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Comparing NPS for Telehealth and In-Home Assessments

Comparing NPS for Telehealth and In-Home Assessments

(Today, we are fortunate to have a guest post from Beth Graham, who is VP of Member Engagement at Matrix Medical Network. She has graciously written up a background of Net Promoter Score and pulled some data to compare in-home and telehealth NPS numbers.)

July 21, 2020

What is NPS?

Net Promoter Score (NPS) is a management tool used to measure member loyalty or affinity. Data has shown when used properly, it’s a strong predictor of future revenue and profit. 

Fred Reichheld pioneered the Net Promoter Score system in 2003. Fred Reichheld is an expert on customer loyalty and is a Harvard MBA, Bain Fellow, business strategist, author, and speaker1

NPS is widely used—in fact by two-thirds of the Fortune 1000 companies2.  It’s used across every industry from airlines to healthcare to solid waste. Traditional customer satisfaction surveys are long, have low response rates and do not provide actionable feedback.  NPS is starkly different from other customer satisfaction surveys in that it asks two simple questions:

  • Likelihood to recommend us to a friend on an 11 point scale (0-10)
  • Why did you give that score? (freeform verbatim)

The simplicity of the metric, the rich data it provides, and the results that firms see when implementing the learnings are what makes it so popular worldwide.  It’s also open source and free, which helps.

How Does it Work?

Members are sorted into three groups based on their survey response:  0 to 6 are Detractors, 7 or 8 are Neutral, and 9 or 10 are Promoters.   The math is simply the percentage of Promoters minus the percentage of Detractors.  The range is from 100 to -100.  It’s one number, and you don’t have to know how many people chose a number or take weighted averages or anything.

Matrix Medical Network has been measuring NPS for the Medicare in-home comprehensive health assessment via a paper mail in survey since 2012.  Our response rate is ~10% of completed assessments.  While our NPS has some seasonality to it, it remains in the 70s throughout the year, which is amazingly high for any industry, and high for health care.  NPS is our best way to have a pulse on our Member experience and preferences.  By fixing the key Detractor issues, we are able to improve our business.  All of our Health Plan partners are extremely focused on NPS as well because high Member satisfaction means Member retention for health plans.  According to the oft-used rubric, acquiring a new Member can cost health plans 5x more than retaining existing ones.  Thus, investing in the Member experience is a wise bet.

For context on what a good NPS looks like, it is helpful to review a cross-industry perspective.

Why does it Matter?

When we began offering telehealth services in March due to the COVID-19 pandemic, I wondered how members would score our virtual assessments.  I was interested in comparing the NPS of our virtual visit to our in-home visit results.  My hypothesis was that telehealth would score considerably lower, primarily because the experience is not as intimate as having a nurse in your home, and consequently the bond might not be as strong.  Further, there is the inability to perform some services virtually, like blood pressure and BMI (Body Mass Index).  Lastly, there is always some risk of technology challenges. 

With our telehealth members, a paper mail in survey was not practical.  We are doing a follow up phone call NPS survey for a percentage of completed visits. This is done within 48 hours of the visit to ensure an accurate recollection of the visit. Here is what we found on a sample size of 2,219 completed surveys:

NPS Scores
Telehealth video 70.4
Telehealth audio-only 62.9
All telehealth assessments 65.7

We do many more video visits than audio-only visits.  It’s remarkable that video telehealth scores are on par with in-home visits.  When we synthesized the member verbatims from the telehealth Promoters, we learned they liked their visit for the following reasons:

  • Convenience
  • Didn’t take much time
  • Helpful, face to face over technology
  • Liked being able to ask questions

Gratitude for our virtual wellness visit was a big theme from many of our members.  They have been experiencing isolation, difficulty getting medications refilled and in desperate need of COVID education.

How is the Data Actionable?

Interestingly, the top two Detractor verbatims are the same as In Home visits – I already have a doctor and I am healthy and do not need this.  The other complaint themes were Prefers an in person visit for vitals and testing and Call quality issues like interference, poor connection, and dropped calls. Matrix is investing in improving our telehealth offering, and we will be rolling out a new platform shortly.  This will minimize the technology challenges, make connecting with our Nurse Practitioners that much easier, and ensure a robust experience.  We are consistently listening to our members and refining our offering to improve the member experience.

Given that video visits perform the same as in-home, we learned that looking a member in the eye is really important to the member experience.  We always try to book a video visit first if the member has a smart phone or other device.  I am confident that health plans who receive assessments via our video telehealth platform can rest assured that the member experience will be just as strong as if we had visited the member in their own home sweet home. 

You can read more about the Net Promoter Score in the Fortune article, The simple metric that’s taking over big business.

 

1 Fred Reichheld, Wikipedia
2 Geoff Colvin, The Simple Metric that’s Taking Over Big Business, Fortune: May 18, 2020.


Have a question or want to learn more about Matrix's Telehealth offering?

Ted Kyi
SVP, Business Intelligence & Analytics at Matrix Medical Network

Ted Kyi is a leader in the Business Intelligence & Analytics group responsible for measurement and analysis of current and new products and services at Matrix.  Ted leads the healthcare analytics and data science teams, and is a subject matter expert on risk adjustment and government programs.  He has worked in healthcare analytics for over twenty years.  Prior to joining Matrix, Ted was president of the analytics vendor Ascender Software, and vice president of the consulting firm Infotech Systems Management.


Conferences and News about Making Telehealth Changes Permanent

Conferences and News about Making Telehealth Changes Permanent

Written by Ted Kyi

July 7, 2020

For those of us working on telehealth and risk adjustment, it’s been a whirlwind recently with the ATA2020, AHIP Institute, and RISE National conferences all happening.  (I also dropped in on the very cool Spark + AI Summit, but that’s a topic for a different blog.)  Let’s take a look at some of the telehealth news coming out of these conferences and from our national and state capitals.

First up, we have news from the AHIP Institute, where almost all experts are saying telehealth usage will increase over prior levels:

“Experts say there’s no going back now that hospitals and doctor’s offices are investing in the tech, payers are reimbursing for it and consumers, including traditionally tech-wary seniors, have gotten a taste.”

with some citing uncoordinated state and federal regulations as one of the challenges to volumes as high as they have been since the public health emergency waivers first took hold in March. 

We are also starting to see some specifics as to which telehealth regulations are going to become permanent. CMS proposes to continue telehealth flexibilities in its home health proposed rule. It’s nice to see in black and white, “one of the first flexibilities provided during the COVID-19 public health emergency that CMS is proposing to make a permanent part of the Medicare program,” and mHealth Intelligence reported from ATA2020 that “CMS officials have reportedly been receptive to extending more telehealth freedoms beyond the current state of emergency, and NAHC officials have said they’re thinking about expanding telehealth coverage for home healthcare.”  They also shared the remarks from Emily Yoder, an analyst in CMS’ Division of Practitioner Services, that

“CMS expects to file proposed regulatory changes for Medicare coverage of telehealth in mid-July in the Federal Register, and urged telehealth providers and advocates to be ready to comment on the proposals.”

This is consistent with the news that the Physician Fee Schedule rule will include permanent telehealth expansions.  This article summarizes the change in consumer sentiment as the driving force behind the changes:

“‘The patient trust barrier has been broken. There is no going back,’ said Brady, who serves as chief of staff to the deputy secretary and senior adviser to HHS Secretary Alex Azar. ‘Telehealth is now the preferred method. People want this as the first site of care. We are seeing a demand from consumers.’ ”

Meanwhile, in Idaho, we see the beginning of states making emergency changes permanent.  Governor Brad Little made permanent more than 150 emergency rules enacted since March to address the coronavirus pandemic, and the Idaho Statesman shares his viewpoint:

“Our loosening of health care rules since March helped to increase the use of telehealth services, made licensing easier, and strengthened the capacity of our health care workforce, all necessary to help our citizens during the global pandemic.  We proved we could do it without compromising safety. Now it’s time to make those health care advances permanent moving forward.”

And boy did telehealth usage increase, with the article citing “Due to the restrictions being lifted, there were about 117,000 telehealth visits from March to May. By comparison, there were only 3,000 telehealth visits in the same time frame of 2019.”

Expect these changes to be just the tip of the iceberg, with so many people talking about permanently making telehealth easier.  There is activity where 340 organizations plead with congress for permanent telehealth reform. If you follow the link, there are some great data points mentioned, like a 4,300% year-over-year increase in telehealth claims for March.  These are the four points the letter asks Congress to prioritize:

  1. Remove obsolete restrictions on the location of the patient
  2. Maintain and enhance the Department of Health and Human Services’ (HHS) authority to determine appropriate providers and services for telehealth
  3. Ensure Federally Qualified Health Centers and rural health clinics can furnish telehealth services after the public health emergency ends
  4. Permanently authorize HHS to issue temporary waivers during public health emergencies

This ties in with the Senate hearings demonstrating support for permanent changes to some telehealth policies as medical professionals advocated in support of maintaining and strengthening expanded telehealth-enabling provisions and a bipartisan group of 30 senators called for making telehealth expansion permanent.  Next up, the House is getting ready to debate extending CARES Act telehealth coverage indefinitely.

We expected these topics to get the early attention, but for the risk adjustment world, the applicability of diagnoses from telehealth encounters for RA is the key regulation whose fate we continue to wait to hear about.  It seems extremely unlikely CMS will expand the current regulation to allow audio-only encounters to risk adjust.  Continuing the status quo of counting HCCs from telehealth visits using video would be a welcome move.

Other telehealth resources

I wanted to take a moment to mention two additional resources, for those who work in these areas.  First is a HHS FAQ about risk adjustment for the ACA commercial market.  This document dates all the way back to April 27 (which is about a year and a half in crazy pandemic time units), but I haven’t linked it previously.  The first paragraph summarizes risk adjustment for the HHS-HCC model more succinctly and better than I ever could (emphasis is mine):

 “Any service provided through telehealth that is reimbursable under applicable state law and otherwise meets applicable risk adjustment data submission standards may be submitted to issuers’ External Gathering Data Environments (EDGE) servers for purposes of the HHS-operated risk adjustment program.  If a code submitted to an issuer’s EDGE server is descriptive of a face-to-face service furnished by a qualified healthcare professional and is an acceptable source of new diagnoses, it will be included in the risk adjustment filtering.  Telehealth visits are considered equivalent to face-to-face interactions, but are still subject to the same requirements regarding provider type and diagnostic value.”

Another great resource is guidance CMS issued on the use of telehealth encounters for eCQMs. This page links to separate documents for the 2020 and 2021 performance periods.  It’s good to see this level of detail for physicians participating in MIPS, APM, and the Medicaid Promoting Interoperability Program.


Have a question or want to learn more about Matrix's Telehealth offering?

Ted Kyi
SVP, Business Intelligence & Analytics at Matrix Medical Network

Ted Kyi is a leader in the Business Intelligence & Analytics group responsible for measurement and analysis of current and new products and services at Matrix.  Ted leads the healthcare analytics and data science teams, and is a subject matter expert on risk adjustment and government programs.  He has worked in healthcare analytics for over twenty years.  Prior to joining Matrix, Ted was president of the analytics vendor Ascender Software, and vice president of the consulting firm Infotech Systems Management.


The 5 Steps for Building Your Post-COVID Business Plan and Reopening Your Business

The 5 Steps for Building Your Post-COVID Business Plan and Reopening Your Business

Written by Daniel Castillo, MD, MBA

June 23, 2020

As employers look to operate in the environment of COVID-19, they must first plan and implement strategies to maximize the safety of their employees, their customers and their daily operations. This can be a daunting task, with the most basic question being the most difficult: “Where do I even start?”

There are five critical areas that business owners and operators should focus on related to post-COVID planning: the physical space, facility maintenance processes, employee screening, employee support and communications. Asking crucial questions about how to move forward in these areas will help prioritize. There is no right answer for everyone, nor do all of these questions apply to every business. But it you take the time to at least ask them, you’ll have a strong understand of which areas need your attention the most.

Translation: you’ll know where to start.

1. Physically adapt the workplace or business environment to social distancing

Unless your business is 100% virtual, you likely have some combination of employees, customers, suppliers and vendors gathered together.

  • How can you change the physical landscape of your business to reduce and minimize people being close and in large numbers?
  • Can you limit the number of customers in your establishment at any given time?
    • What products or services could be sold online?
    • Do you have the technical capabilities in place?
  • Can you reduce or limit the number of employees in your establishment at any given time?
    • What changes are needed to support a remote workforce in the long term?
  • Can you implement delivery or curbside pickup options?
    • For operations where this isn’t realistic, what other measures can you take?
  • How do your plans vary whether your employees are inside or outside (construction, for example)?
  • Can you restrict or prohibit visits to your place of business by anyone non-essential such as a suppliers or vendors?

2. Implement the use of new disinfection techniques and personal protective equipment (PPE)

Being proactive to mitigate the threat of viruses is key to any return strategy.

  • What is your current process for disinfecting your location and how well is it enforced?
  • What physical locations in your facility are the most likely to be problem areas?
  • How do you currently use PPE in your business and to what level?
  • How do you train on the proper use of this equipment?
  • Are you able to secure an adequate supply of what’s needed?
  • What restrictions could you consider placing on customers, suppliers and vendors who enter your facilities?

3. Institute employee screenings and testing

There has been a great deal of focus on screenings and testing as key tools to combat the spread of the virus, and appropriately so. Early on, some companies implemented temperature screenings and even though we now know that many people spreading the disease don’t have fevers, those screenings may still have a role.

  • How can your business implement either diagnostic testing (does someone currently have the disease?) and/or antibody testing (did someone previously have the disease?)?
  • What should your thresholds be for each test?
  • What should your protocol be should someone cross those thresholds?
  • What role can your insurance provider play in these decisions?

Reminder: testing is still just a tool. There is no testing protocol that can guarantee you will prevent an infected (and potentially infectious) person from entering your workplace. What it can do is help you identify a potential threat earlier so that you can reduce the chance it becomes a widespread outbreak.

4. Enhance communication and education provided to employees

This is not a time for spin or fear of “What will our employees think?” Be honest, say what you know and, yes, say what you don’t know.

  • What are the major concerns of your various constituents (employees, customers, vendors, suppliers, etc.) as they relate to your business?
  • Who (owner, senior leadership, human resources, etc.) should be your spokesperson to deliver these messages?
  • What are the various ways you can communicate with your constituents (meetings, emails, phone, website, etc.)?
  • How frequently should you communicate with each group?

5. Provide easy access to healthcare resources

Whether people are distracted, fearful of visiting a medical office or clinic, or whether those medical resources are even readily available, there has been a significant drop in healthcare provided outside of COVID-19. But people, including employees, still have the same basic healthcare needs. This need for a broad array of solutions that provide innovative targeting and engagement strategies is why we are here.

  • What are the current resources for employees to access health benefits?
  • How can you show support for employees so they feel comfortable seeking out health-related resources?
  • What role can telemedicine play for your employees?
  • Is an onsite medical staff an option for your business?
  • How can you partner with health insurance providers to communicate effectively?

 

The answers to these questions—at least the ones that apply to you and your business—will put you in position to prioritize appropriately. Doing this planning sooner rather than later will be crucial to success as your business reopens to the new normal.


Have a question or want to learn more about Matrix's COVID-19 management program?

Daniel Castillo, MD, MBA
Chief Medical Officer & Group President, Product, Quality & Innovation

As the Chief Medical Officer of Matrix Medical Network, Dr. Daniel Castillo leads a national staff of nurse practitioners, physicians and other providers delivering healthcare services to individuals in their homes, workplaces and through a fleet of mobile health clinics. Dr. Castillo is highly focused on assisting employers keep their employees safe and their critical sites operating in the wake of the COVID-19 pandemic. Having also earned his Masters of Business Administration, Dr. Castillo’s  unique understanding of both clinical and business concerns has made him a leading voice in helping companies navigate a path forward.

Dr. Castillo has a unique personal and professional perspective on COVID-19 as he treated one of the very first COVID-19 patients in Illinois and ended up contracting the disease himself. He understands firsthand the clinical challenges and personal toll of this disease and has been active in advancing solutions and approaches to keep people safe and improve their access to healthcare resources.


Telehealth Targeting Strategies

Telehealth Targeting Strategies

Written by Ted Kyi

June 23, 2020

Today, I’d like to present a survey of telehealth strategies focusing on the timing and prioritization of outreach to members for prospective telehealth visits.  These strategies will tie in with the approach taken for transitioning back to in-home assessments.  It is assumed that whether using insourced or outsourced analytics, members have already been stratified and selected for prospective assessments based on their risk adjustment gaps, quality gaps, and other care management criteria, so those decisions are not discussed here.

If we had expected to only do telehealth visits through the end of the year, never returning to in-home assessments in 2020, then the decision making would have been simple:  just offer telehealth to all targeted members.  With some areas already resuming in-home assessments, and assuming we will be performing in-home visits everywhere, at some point later this year, we now have choices about how and when we offer telehealth visits.

Here is a list of things to consider when making decisions about how to target and prioritize members for telehealth vs. in-home assessments.

Transitioning to a dual in-home and telehealth offer

One factor which can affect other decisions around prioritizing members for telehealth is the approach taken for returning to in-home visits.  Some of the below items may seem like either-or choices.  If resuming in-home visits is done in a way where members will be offered a choice of either in-home or telehealth, then these options may not be mutually exclusive.  For example, it may be beneficial to offer younger members a telehealth visit.  If resuming in-home isn’t the end of telehealth, then these younger members can be offered their choice of venue even after in-home assessments resume.  This lessens the pressure to outreach to these members earlier.

Flexible return to in-home

Similarly, if your assessment program is flexible in where and when to resume in-home visits, then there is less pressure to engage certain members early.  More flexibility, such as making in-home decisions by state and county, allows a finer grain policy and avoids all-or-nothing high stakes decisions about in-home and telehealth.

Members with current needs

Separate from their risk adjustment and quality priorities, several clients I work with are prioritizing outreach to those members who are most likely to have current needs.  This identification is often done in conjunction with the care management team based on age, health status, and previously identified SDOH factors.

Prioritize by age

Members agree to telehealth assessments differently.  One of the most notable differences we’ve seen is the variation in rates of scheduling visits by age group.  The table below shows how much more (or less, if negative) contacted MA members schedule a telehealth visit than they schedule an in-home visit, broken out by age.

Age Range Telehealth Change in Consent Rate
0 to 49 8.4%
50 to 54 2.2%
55 to 59 -1.2%
60 to 64 -4.8%
65 to 69 -7.1%
70 to 74 -11.2%
75 to 79 -16.6%
80 to 84 -22.5%
85 to 89 -25.2%
90 to 94 -26.0%

Average of two studies comparing telehealth consent rates to in-home consent rates

In-home visit consent rates increase with age, peaking in the 85 to 89 year old range.  Telehealth consent rates start higher, but consistently decrease with age.  The net effect we see in the above table is that members under 55 accept telehealth visits at a higher rate than in-home, and those over 55 accept at a lower rate, with the gap widening the higher the age.

Based on the higher consent rates for telehealth, you can see why it is advantageous to reach out to younger members while telehealth is an option.  We may not exclude older members from outreach at the same time, but we want to ensure that all of the younger members eligible for a comprehensive health assessment are offered a telehealth option.

Member who have said they don’t want someone in their home

In the Matrix contact center, the member relations team logs a disposition with each call.  When members decline a visit, they also record a decline reason.  Members aren’t always forthcoming with their reasoning, but many do share, and about 3.5% cite not wanting anyone coming to their home as the decline reason.  These members can be prioritized for telehealth outreach.  Given the inexact nature of the decline reasons, we could also more broadly prioritize telehealth engagement for members who have repeatedly declined in-home assessments.  Just like younger members, engagement may be more successful if a telehealth visit is offered before in-home.

Members harder to assess in-home

The realities of the clinician network doing the in-home visits, and the logistics of turning scheduled visits into daily routes, means that some members are easier to visit in their home and some are harder.  This is true whether you perform your own assessments or outsource them.  The factors that affect difficulty include driving distances, traffic, the density of your provider network, the days and hours clinicians are available, and sometimes weather and safety.  Completing virtual assessments earlier in the year means you don’t have to worry about these logistics for in-home assessments later.

In-person diagnostics and screenings

A few plans are also weighing which members have been identified for diagnostics and screenings.  The more optimistic your outlook is for performing in-home visits where the member lives, the less risky you would judge deprioritizing these members for telehealth visits.  Maximizing program yield requires time to run through cycles of outreach and rest.  Shortening the window for outreach puts downward pressure on the number of visits that can be completed, but can be a net win if the per visit value is increased enough.  I have discussed with several clients the risk adjustment impact of vascular disease diagnoses from PAD tests and the number of members with multiple quality gaps, so they can assess this tradeoff between expected volume and value per visit.  If the value is considered high enough, these members can exclusively be offered in-home visits until late in the year.  Typically, in the fourth quarter everyone is focused on completing as many visits as possible before the end of the year, not focusing on the per visit value.

Device lending

Another wrinkle which a few clients have discussed with me is lending devices to members so they can complete telehealth assessments.  Device lending programs have existed prior to the current pandemic, and it seems that the best candidates for this type of program may be members the plan is trying to engage in self-care.  The additional cost of device lending can pay big dividends if the result of a visit is patient activation in addition to a completed comprehensive health assessment.

Self-administered testing kits

One last telehealth option I will mention is mailing self-administered testing kits to members in conjunction with their telehealth assessment.  This idea is intriguing because it would enable closing several quality gaps with a telehealth visit.  It seems to me that the key to success of a kit mailing program is the test completion rate.  I’m planning to closely monitor test completion rates when we start mailing kits, to see how viable this option really is.

 

The intent of this overview is to give you a variety of dimensions to consider for configuring your telehealth program.  Which way to go with these choices will vary for each group or plan, depending on the scope and goals of the assessment program.  I hope this summary helps you move forward in a thoughtful way that serves both your members and your organization.

More telehealth reading:

Here are a few more telehealth articles worth giving a read.  In my last post, I shared an article with comments from Dr. Steven Green about allowing audio-only telehealth to risk adjust.  CMS has discussed this issue with plans, and they seem to be forming an extremely conservative position that would be highly restrictive.  The Better Medicare Alliance sent a response letter to CMS, making the argument:

“We believe that the ten guardrails CMS proposed in their entirety are unworkable, place an undue burden on health plans and clinicians, and detract from the focus on providing high- quality, accessible care during this period of social isolation”

Health Payer Intelligence summarizes the entire letter: MA Risk Adjustment Should Include Audio-Only Telehealth Diagnoses.

Another topic which so many of us working with telehealth are monitoring is what will happen to telehealth regulations once the public health emergency ends.  We see CMS saying some temporary telehealth provisions will become permanent.

Senate health committee Chairman Lamar Alexander (R-TN) has picked his two most important policies he thinks should be made permanent. It is exciting to see growing support for telehealth, but I’m waiting for the details to come from CMS to see whether the agency embraces the kind of progress we’re hoping for.


Have a question or want to learn more about Matrix's Telehealth offering?

Ted Kyi
SVP, Business Intelligence & Analytics at Matrix Medical Network

Ted Kyi is a leader in the Business Intelligence & Analytics group responsible for measurement and analysis of current and new products and services at Matrix.  Ted leads the healthcare analytics and data science teams, and is a subject matter expert on risk adjustment and government programs.  He has worked in healthcare analytics for over twenty years.  Prior to joining Matrix, Ted was president of the analytics vendor Ascender Software, and vice president of the consulting firm Infotech Systems Management.


Risk Adjustment from Early Telehealth Visits

Risk Adjustment from Early Telehealth Visits

Written by Ted Kyi

June 16, 2020

Because of social distancing concerns about the spread of COVID-19, and CMS’s acceptance of telehealth visits as risk adjusting encounters, most plans have started doing prospective telehealth visits.  With a couple months of experience completing prospective visits virtually, it’s natural to ask how the risk adjustment impact from telehealth visits compares to in-home visits.  I’ve been monitoring this situation, and wanted to share some early data.

First, let me say a word about some challenges to comparing diagnosing from different time periods.  The main challenge is that there is strong seasonality in the complexity of patients seen, and there can be significant variation from plan to plan or from year to year.  Below is a chart showing a high level snapshot of the seasonality in risk scores for a few sample plans:

Chart showing large month by month variability in patient complexity for four MA plans, which combined averaged over 15,000 visits per month in 2019

The overall increasing or decreasing trends and the sharp spikes both make it difficult to get a reasonable apples-to-apples comparison between any two time periods.  A simple solution to this problem is to compare charts for the same patient from this year and from last year.

A second challenge to measuring revenue management impact is that most plans use some form of net impact calculation, measuring the RAF impact from diagnoses that are unique to the prospective assessment, and not counting any conditions that come across claims from any other provider in that same calendar year, before or after the assessment.  Given that we are looking to analyze telehealth assessments from April and May, we will have only a tiny fraction of the claims run out needed to accurately measure net impact.  To address this challenge, we will use the All Lift (AL) risk score, which includes every diagnosis from the prospective assessment.  I have found that the ratio between the net impact and the AL risk score tends to stay relatively constant over time.  This means that if the AL score goes up then the net impact usually also goes up, and if the AL score goes down then the net impact usually also goes down.  By checking to see if there is any change in the AL risk score from last year to this year on same patient reassessments, we get a pretty good leading indicator whether there will be any change to the net revenue management impact.

With those preliminaries out of the way, let’s take a look at the results.  My analytics team has performed multiple reassessment analyses, and here are the results of the latest one.

Upon reviewing the data, it was immediately clear that risk scores are up overall in 2020.  I know that my organization implemented clinical guideline changes in January and early February, so we devised a way to control for that.  We started by looking to see how much telehealth diagnosis rates and risk scores from April and May reassessments changed from the prior year assessment.  Then we did the same thing for late February and early March in-home reassessments.  To control for the impact of the clinical guideline changes, we planned to subtract the increases we saw from the in-home reassessments from the increases we saw from the telehealth reassessments.  Subtracting should adjust for any underling increases in 2020 that weren’t due to telehealth.  When we pulled the data for Feb/Mar in-home and Apr/May telehealth reassessments, what we saw was they had identical percentage increases in both average AL risk scores and number of HCCs diagnosed per assessment.  Telehealth was right on parity with in-home, with both increasing over 2019 by the same amount.

In terms of individual HCCs, the top ten HCCs diagnosed were the also the same for both in-home and telehealth, although in a slightly different order:

Home Telehealth
1 HCC18 – Diabetes with Chronic Complications HCC18 – Diabetes with Chronic Complications
2 HCC108 – Vascular Disease HCC59 – Major Depressive, Bipolar, and Paranoid Disorders
3 HCC22 – Morbid Obesity HCC22 – Morbid Obesity
4 HCC111 – Chronic Obstructive Pulmonary Disease HCC19 – Diabetes without Complication
5 HCC96 – Specified Heart Arrhythmias HCC111 – Chronic Obstructive Pulmonary Disease
6 HCC59 – Major Depressive, Bipolar, and Paranoid Disorders HCC96 – Specified Heart Arrhythmias
7 HCC85 – Congestive Heart Failure HCC108 – Vascular Disease
8 HCC19 – Diabetes without Complication HCC85 – Congestive Heart Failure
9 HCC88 – Angina Pectoris HCC88 – Angina Pectoris
10 HCC40 – Rheumatoid Arthritis and Inflammatory Connective Tissue Disease HCC40 – Rheumatoid Arthritis and Inflammatory Connective Tissue Disease

Most commonly diagnosed HCCs in 2020 comprehensive health assessments

In the telehealth timeframe, HCC 59 (major depression) and HCC 19 (uncomplicated diabetes) have moved up, and HCC 108 (vascular disease) has moved down.  Note that while existing vascular disease conditions were largely being re-diagnosed in telehealth visits, no PAD diagnostic tests were being performed, eliminating that source of PAD diagnoses.

Looking at this study as well as an analysis of national payers, Medicare Advantage diagnosis rates for telehealth for major depression and uncomplicated diabetes seem to be about 1% higher than earlier 2020 in-home assessments.  On the other hand, vascular disease, morbid obesity, and congestive heart failure have decreased about 2%.

One question I’ve gotten multiple times is if there are HCCs we no longer capture in telehealth visits.  Our clinical and coding teams reviewed each of the body systems and reported that they expected decreased diagnosis rates for morbid obesity, malnutrition and chronic skin ulcers, but there were no HCCs which we diagnose in the home that would drop to zero.  This has been verified in the telehealth reassessment data.  Every single HCC category with diagnoses in 2019 also had diagnoses in 2020 telehealth assessments.

It should be noted that while the risk adjustment impact for telehealth assessments is close to that of in-home assessments, there are key limitations to the virtual encounter:

  • Most in-person diagnostic tests, such as PAD testing or spirometry, are not being performed
  • While some tests can be mailed to members, such as a FIT kit, the key metric of test completion rate remains unproven
  • Blood pressure, BMI, and other portions of the physical exam are infrequently documented
  • Environmental scans and other elements of the assessment are limited

While we are dealing with the COVID-19 pandemic, the early data shows that prospective telehealth visits are a viable alternative to prospective in home visits for overall proper documentation of each member’s disease burden.  For members who are comfortable with the virtual encounter, the risk adjustment impact is probably around 95% that of in-home assessments, and both the member and provider can safely stay in their homes.

Interesting recent articles about telehealth:

There are many articles about telehealth these days.  Here are just a couple articles I thought were worth mentioning.

Right in my backyard, in San Diego, Steven Green from Sharp Rees-Stealy commented on the need to allow audio-only telehealth visits to risk adjust.  There are several good quotes, but this is my favorite:

“The main value of having a video visit is more for the human connection and seeing their face. I agree that a video visit can help you get more of a connection to the patient while you’re talking with them,” he emphasized. “But I don’t think it contributes very much to what’s going on in their clinical care.”

You can read the full article and all of his arguments here: Audio-only Telehealth Coverage Essential During COVID-19 Outbreak.

I’m also paying attention to the Washington Post story about a Census Bureau survey about anxiety and depression, where they reported that a third of Americans are showing signs of clinical anxiety or depression.  It was nearly one half in Mississippi.  I’m interested to follow these kinds of reports, and to see if we can analyze the data from our assessments to see increases in depression diagnoses.  I invite readers to share their own experiences, or to suggest other ideas for research.


Have a question or want to learn more about Matrix's Telehealth offering?

Ted Kyi
SVP, Business Intelligence & Analytics at Matrix Medical Network

Ted Kyi is a leader in the Business Intelligence & Analytics group responsible for measurement and analysis of current and new products and services at Matrix.  Ted leads the healthcare analytics and data science teams, and is a subject matter expert on risk adjustment and government programs.  He has worked in healthcare analytics for over twenty years.  Prior to joining Matrix, Ted was president of the analytics vendor Ascender Software, and vice president of the consulting firm Infotech Systems Management.


Clarification of Coding for Medicare Advantage

Clarification of Coding for Medicare Advantage

Written by Ted Kyi

May 26, 2020

There have been a lot of questions about appropriate coding for telehealth visits.  (Full disclosure, as new information was coming out, I have offered different coding recommendations, so I may have contributed to the confusion.)  Let’s recap some of the discussion about coding telehealth visits for Medicare:

First, the March 17 FAQ about the section 1135 waiver mentioned the use of POS code “02” for all telehealth encounters.

Q: How does a qualified provider bill for telehealth services?

A: Medicare telehealth services are generally billed as if the service had been furnished in-person. For Medicare telehealth services, the claim should reflect the designated Place of Service (POS) code 02-Telehealth, to indicate the billed service was furnished as a professional telehealth service from a distant site.

Then, the April 10 memo on applicability of diagnoses from telehealth services for risk adjustment offered CPT modifier “95” as a second option:

“In order to report services to the EDS that have been provided via telehealth, use place of service code “02” for telehealth or use the CPT telehealth modifier “95” with any place of service.”

This seems to offer flexibility between using the POS code or using the CPT modifier to designate a telehealth encounter.

The latest Medicare guidance that I’ve read differentiates telehealth allowed before the pandemic from services under the waiver:

“To implement this change on an interim basis, we are instructing physicians and practitioners who bill for Medicare telehealth services to report the POS code that would have been reported had the service been furnished in person. This will allow our systems to make appropriate payment for services furnished via Medicare telehealth which, if not for the PHE for the COVID-19 pandemic, would have been furnished in person, at the same rate they would have been paid if the services were furnished in person. Given the potential importance of using telehealth services as means of minimizing exposure risks for patients, practitioners, and the community at large, we believe this interim change will maintain overall relativity under the PFS for similar services and eliminate potential financial deterrents to the clinically appropriate use of telehealth. Because we currently use the POS code on the claim to identify Medicare telehealth services, we are finalizing on an interim basis the use of the CPT telehealth modifier, modifier 95, which should be applied to claim lines that describe services furnished via telehealth. We note that we are maintaining the facility payment rate for services billed using the general telehealth POS code 02, should practitioners choose, for whatever reason, to maintain their current billing practices for Medicare telehealth during the PHE for the COVID-19 pandemic.”

(Note that CMS is referring to the Public Health Emergency as “PHE” and abbreviating the Medicare Physician Fee Schedule as “PFS.”) Based on this information, I recommend that only the telehealth services that were allowed prior to the pandemic and the section 1135 waiver should use POS “02.”  Those services always used POS “02,” and they should continue to be coded exactly the same way they used to be coded.

For Medicare services which would have taken place in person, but are now using telehealth under the section 1135 waiver, I recommend the claims use the same CPT and POS codes they would have used if they had taken place in person, with the only change being the addition of the CPT modifier “95.” I haven’t seen anything saying that POS “02” won’t be accepted on EDS submissions, so plans not coding this way do not have to change. It seems that for anyone reviewing or newly implementing coding, the CPT modifier is the safer route.


Have a question or want to learn more about Matrix's Telehealth offering?

Ted Kyi
SVP, Business Intelligence & Analytics at Matrix Medical Network

Ted Kyi is a leader in the Business Intelligence & Analytics group responsible for measurement and analysis of current and new products and services at Matrix.  Ted leads the healthcare analytics and data science teams, and is a subject matter expert on risk adjustment and government programs.  He has worked in healthcare analytics for over twenty years.  Prior to joining Matrix, Ted was president of the analytics vendor Ascender Software, and vice president of the consulting firm Infotech Systems Management.


Telehealth Risk Adjustment by Line of Business

Telehealth Risk Adjustment by Line of Business

Written by Ted Kyi

May 5, 2020

I know I have focused on Medicare Advantage in my posts here, which is a reflection of both the size of the risk adjustment market for MA, as well as the lack of clarity about risk adjustment which had surrounded MA.  Here is a recap of how telehealth visits can be used for risk adjustment by line of business:

Medicare Advantage – telehealth is allowed, requires video with audio for diagnoses to count toward risk adjustment

ACA commercial – telehealth allowed, state regulation of the practice of medicine determines allowed modalities (audio-only or video)

Medicaid – regulation delegated to the states, so also state-by-state which modalities allowed.  Note that Medicaid regulations about telehealth aren’t always the same as the regulations that govern ACA in the same state. For example, in Georgia, “standard telephone” calls do not constitute telemedicine services, but the Georgia Medicaid waiver explicitly allows telephone communication.

CMS has extended section 1135 waivers for many states, allowing them to relax rules during the public health emergency.  These waivers cover expanded use of telehealth, reduced cost sharing, as well as extending out of state license reciprocity.  Three great resources for tracking the individual state regulations on licensure and telehealth regulations are:

National Council of State Boards of Nursing (NCSBN)

Federation of State Medical Boards (FSMB)

Center for Connected Health Policy (CCHP)

You should also refer to the CMS website for the list of approved state waivers.


Have a question or want to learn more about Matrix's Telehealth offering?

Ted Kyi
SVP, Business Intelligence & Analytics at Matrix Medical Network

Ted Kyi is a leader in the Business Intelligence & Analytics group responsible for measurement and analysis of current and new products and services at Matrix.  Ted leads the healthcare analytics and data science teams, and is a subject matter expert on risk adjustment and government programs.  He has worked in healthcare analytics for over twenty years.  Prior to joining Matrix, Ted was president of the analytics vendor Ascender Software, and vice president of the consulting firm Infotech Systems Management.


Telehealth Visits Will Risk Adjust for Medicare Advantage

Telehealth Visits Will Risk Adjust for Medicare Advantage

Written by Ted Kyi

April 10, 2020

The official guidance which those of us in the risk adjustment community have been waiting for has finally arrived.  Exactly one month after the HPMS memo authorizing MA plans to expand use of telehealth, the agency has announced that diagnoses from telehealth visits will be included in risk adjustment calculations.

The requirements are that the encounter meet the usual face-to-face rules, and that the telehealth use audio and video.

CMS is stating that Medicare Advantage (MA) organizations and other organizations that submit diagnoses for risk adjusted payment are able to submit diagnoses for risk adjustment that are from telehealth visits when those visits meet all criteria for risk adjustment eligibility, which include being from an allowable inpatient, outpatient, or professional service, and from a face-to-face encounter….  Diagnoses resulting from telehealth services can meet the risk adjustment face-to-face requirement when the services are provided using an interactive audio and video telecommunications system that permits real-time interactive communication.


Have a question or want to learn more about Matrix's Telehealth offering?

Ted Kyi
SVP, Business Intelligence & Analytics at Matrix Medical Network

Ted Kyi is a leader in the Business Intelligence & Analytics group responsible for measurement and analysis of current and new products and services at Matrix.  Ted leads the healthcare analytics and data science teams, and is a subject matter expert on risk adjustment and government programs.  He has worked in healthcare analytics for over twenty years.  Prior to joining Matrix, Ted was president of the analytics vendor Ascender Software, and vice president of the consulting firm Infotech Systems Management.


MA Final Notice Silent on Risk Adjustment for Telehealth

MA Final Notice Silent on Risk Adjustment for Telehealth Visits

Written by Ted Kyi

April 6, 2020

As I suspected, the final notice for MA and Part D came out today, and it does not address whether telehealth visits will risk adjust. In the announcement, CMS is limited to finalizing regulations which were proposed in the Advanced Notices and went through public comment. For this reason, telehealth needs to be addressed separately. Guidance about telehealth may come soon, but it will be under the umbrella of the Section 1135 waiver authority of the public health emergency. Stay tuned!


Have a question or want to learn more about Matrix's Telehealth offering?

Ted Kyi
SVP, Business Intelligence & Analytics at Matrix Medical Network

Ted Kyi is a leader in the Business Intelligence & Analytics group responsible for measurement and analysis of current and new products and services at Matrix.  Ted leads the healthcare analytics and data science teams, and is a subject matter expert on risk adjustment and government programs.  He has worked in healthcare analytics for over twenty years.  Prior to joining Matrix, Ted was president of the analytics vendor Ascender Software, and vice president of the consulting firm Infotech Systems Management.


Telehealth as an Alternate Modality for Medicare

Telehealth as an Alternate Modality for Medicare

Written by Ted Kyi

March 17, 2020

Today, CMS published a fact sheet and FAQ which answered a lot of questions about the use of telehealth for Medicare beneficiaries.  I still have questions as to the degree to which these announcements pertain only to FFS Original Medicare, or also apply to Medicare Advantage.

To understand today’s documents, we have to go back to March 6, 2020 when H.R.6074 — the Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020 — was signed into law.  This act amended the section 1135 waiver authority granted to the HHS Secretary.  Secretary Azar declared a public health emergency on January 31, 2020, and as soon as the act became law, used the expanded section 1135 waiver to broaden access to telehealth services so that Medicare beneficiaries can receive a wider range of services from their doctors without having to travel to a healthcare facility.

The waiver applies to three virtual services:  Telehealth visits, Virtual check-ins, and E-visits.  In brief, these services are defined as:

  • Telehealth visits pertain to general office visit services
  • Virtual check-ins are brief communications with established patients
  • E-visits are communications with established patients via an online patient portal

Wearing my risk adjustment hat, prospective health assessments, like the Matrix Comprehensive Health Assessment, are neither brief nor patient initiated through an online patient portal, so they align with telehealth visits.

Under the telehealth visits provision, visits with a provider (which include NPs) that generally take place in-person may take place using audio and video telecommunications between a distant site and the patient at home.  The usual restrictions regarding a prior established relationship or the originating site are explicitly waived.

Additionally, providers are allowed to use everyday communications technologies, such as FaceTime or Skype, without fear of penalties for HIPAA violations.

“Effective immediately, the HHS Office for Civil Rights (OCR) will exercise enforcement discretion and waive penalties for HIPAA violations against health care providers that serve patients in good faith through everyday communications technologies, such as FaceTime or Skype, during the COVID-19 nationwide public health emergency.”

This will make a significant impact on the ease with which providers will be able to ramp up telehealth, since they will be able to use commercially available products, and not have to stand up HIPAA certified applications.

Expanded telehealth services will be allowed from March 6, 2020 through the end of the public health emergency.

Both the CMS fact sheet and FAQ are available on the CMS website.


Have a question or want to learn more about Matrix's Telehealth offering?

Ted Kyi
SVP, Business Intelligence & Analytics at Matrix Medical Network

Ted Kyi is a leader in the Business Intelligence & Analytics group responsible for measurement and analysis of current and new products and services at Matrix.  Ted leads the healthcare analytics and data science teams, and is a subject matter expert on risk adjustment and government programs.  He has worked in healthcare analytics for over twenty years.  Prior to joining Matrix, Ted was president of the analytics vendor Ascender Software, and vice president of the consulting firm Infotech Systems Management.