Integrating Risk Adjustment, Quality Measurement to Reduce Administrative Burden

Paige Kilian, MD, is the chief medical officer of Inovalon. In this interview, Dr Kilian shares how siloed risk and quality measurement processes can increase administrative burden and interfere with patient care. She also offers guidance for health plans seeking to improve interoperability and reduce provider burnout.

What challenges do payers face regarding risk adjustment and quality measurement?

It is important to recognize health plans have enormous reporting obligations for both risk adjustment and quality metrics.

Specifically, I think of data requirements and precisely how they must be submitted to the Centers for Medicare & Medicaid Services, the US Department of Health and Human Services, or the state. Those requirements vary depending on the line of business—Medicare Advantage, Affordable Care Act, Medicaid.

But these obligations all depend on the doctor, nurse practitioner, or physician’s assistant seeing patients and documenting encounters. This is of considerable expense to health plans and a significant administrative burden to practices.

Health plans must sort through mountains of data. They must figure out what information is accurate, meaningful, and necessary, as well as what requires action, and the processes they employ to do all that are largely siloed. These processes are split into risk adjustment and quality reporting arms, which might or might not be communicating effectively with patients, doctors, or even each other.

Lack of coordination and integration leads to redundancy, waste, and abrasion. It also leads to increased expense. It irritates patients and physicians alike, and of course, all that redundancy contributes to the mounting administrative burden to practices, on which plans and patients depend for the actual delivery of health care. The more providers are burdened with, the less time they have to deliver care.

How do these challenges impact stakeholders and the health care system more generally?

In 2015, the American College of Physicians (ACP) launched an initiative called Patients Before Paperwork, largely in response to physicians complaining. Physicians were recognizing the burgeoning administrative burden, so the ACP decided to evaluate and measure it where they could.

Within a couple years, the ACP published 2 papers. One was a call to action for Medicare Advantage aimed at streamlining burden. Three major initiatives came from that, one of which was streamlining requirements for evaluation and management documentation. And they have largely accomplished that.

The ACP also aimed to improve information technology and interoperability in health care. They are certainly not alone in recognizing this is necessary. We are all working toward this aim, and there is still more progress to be made.

The ACP’s third aim was to measure and assess the effect of administrative burden on quality outcomes, the suspicion being all the efforts going into measuring quality and risk are undermining physicians’ availability to provide care. This specific concern is further substantiated by the fact that back in 2016, Annals of Internal Medicine published an evaluation of how outpatient physicians spend their day. This research revealed physicians spend only 27% of their workdays engaged in direct patient care, with almost 50% of their time spent on administrative tasks, whether through the electronic health record or on paper.

In an environment where access to care is so critically important, and even measured as a quality standard, it is unsustainable for processes to be set up this way. Our very efforts to try to drive quality are playing a role in undermining it.

At the end of 2020, Medical Economics surveyed its readership and found the leading challenge identified for the coming year was paperwork. We were midpandemic, it was the end of 2020, we just got vaccines, and the leading challenge for the coming year was paperwork. That is extraordinarily revealing to me.

This survey certainly also showed a lot of physicians were recognizing burnout, and the leading contributor to burnout among those who reported it was administrative burden, not pandemic obligations. And leading the pack in the paperwork complaint was the administrative burden associated with prior authorizations and reporting quality metrics.

Regarding quality metric reporting specifically, there is a perception that their addition to the burden is not offset by a significant impact on improving the quality of care delivered. That perception does not even factor in the lack of perceived value in risk adjustment and reporting burden. You would be hard pressed to convince doctors there is value there.

I am not saying there is not value, but I am saying that, from the primary care provider’s perspective, reporting for risk adjustment does not seem to benefit the patient or the doctor. If they do not see value in measuring and reporting on quality metrics, you can imagine how skeptical they are about measuring and reporting for risk adjustment.

In a nutshell, the requirements to track and report the specifics of care delivered—the diagnosis made, the treatment delivered, the outcomes achieved—have the unintended consequence of making that care less accessible.

What are some strategies payers can use to improve their analytics and make this whole process easier?

Integration. They need to integrate their risk and quality analytics. It really comes down to that.

And integration is a challenge, depending on the size of the payer. If you are a large payer, extensive expertise and entire careers may have been built in the risk adjustment silo or the quality measurement silo. It can, quite understandably, be very hard to merge these well defended silos. For large plans in particular, the directive to integrate, to preserve our health care industry, must come from the top.

For smaller and regional plans, the impetus sometimes can come from the practices. Because smaller plans are often a little more closely tied to their provider groups, the provider groups may have more of an ear with the plan. The provider engagement team for the plan sometimes can drive integration and streamlining. We have seen smaller regional plans where their provider engagement team says to the risk and quality teams, “Show us your analytics, and we will integrate the messaging so we can present it to practices in a way that is less intrusive and less redundant.”

Certainly, there are integrated tools and analytics platforms. The extent to which those are used depends on the health plan and directive—how big they are, and how much they recognize integration is critically important.

What should payers keep top of mind when selecting a partner or new technology to enhance their data?

Top of mind should be the ability to integrate messaging and provide tools at the point of care that reduce administrative burden while still yielding the results patients need and the requirements health plans need to meet reporting obligations for both risk and quality.

Inovalon does prioritize this. We are a physician-founded, physician-led company, and our programs and analytics are physician-designed.

The reality is everyone is talking about integration. We are not alone. I am not sure, though, if everyone in the market is recognizing just how critical it is. We are focused on facilitating the physician-patient interaction. We have been for 15 years.

Does that mean the problems are solved? I wish I could say they were, but of course not. Is it our number one focus, streamlining messaging so we can preserve the integrity and effectiveness of the provider-patient encounter? Absolutely. And I encourage that dedication and focus be top of mind as partners are selected.

Where do you see the future of risk and quality measurement headed?

Interoperability is critical. As part of that, we must show doctors value. It is always going to be difficult to convince doctors that correct risk adjustment reporting makes a big difference to them or to their patient.

You can tie it to value-based contracting, and that is convincing. But what we really need to do to compel doctors is demonstrate that quality measurement and reporting make a difference in patient outcomes, because there is the perception that it simply adds burden without being offset by a significant benefit. So we have to prove there is a benefit, show it to them simply, and link the quality asks to the risk adjustment asks so they are not duplicates or seem nonsensical to the physician.

If last year we focused on 3 quality measures in particular, we can say to the doctor, “Look, this is where we were with breast cancer screening last year. With your help, this is where we are this year. Thank you. Now we're focused on colorectal cancer screening. Here's where we are, where we're going, and what we need you to do.”

Show the value. Show the outcomes have been achieved. Show these measures are making a difference to the care that patients are receiving, and you will get doctors’ attention. But you must link this to all the other requirements so you are not hitting them day after day, month after month, with different questions on the same patients that all could have been answered at once.

Is there anything else you would like to add?

I know I have hit the issue of administrative burden hard, but something I would love for everyone to consider is this: each practice is dealing with not just 1 health plan’s siloed systems, but with 10 or 12 health plans across multiple lines of business.

In January 2022, the American Medical Association published a survey of 20,000 physicians across 124 institutions. They found 1 in 5 clinicians planning to leave practice in the next 2 years, and 1 in 3 clinicians planning to reduce hours. This is simply not sustainable. And it is not just the doctors—it is nurses, medical assistants, back-office staff, all people who are critical, not only to delivering patient care, but to reporting on that care as well.

I want to emphasize, too, that we can fix this. Integrating risk and quality programs must be prioritized at the highest health plan executive levels and supported by technology that translates mountains of data into meaningful, actionable, integrated analytics and platforms, such as those Inovalon provides.

Thank you very much for having me. I appreciate the opportunity to share my thoughts.

About Dr Kilian

Paige Kilian, MD, is the chief medical officer for Inovalon, where she has worked for 15 years. She is an internist by training and practice, and she remains a primary care physician at heart.