By Marisa Smith
As the shift to value-based care accelerates, healthcare providers are being asked to rapidly transition from a fee-for-service model toward one in which reimbursement is directly tied to health outcomes. Under such a system, providers must ensure patients are receiving all of the care they need, and especially those with chronic conditions. But managing patient populations is a challenging task — one that requires proactive outreach, engagement, and follow-ups. Although providers have implemented myriad digital tools to aid them in their practices, there is a more “analog” tool that has often been overlooked: the health risk assessment, or HRA.
HRAs can be traced all the way back to the 1940s, when Dr. Lewis Robbins began documenting patients’ health risks in an effort to prevent cervical cancer and heart disease. Unlike typical office visits, which usually focus on a specific issue (such as an ear infection), an HRA is designed to establish a holistic view of a patient’s health. HRAs and related annual wellness visits are preventive in nature and allow providers to develop personalized health plans based on a patient’s individual risk factors.
In a typical HRA, a nurse practitioner or physician’s assistant will spend between 45 minutes to an hour gathering information on health history, medications, and a patient’s overall physical and mental well-being. These visits typically take place in a patient’s home (or via telehealth during the pandemic), allowing providers to gain perspective on environmental and social determinants of health that could contribute to health outcomes, but would be unlikely to come up in a clinical setting.
HRAs can capture information that patients might forget to mention in a typical office visit, such as questions about medications. They can also uncover critical information that would not be revealed in a clinical setting. For example, this might be relevant to a patient who seems stable when walking through a clinic, but who is regularly exposed to fall risk due to poor lighting and multiple sets of stairs in their home. Like many risks that can be identified during an HRA, this could be addressed with simple, low-cost measures that can help prevent emergency interventions. This also allows the provider to follow up with ongoing services, tests, and treatments.
Barriers to Adoption
Despite their usefulness and gradual adoption among healthcare organizations, HRAs have yet to gain widespread acceptance among providers. Most are still concerned that the assessment will compete with the annual wellness visit (or AWV), which usually commands a higher fee. They worry that patients who undergo an HRA will no longer be eligible for an AWV or simply won’t want to participate in both. In truth, all AWVs can include HRAs, but not all HRAs count as an AWV. If not communicated effectively, this nuance can lead to unintended consequences for provider billing and patient copays.
Some Medicare Advantage plans conduct HRAs without involving a patient’s primary care provider. If a vendor uses the same code that the PCP uses to code the AWV, this could result in the PCPs being denied, essentially “stealing” the AWV fee from the provider. However, this can be avoided by making sure the vendor is integrated within the primary care team and that health plans choose a more appropriate code for non-PCP HRA encounters.
The Office of Inspector General (or OIG) sees a potential pitfall in the system by redirecting healthcare spending to their own accounts. A report from the same organization estimated that in 2017, in-home HRAs accounted for 80% of the $2.6 billion in Medicare Advantage payments made toward diagnoses unrelated to any clinical services. Similarly, it found that in the previous year, 20 Medicare Advantage organizations generated millions in payments from these assessments for beneficiaries who otherwise did not exist in their records.
Still, HRAs can be immensely useful to providers and patients alike. The assessments can serve as a critical first step in getting health costs under control, as they generate a plethora of insights about the kinds of ongoing services and support patients need. When acted upon in a timely manner, those insights can help prevent bigger problems in the future.
Making HRAs Work for Everyone
HRAs don’t occur any more frequently than AWVs, so they can’t overcome the challenges associated with patients who only interact with their healthcare provider once a year. Even so, half the battle for providers seeking to deliver preventive care in a value-based care model is diagnosing disease and matching patients with the programs that can help them. HRAs are an opportunity to do just that. In order to be successful, though, HRA programs should include the following components:
1. Respect the larger context of care.
The most effective way for HRAs to be used is for the HRA provider to be integrated with the primary care team. Typically, data sharing with PCPs has been an afterthought, resulting in potentially conflicting care plans and a disjointed patient experience. A successful HRA program begins and ends with the patient’s PCP. Vendors that can arm HRA providers with historical patient records; identify opportunities for patients to better leverage their benefits and the services offered by their health plan; and feed findings back to the PCP’s electronic medical records system can act as extenders beyond the support that they provide filling in documentation gaps.
2. Address the whole person.
It’s not enough to tell a patient with uncontrolled diabetes to eat healthy food — there needs to be downstream support for the patient’s efforts and underlying needs, particularly when it comes to social determinants of health surfaced in the HRA setting. Lack of social support or limited financial resources can derail even the best intended care plan. Although most HRA providers are nontreating and nonprescribing, they can take a broader view of their scope of practice to address these barriers to improved outcomes.
3. Deliver personalized education.
Raising patient awareness of health risks and driving behavior changes through counseling and coaching is a necessary component of an effective HRA program. Health education should be tailored to various cultural, literacy, demographic, and age groups and accessible to individuals with disabilities. Health plans can further augment patient knowledge by incorporating ongoing independent learning opportunities into their HRA offering via books, podcasts, mobile apps, or some other format. A robust educational component will also empower patients to take action on recommendations by ensuring they understand the control they have over their health.
4. Link to ongoing support.
Health plans must ensure assessments are valuable to both patients and providers by emphasizing ongoing support triggered by the information gathered in the HRA. When a potential health risk is uncovered, patients should be guided toward appropriate action. In some cases, that might be assistance with scheduling follow-up visits with their PCP or appropriate specialist. In others, it might mean referring patients to fitness facilities, support groups, or wellness coaches.
The best HRAs give providers and patients alike a wealth of knowledge that directly enables effective action through functions such as case-management referrals. Providers shouldn’t discount this fact. Rather, they should instead treat these assessments as a complement to the care they already give. For their part, health plans should strive to continually gain the trust of providers by playing an impactful role in driving better patient outcomes. When patients, plans, and providers work together to address patient health, everyone wins.
Marisa Smith is VP of Clinical Solutions at Episource, which provides services and products to simplify the way Medicare, Commercial, and Medicaid health plans manage their risk adjustment and quality programs. Smith is responsible for leading programs leveraging clinical data to proactively address chronic conditions and improve outcomes.
The Editorial Team at Healthcare Business Today is made up of skilled healthcare writers and experts, led by our managing editor, Daniel Casciato, who has over 25 years of experience in healthcare writing. Since 1998, we have produced compelling and informative content for numerous publications, establishing ourselves as a trusted resource for health and wellness information. We offer readers access to fresh health, medicine, science, and technology developments and the latest in patient news, emphasizing how these developments affect our lives.