The uncertainty and risk created by pandemic-related disruptions in care have health plans in uncharted water when it comes to relying on claims data and utilization patterns to inform their risk models. But while these disruptions weakened the reliability of traditional risk models, they also created opportunities to deepen and enrich member data by leveraging consumer and other data related to social determinants of health (SDoH) that can deliver significant performance and accuracy benefits.
Expanding data sources and enhancing analytics capabilities allows health plans to develop the capacity for more precise, holistic member engagement while improving the most impactful health outcomes in individuals and populations. Doing so will help lift Star Ratings, improve care compliance, close gaps, enhance member satisfaction, reduce costs and drive profitability gains.
Pandemic-Era Compliance Levels
When elective procedures were paused and care was delayed or diverted in early 2020 in response to the initial COVID-19 surge, it had an immediate impact on utilization and ancillary activities like testing and imaging, diagnoses, treatment plans, etc. By late summer, most provider organizations had reopened for procedures and care under strict social distancing measures. This subsequently generated sufficient claims data for Carrot Health to analyze and estimate the impact of disruption.
We opted to focus on compliance levels among Medicare Advantage populations for specific procedures, tests, and care interventions. This is because risk models—following Centers for Medicare and Medicaid Services (CMS) guidelines—emphasize appropriate care and member experience to meet quality standards central to Star Ratings. In that sense, key compliance levels serve as proxies that track changes in care volume.
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We found that, while the overall volume of care showed signs of returning to normal levels by the end of 2020, the erratic cadence of care delivery throughout the year would significantly impact compliance rates, engagement levels, and risk models going forward.
In the first two quarters of 2020, all plans experienced dips in compliance. Our data shows annual wellness visits dropped by 60%, and hemoglobin A1c testing dropped by 40% when compared with the previous year.
The drop was so dramatic that leading plans took urgent steps to improve compliance and care delivery, as reflected in the surge in telehealth earlier in the year. And while that surge receded over the course of the year, telehealth has shown staying power which may impact how care is delivered for the foreseeable future.
To determine the degree to which care utilization bounced back in the fourth quarter, we examined Medicare/Medicare Advantage data from October 2019 to October 2020. That data was collected from health plan customers across a number of states and serves as a nationally representative sample.
It showed that even with the third- and fourth-quarter recovery, 2020 compliance rates fell short across key quality measures as compared to 2019. Most notably, colorectal screening fell by 8% and annual wellness visits by 5%. Medication adherence across diabetes, renin-angiotensin system (RAS), and Statins either rose or were unaffected.
It’s possible to make inferences based on these numbers and the events of 2020. The decline in primary care visits was not as severe as other measures because primary care includes any consultation with a clinician, whether in-person or via telehealth, through hospitals, clinics, or urgent care centers.
On the other hand, wellness visits fell significantly despite regulatory changes implemented by CMS allowing for these examinations to be conducted via phone. The persistence of the decline could be due to the perceived lack of urgency, given other concerns. It’s also possible providers were not sufficiently educated on the policy change to adjust their care practices accordingly.
Likewise, breast cancer and colorectal screenings fell, possibly because they require an in-person diagnosis. Some beneficiaries likely considered the examination to be worth delaying because of the risk of contracting COVID-19.
It is also likely that medication adherence stayed flat or rose because prescriptions can be automatically refilled without clinician intervention, and can be received by mail or through drive-through pharmacy services. Moreover, many of the illnesses for which those medications are prescribed may count as comorbidities with COVID, giving patients strong motivation to adhere to their care plan.
Regardless of the reasons for the decrease in compliance and appropriate care, it’s likely that they will contribute to worsening health outcomes in subsequent years. Patients who did not receive annual wellness checks or important screenings may develop conditions that could have been prevented or treated earlier. Similarly, fewer visits and interactions with care providers can diminish engagement and adherence to treatment plans, medications, and healthy lifestyles and behaviors.
Source: Hitconsultant