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Is Telehealth on Par with In-Person Risk Adjustment Assessments?


Evaluating patients to determine their risk scores for Medicare Advantage payments traditionally involves face-to-face encounters, either in the physician’s office or increasingly in patients’ homes. The opportunity to sit down with patients, create a human connection, confirm existing chronic conditions and uncover any new health issues is considered an industry best practice.

Or at least it was until COVID-19 became a pandemic.

Ted Kyi

Ted Kyi

Just like that, primary care physician offices were limiting or stopping entirely all but COVID-19-related care, and health payers were telling clinicians not to conduct risk adjustment assessments in patient/member homes, to prevent the spread of the virus to other patients/members and to the clinicians themselves.

Of course the advent of a global pandemic did not mean treatment for all those other chronic conditions could be put on hold until it passed. Patients still needed care, and healthcare organizations needed to be reimbursed for that care, which means they still needed to have their risk score house in order. What to do?

The obvious answer to these competing priorities appeared to be telehealth, specifically

audio-video visits over the Internet. The question, however, was how effective these visits would be compared to traditional in-home visits?

We now have an answer. In comparing our own telehealth diagnosis rates and risk scores from April and May 2020 reassessments to metrics for the same members seen in 2019 when we were doing in-home assessments, we saw that there was no difference (adjusted for some clinical guideline changes). The same was true when comparing in-home reassessments in late February and early March 2020 versus same member in-home assessments from 2019.

Telehealth on par with in-home visits

When we compared the data, both the 2020 in-home and telehealth time periods had identical percentage increases in both average all lift (AL) risk scores (every diagnosis from the prospective assessment) and the number of Hierarchical Condition Codes (HCCs) diagnosed per assessment. In other words, overall telehealth was just as effective as in-home visits in capturing risk.

This parity was further demonstrated by the fact that the top ten HCCs diagnosed in these reassessments were the same for both in-home and telehealth. There was a small difference, however, in the order of how common each of them was.

For example, in the in-home visits, HCC108 Vascular Disease was the second most common diagnosis during in-home visits while it fell to seventh in telehealth. This likely was due to the inability to perform peripheral artery disease diagnostic (PAD) tests via telehealth, eliminating that source of PAD diagnoses.

On the other side, HCC59 Major Depressive, Bipolar, and Paranoid Disorders was the second most commonly diagnosed condition through telehealth, while only ranking sixth during in-home visits. Additionally, HCC19 Diabetes without Complication was the fourth highest condition documented through telehealth, while only being eighth in in-home reassessments.

Given issues such as PAD tests for vascular disease requiring an in person presence, some have asked whether there are HCCs that simply cannot be captured via telehealth assessments. The short answer is no. While telehealth does have some limitations in terms of the types of testing that can be performed, every HCC that was captured during in-home visits in 2019 also appeared, usually with similar volumes, in 2020 telehealth results.

Comparing Net Promoter Scores

We also recently compared the Net Promoter Scores (NPS) of virtual visits to in-home visits.

We conducted follow up phone calls within 48 hours of the telehealth appointment to ensure an accurate recollection of the visit. On a sample size of 2,219 completed surveys we found that video telehealth net promoter scores are on par with in-home visits at 70%. Gratitude for virtual wellness visits was a big theme from members. Many have been experiencing isolation, difficulty getting medications refilled, and the need for COVID education.

As we learn more, we may discover that offering patients/members a choice between in-home and telehealth visits enables us to increase assessment completion rates by matching the delivery mechanism to their comfort level – while remaining confident that the assessments using either modality provide a great patient experience and accurately capture the information needed for proper risk adjustment.

Ted Kyi is senior vice president of business Intelligence and analytics for Matrix Medical Network, a clinical services organization in Scottsdale, Arizona, that focuses on high-risk members.

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