must first determine the current state of accessing data across EHRs.

Introduce prospective risk adjustment process to scale data
Once your organization is able to seamlessly and securely access data, the next step is leveraging this data to capture risk and drive patient outcomes. The optimal time to do this is to do so prospectively during pre-visit chart preparation. With 10-15 minutes of face time with each patient, clinicians have very little time to thoroughly review patient charts to fully capture risk at the point-of-care. However, with a prospective risk adjustment approach combined with AI-powered tools that allow clinical teams to surface actionable insights prior to the point-of-care, clinicians will be able to review charts faster, flag conditions for recapture and suspected, and help close care gaps to improve risk management and outcomes at scale.

Pro tip: Connect with your provider network and learn more about the stop-gaps and bottlenecks within their pre-visit workflow.

Improve HCC coding with an approach that looks both ways

Medicare ACOs are charged with maximizing value for their organizations while maintaining the highest coding accuracy standards. However, risk capture can be difficult to operationalize and scale, creating a huge administrative burden for providers due to the complex and time-consuming chart review process. By utilizing a proper coding, workflow, and auditing approach that is able to identify both missed coding opportunities and unsupported known codes, your team can have a complete and accurate view of the population’s disease burden.

Pro tip: Benchmark your population’s disease burden relative to your geography and evaluate how to identify the disease burden across your patients.

Risk adjustment success is attainable for your organization. And with the right steps, you can make this success a reality.

FAQs

What is the difference between ACO Reach and MSSP?

CO Reach and MSSP (Medicare Shared Savings Program) are both initiatives aimed at improving the quality and efficiency of healthcare delivery. However, ACO Reach is a specific program offered by certain accountable care organizations (ACOs) to expand their geographic reach and partnerships beyond traditional boundaries. MSSP, on the other hand, is a Medicare program that enables ACOs to share in the savings they achieve through coordinated care. While ACO Reach focuses on expanding the network, MSSP emphasizes cost savings through care coordination.

What is the strategy behind accountable care organizations (ACOs)?

ACOs employ a strategy focused on improving the quality of care while controlling costs. The key principle behind ACOs is the coordination and collaboration among healthcare providers to deliver integrated, patient-centered care. By aligning incentives and sharing accountability for patient outcomes, ACOs aim to achieve better care coordination, reduce unnecessary healthcare utilization, and improve overall population health.

What are the risks associated with accountable care organizations (ACOs)?

ACOs face several risks in their pursuit of improved healthcare delivery. One of the primary risks is financial, as ACOs often operate under shared savings or shared risk models. If the ACO fails to meet quality and cost benchmarks, it may face financial penalties or losses. Additionally, ACOs must navigate the challenges of care coordination, data sharing, and physician engagement. Regulatory and compliance risks also exist, as ACOs must adhere to various healthcare regulations and reporting requirements.

How can ACOs master the challenges they encounter?

ACOs can master their challenges by implementing effective strategies and best practices. Some key areas to address include developing robust care coordination processes, fostering strong physician engagement, leveraging data analytics for population health management, and establishing effective communication channels among ACO participants. A focus on patient-centered care, continuous quality improvement, and effective risk management can also contribute to mastering the challenges faced by ACOs.

What is risk adjustment in the context of MSSP?

Risk adjustment is a crucial aspect of the MSSP, which aims to ensure fair and accurate comparisons of ACO performance. Risk adjustment accounts for differences in the health status and risk profiles of patients attributed to each ACO. By adjusting for varying patient risk levels, the program can more accurately assess an ACO’s performance and avoid penalizing organizations that care for sicker populations.

How can ACOs effectively manage the risks they face?

ACOs can employ several strategies to effectively manage the risks associated with their operations. These strategies include comprehensive data analysis to identify high-risk patients, implementing care coordination programs to improve patient outcomes, utilizing robust health IT systems to track and manage patient data, establishing strong partnerships with payers and providers, and engaging in continuous quality improvement efforts. Additionally, ACOs can invest in risk management tools and expertise to assess, mitigate, and monitor the various risks they encounter.

What are ACO risk adjustment services?

ACO risk adjustment services involve the use of specialized tools, methodologies, and expertise to accurately assess and adjust for the risk profiles of patients attributed to an ACO. These services help ACOs ensure fair performance evaluations, account for differences in patient populations, and provide a more accurate representation of the organization’s performance. ACO risk adjustment services may include data analysis, risk scoring, risk stratification, and predictive modeling to support effective population health management and financial sustainability.

Contact us to learn more about how to bring these solutions to help support your risk adjustment program.

Additional Resources
Download our risk adjustment for Medicare ACOs brochure to see how Apixio’s solutions can help.