Using a proprietary dataset of 550K ACA lives from the Pareto Community, Pareto analyzed all scored claims with a documented HCC to identify the services, places of service and conditions that impact risk adjustment. This data has been updated through August 2020 and will continue to be updated as new data is available.

For the results presented below, the data is limited to scored claims from the places of service most impacted by COVID-19: Telemedicine, Office, Hospital Outpatient Department - Off Campus (HOPS-OFF CAMPUS), Hospital Outpatient Department - On Campus (HOPD-ON CAMPUS), Hospital - Inpatient (HSOP-INPATIENT) and Ambulatory Surgery Center (ASC).

Which services document the most conditions (i.e., HCCs)?

Of the services that have historically captured the most HCC codes,

Patient Evaluation and Management (E&M) services

for new and established patients accounted for

50.1%
of conditions captured

across all impacted places of service.

Note: This data is limited to ACA claims in January – Aug 2020 from the places of service most impacted by COVID-19, as shown in the "Place of Service" filter.

Has COVID-19 impacted how often these services are performed?

For "Patient Evaluation and Management" services,

total claims have reduced by

86%*

since January.

 

"Pathology/Laboratory" and "Pulmonary" services have dropped even further to

63%* & 39%*
of January claims volume, respectively.

Note: This data is limited to ACA claims in January – Aug 2020 from the places of service most impacted by COVID-19, as shown in the "Place of Service" filter.

*Using July as the comparison month rather than August due to August not being fully processed/incomplete.

INSIGHT

Because the most risk-adjustable conditions are documented through these services, and they are being performed less often, health plans will likely see a significant increase in undocumented risk gaps, until the diagnoses that would normally be documented through these services are documented elsewhere or through gap closure campaigns.

How has utilization of common places of service changed due to COVID-19?

The place of service experiencing the largest surge in visits is "Telemedicine," with a nearly

80% 
claims volume increase

in July.
(August values represent incomplete dataset)

 

Visits to "Hospital Outpatient Departments - On Campus" decreased to only

68%
of January claims volume.

Note: This data is limited to ACA claims in January – Aug 2020 from the places of service most impacted by COVID-19, as shown in the "Place of Service" filter. May values are not fully representative due to incomplete data from some sources. Note that the discrepancy between the "grand total" values in the table above and the percentages at the top of this chart is due to the fact that a single claim can have multiple procedure codes.

INSIGHT

Prior to COVID-19, telehealth visits were included in risk adjustment calculations for the Affordable Care Act (ACA) market—though telemedicine was not often utilized—but they were not allowable for Medicare Advantage (MA). CMS has since expanded the applicability of diagnoses from telehealth, allowing MA plans to submit conditions collected during virtual visits for risk adjustment.

As shown above, with less visits to in-person sites of care, health plans can no longer rely on these locations and services to capture conditions with a risk adjustment impact. Plans have already begun enhancing telehealth programs and activating new risk adjustment strategies (e.g., virtual in-home assessments); we anticipate seeing increased use of telehealth to evaluate and document diagnoses. Plans should also expect to see more conditions documented in different or atypical locations, such as “Hospital – Inpatient” visits, as people refrain from seeking care unless absolutely necessary.

What are the top condition categories captured in claims data?

This analysis shows that 

Neoplasms

have the most captured conditions overall, which accounts for

18.0% 
of monthly claims,

followed by Endocrinological/Pancreatic conditions, which account for

16.4%
of monthly claims.

Note: This data is limited to ACA claims in January – Aug 2020 from the places of service most impacted by COVID-19, as shown in the "Place of Service" filter.

How has COVID-19 impacted the capture of HCCs at affected places of service?

Since January, Telemedicine visits for Neoplasms & Endocrinological/Pancreatic Conditions

increased by

23x-28x.

"Hospital Outpatient Departments -
Off Campus" visits reduced to

27% to 45%
of January claims volume

for Endocrinological/Pancreatic Conditions,
while neoplasms is back to January levels
for HOPD of off campus at

105%*

Note: This data is limited to ACA claims in January – Aug 2020 from the places of service most impacted by COVID-19, as shown in the "Place of Service" filter.

*Using July as the comparison month rather than August due to August not being fully processed/incomplete.

INSIGHT

While overall volume of services is decreasing, there has been a rapid rise in the use of virtual visits to capture a broader array of HCCs. It's unclear how long the impacts of COVID-19 will last, but expect to see more health plans adding telehealth to risk adjustment program strategies as an ongoing solution, beyond addressing the challenges of this pandemic environment.

Predicting Risk of Serious COVID-19 Complications

Leveraging a proprietary predictive model and the health history of our Pareto Community, we have identified the medical conditions and social determinants of health (SDOH) contributing to a decline in overall health status that could potentially be worsened by a COVID-19 diagnosis. By combining this with external research and clinical input, we developed a process that identifies a population suspected as being at risk for serious COVID-19 complications.

Can predictive analytics and social determinants of health data help fight COVID-19?

Pareto's COVID-19 risk model identifies members with greatly elevated risk for severe complications and those at risk for hospitalization if faced with a positive coronavirus diagnosis.

On average,

10%
of a health's plans membership

is prone to serious complications as a result of exposure to COVID-19.

Viz_4_donut

This model considers the contributing factors for increased severity related to other respiratory viruses, as well as the progression of those infections, using outcomes from the Pareto Community. For example, through our analysis and model refinement, we found that a history of cancer and chemotherapy is the greatest risk factor contributing to the seriousness of complications from respiratory viruses. Additionally, Lupus and advanced kidney disease are significant contributors. We have incorporated these insights into our COVID-19 risk identification methodology, while also leveraging general health history, external research and clinical input.

An analysis like this one from Pareto equips care and case management teams with additional insight into members, which will ultimately help these groups efficiently deliver the services people need to stay safe and healthy during this pandemic.
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The impacts of COVID-19 will be felt by healthcare organizations well beyond reopening and lifting of social distancing restrictions.

Particularly for risk adjustment, the parameters that define which members to target for risk gap closure, as well as the strategies and campaigns you use to target them, will be drastically different in a post-COVID-19 world.

The above insights are just the tip of the iceberg of the ways Pareto is rethinking risk adjustment analytics. If you find yourself unsure of what to do, we can help you prioritize which members to target for which types of encounters (e.g., telehealth versus face-to-face) to ensure optimal risk score performance.

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