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Following a checklist improves data capture, enhances patient engagement, and increases access to care.
In the wake of revenue loss related to COVID-19, smaller hospitals, public hospitals and rural hospitals are among those most likely to face financial challenges and may be at risk of closing or merging. If patients don’t receive non-emergent care, health outcomes will decline. This will impact patient outcomes and performance, which are increasingly tied to financial incentives by private payers and CMS.
Furthermore, payers have seen an overall reduction in claim volume, particularly in commercial lines of business, as members lose employer-sponsored coverage. Additionally, there has been a drop in emergency department, inpatient and office visit claims across all plan types.
In this uncertain environment, healthcare leaders must take proactive steps to close care gaps and ensure patients can access the level of care they need to prevent disease and control chronic conditions. This means finding new ways to tap into operational efficiencies and adopt tools that deliver a 360-degree view of the patient and intelligent analytics to identify care gaps and closure opportunities for quality and risk adjustment.
Numbers Paint a Picture
During the COVID-19 pandemic, primary care visits dropped 60%with many Americans temporarily putting off going to the doctor. Experts speculate that this will lead to a decline in health outcomes and a rise in potentially negative consequences for those who delayed preventive screenings and treatments. The decrease in doctor visits has also led to unaddressed care gaps and strained revenue for many health systems. In fact, providers averaged a 32% loss in revenue since February 2020.
The relative decline in visits remains largest among surgical and procedural specialties and pediatrics. ED visit patterns show smaller decline for more severe conditions, such as stroke and acute myocardial infarction, compared to visits related to less severe conditions, such as dermatitis and conjunctivitis. Analysis of electronic health record (EHR) data for breast, cervical and colon cancer screenings showed an even sharper decline beginning in early March of 2020 followed by an increase in screenings, although screening rates have remained far below 2019 levels. By mid-June of 2020, weekly volumes for cancer screenings remained roughly 30% to 35% lower than their pre-COVID-19 levels.
Payers Make Proactive Changes
Experts believe that the COVID-19 pandemic has accelerated the move toward value-based payment, which could disrupt traditional utilization patterns and fee-for-service payment. Such a shift requires more intense focus around data-sharing to support improved outcomes.
Payers should look for opportunities to alleviate provider administrative burden, including increasing access to data analytics and adjusting value-based payment programs to focus on outcome improvements that are within provider control. Success for providers and payers will depend upon leveraging data to highlight opportunities for quality improvement and sharing data to aid identification of at-risk members.
As payers gather data around member diagnoses, procedures and outcomes, they should expect the majority of information for risk analyses to reflect pre-COVID periods. This means that they will not yet see drastic changes in risk scores that are proportional to member changes in utilization for several months.
Real-time data analysis will be key to understanding the pandemic’s effect on cost-of-care trends and member risk profiles, and how to manage and triage care in ways that most effectively add value.
To turn this crisis into opportunity, payers can implement important strategies to close care gaps, while simultaneously aligning with ongoing quality improvement initiatives:
Identify highest-risk individuals with claims data and other tools that also enable providers to prioritize patients for outreach and face-to-face visits.
Ensure messages reach their target demographic and identify member preferences for engagement, such as texting versus a phone call.
Help members better understand their virtual care visit opportunities and encourage its use for ongoing healthcare management needs, especially for behavioral health counseling.
Support follow-up with patients to not only assess the effectiveness of outreach and engagement tactics, but also understand strategies that don’t work.
It will be equally important to partner with a population health management solution that offers data analytics and the highest level of data connectivity. These solutions enable payers and providers to better address member healthcare needs, monitor vulnerable populations and take steps to enhance health and reduce risk. The goal is to improve outcomes and strengthen payer performance—for now and beyond the pandemic.
Checklist for Data Connectivity
Data connectivity for members, payers and providers has become increasingly important since the passing of the 21st Century Cures Act—which is intended to help accelerate medical product development and bring new innovations and advances to patients who need them faster and more efficiently. The right population health management solution offers connectivity with EHRs, health information exchanges (HIEs) and the bi-directional data feeds between these systems to extract continuity of care document (CCD) data.
Look for critical capabilities:
An innovative and advanced value-based care enablement solution gives providers more time to spend caring for patients and access to data from multiple payers, with real-time reporting and dashboards at the point of care. This level of data capture enhances patient engagement, improves clinical outcomes, increases quality care gap closures and improves value-based contract performance for a more sustainable healthcare system.
Josh Hetler is the executive vice president for Business Intelligence, DataLink.