Health Data Decisions is actively monitoring the required business activity modifications that the COVID-19 pandemic is mandating for our clients and stakeholders. While we weather this challenge together with our clients, HDD will continue to provide consultative and analytic support in the remote virtual office and data access environment that has always been our standard operating model.
At this time, we recognize that our clients will require some creativity to maintain health plan and provider operations. Regular wellness activities and health maintenance are no longer the main priority and many patients are already experiencing overwhelming challenges with accessing care, getting medications and ensuring proper nutrition as groceries are becoming out of stock and more expensive.
It has already become more difficult to treat the conditions which drive HEDIS®, Star Ratings and Risk Adjustment Payments. HDD expects significant disease progression for pre-diabetes, diabetes, mental health, substance abuse, cardiac and pulmonary conditions regardless of hospital bed shortages. We anticipate decreased member satisfaction and confidence as most non-essential procedures will be postponed for many months, if not an entire year or more. Additional challenges will arise from the anxiety, fear and economic uncertainty that members, caregivers and providers will experience.
In the many communications that have been distributed in the past week, CMS has allowed increased flexibility in the provision of health benefits and invited innovative models via the waiver process to address access to care and care continuity. NCQA is already offering relief and flexibility for HEDIS reporting for health plans and for state Medicaid entities who have P4P programs and will likely soon be announcing additional modifications to HEDIS and CAHPS as they typically follow the lead of CMS in these situations. Some key areas of focus including recommendations are detailed below.
Member Engagement and Communication Strategy
Prior year member survey results, such as CAHPS, can be leveraged to stratify membership to prioritize outreach to those members that are most likely to feel disconnected or have challenges accessing care. A combination of outgoing communication and increased capacity on phone and chat lines can help facilitate member’s confidence in their health insurer and providers.
Recommendations
Dedicate additional resources to the call center
Create a dedicated COVID hotline and online chat functionality; members may need the plan’s help to locate healthcare providers with capacity as the pandemic progresses
Perform e-mail outreach directing members to health plan and local government resources
Identify members that are at high risk for COVID-19 and complications using existing population health and demographic data including SDOH as well as public health surveillance reports.
Provider Communications and Supply Logistics
The American healthcare system faces unprecedented demand to perform tests, triage patients, and provide treatment for COVID-19, yet there will not be adequate capacity of facilities, clinicians and medical supplies and equipment in the coming months.
Recommendations
Health plans are uniquely placed at the intersection of providers, members and state and federal governments, and should start a centralized task force or project team which can leverage all available resources to support providers and help address demand of various parts of the system and alleviate strain wherever possible.
Consider breaking down barriers with competitors to form health care leadership teams within your state or region to address the unprecedented challenges posed by this pandemic
Model of Care Changes
Flexibility and agile responses to the rapidly changing health care environment in the face of the COVID-19 pandemic should be the focus of the plan at this time.
Acute care hospitals have been encouraged to delay non-essential procedures and discharge inpatients to skilled nursing (SNF) as soon as possible, particularly in rural areas (see CMS March 17 call transcript).
Recommendations
Engage with CMS and local regulators on any waiver or exception process that will allow the plan to make changes to their care delivery model
Expand paid at-home services via vendor or in-house staff for home assessments, labs, clinical visits, CNAs, personal care attendants and other caregivers to reduce the need for members to interact with other patients in a doctor’s office waiting room
Focus on continuity of care which is likely to be interrupted; use risk suspecting algorithms to identify and contact members who need maintenance visits rescheduled or transitions to telehealth. Prior utilization patterns can be used to identify members who access a certain mode of care on a recurring basis.
Review billing arrangements with SNF and rehab facilities to ensure they are fully populating their claims with all relevant clinical and diagnostic information
Telehealth and eVisits
eVisit access has been expanded from members in rural areas to all members. CMS will cover brief visits via telehealth for all beneficiaries even if the eVisit standard isn’t met; these visits are now considered equivalent to in-person visits for Risk Adjustment.
Recommendations
Ensure that members are aware of this option and the benefits vs. in-office care
Help vulnerable members get technology set up in their homes to enable eVisits
Outreach to providers performing eVisits to educate them on the use of the G2010 and G2012 billing codes which are accepted in the 2020 EDPS model (but not RAPS)
Maintaining Quality of Care
As the U.S.’s health care system’s focus turns towards managing the pandemic, chronic and acute episodes will continue to require care. Increasing remote care capability where possible may become vital as hospitals’ and doctors’ capacity becomes overwhelmed by emergency care and maintaining social distance is imperative. Some care will still necessitate in-person encounters, but the health plan can play a vital role in alleviating capacity pressure by enabling as much care-at-a-distance as possible.
Recommendations
Support behavioral health providers’ efforts to provide telehealth services
Ensure mail-order pharmacy and mail-order DME items such as blood pressure cuffs and glucose test strips are available to as many members as possible and that the process is meeting needs
Use telehealth to triage members to the most appropriate mode and level of care and help limit unnecessary procedures or encounters
Encourage providers’ use of telehealth for medication maintenance for chronic conditions
Utilize prescription claims data to surveil medication refill patterns and proactively identify and address gaps, especially those that typically result in ER visits or hospital stays
Evaluate the feasibility of setting up remote care capability such as BP monitoring, glucose monitoring, and screenings such as
Double down on hospital readmission prevention efforts, as beds become more scarce
Medical Economic Impact
COVID-19 will dramatically impact the economics of medical care for several years. Although there are still many unknowns, plans can and should start to model the financial implications of the pandemic and modify these models as more data becomes available.
Recommendations
Start to modify utilization projections and associated reserves to account for patterns of care changes at various points of the COVID-19 pandemic and associated response
Evaluate the impact of macroeconomic changes on the plan’s membership including unemployment, changes in consumer behavior and the impact of social distancing protocols
Start developing new benefit and pricing models to adapt to the new economic landscape that the pandemic will drive in the next 6-12 months and beyond
The team at Health Data Decisions is committed to effectively using data to facilitate a positive impact on the challenges our friends, clients and partners face during and after this health crisis. I want to thank my staff for all their hard work, dedication and passion to this cause. We would welcome your feedback. You can contact me directly at Mike@healthdatadecisions.com.
