Working in research for two decades has taught me that it is curiosity and a desire to find the truth that drive researchers to investigate markets, ask questions, collect data, and share insights. Zora Neale Hurston said, “Research is formalized curiosity; it is poking and prying with a purpose.”
With formalized curiosity, KLAS pokes and pries with a purpose. We dig and investigate. Traditionally, our efforts have been devoted to the provider markets. Recently, in the spirit of curiosity, we have moved deeper into the payer space.
KLAS has come to realize that improving healthcare requires investment from stakeholders beyond just providers and their vendors. It’s been incredibly exciting to begin to piece together other perspectives of the healthcare puzzle. As I’ve attended payer conferences and had conversations with payer organizations, I’ve begun to learn what subjects drive payers’ decisions. A topic that has surfaced repeatedly is risk adjustment.
Risk adjustment (RA), in relatively simple terms, is the process by which a health plan forecasts health care costs based on the actuarial risk of enrollees. RA calibrates payments to health plans based on the relative health of populations using Hierarchical Condition Categories (HCC) to score and classify at-risk members. Health plans with above-average HCC scores receive reimbursement, while plans with scores below the HCC average make payments to compensate plans with the higher risk.
Because pre-existing conditions are no longer grounds for denying coverage under the ACA, the amount of risk that health plans are responsible for has increased dramatically. As a result, a lasting RA program for Medicare Advantage and commercial insurers has been established to mitigate the impact of adverse selection and risk selection.
This has created opportunities for software and services vendors to offer unique solutions to their payer clients. KLAS has begun interviewing health plans to understand the solutions vendors offer and how those solutions perform.
Early interactions with health plans indicate that vendors who play in this space typically offer:
- Quick categorization (HCCs)
- HCC analytics
- Auditing and compliance support
- Risk Adjustment Processing Systems (RAPS) for submission and reconciliation with CMS
RA is also tied closely to quality analytics, as HCCs are often used to identify gaps in care. So do payers need real-time data? During a recent call with our Payer Advisory Board, the board members expressed a desire for KLAS to conduct research on which vendors provide real-time data for quality analytics.
The reason behind this request?
The faster a health plan can get their data analyzed, the more time they have to make changes before reporting is due. In many cases, it take so long just to generate the reports that they have little to no ability to solve problems before the deadlines for HEDIS, etc.
A colleague of mine told me of a conversation in which a member of an investment/consultant firm told him that one of the firm’s customers had actually paid the firm to take the data from the organization’s system, analyze it, and return it to the organization. Why? Because that was faster than waiting for the vendor to do the analytics themselves.
While KLAS is still in the early stages of research for our Payer Quality and Analytics report, that firm’s story seems so far to be descriptive of industry difficulties as a whole. While most vendors are heading in the direction of real-time analytics, I haven’t heard of many vendors that have truly arrived. We’re excited to hear the final word from payers as we move closer to publication on our upcoming report.
[This piece was written by Pete Van Mondfrans, Research and Sales Director at KLAS Enterprises, focused on Payer Care Management Solutions and Payer Quality Analytics. For more information about KLAS, click here. To follow KLAS on Twitter, click here.]
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