Three questions with Sandeep Wadhwa, MD, MBA: Medicare Advantage in 2022—Part 1

Jan. 6, 2022 / By Sandeep Wadhwa, MD, MBA, Kelli Christman

I sat down with 3M Health Information Systems Global Chief Medical Officer Sandeep Wadhwa, MD, MBA, to discuss new benefits for Medicare Advantage enrollees and the importance of accurate and complete coding in part one.

Happy New Year! 2022 starts a new benefit year for Medicare Advantage (MA) enrollees. Can you share your thoughts on the importance of complete and accurate coding for MA members that are affiliated with a health system or provider organization?

Happy New Year! I’d be happy to. Today I’ll unpack quality of care, the first of three major domains where coding accuracy contributes to dimensions of performance. In our next conversation, I’ll tackle clinical and financial risk management, and the accurate burden of illness/risk stratification determination (read part two here).

Sounds great! Let’s get into it with quality of care and why coding accuracy matters.  

First, you may ask, why focus on health systems and MA? Two big reasons: its rapid growth and an increase in risk sharing arrangements between provider organizations and MA plans. By way of quick background, MA is a managed care option for Medicare beneficiaries. Instead of defaulting into Medicare fee for service, beneficiaries can pick an MA plan during open enrollment in the fall. The MA plan receives a monthly amount from the federal government for each enrollee from which providers are paid.

MA plans are becoming very popular. More than 40 percent of Medicare enrollees are now in an MA plan and projections are that within a decade more than 50 percent of enrollees will be in an MA plan. Only five years ago, there were a little more than 30 percent of beneficiaries in MA. Health systems are adjusting accordingly. Health systems have traditionally been well attuned to Medicare fee for services rules, payment policies and quality initiatives. Now, with an increasing share of patients under MA programs, health systems are paying more attention to the additional set of MA specifics.

Furthermore, many health systems have expanded the breadth of service offerings as well as their regional footprint. Health systems are flexing to be “one-stop shops” to meet a population’s care needs. These changes, along with more experience with value-based contracts, put health systems in much stronger positions to not only contract with payers for upside risk (largely contracting for quality of care or shared savings bonuses), but also for downside risk.

What are upside risk and downside risk?

Upside risk describes bonuses for meeting or exceeding performance targets but not penalties for missing them. Downside risk in this context means the health system or provider organization is financially liable for poorer than expected performance. With more “skin in the game” there is more opportunity for higher returns.

Success in these MA upside and downside risk arrangements demand existing and new competencies extend across clinical and financial risk management, network design, data ingestion/integration and analytics, as well as actuarial and pricing expertise.

A key asset that health systems already have, however, is coding core competency. Excellence in coding is important to providers to ensure that they have accurately documented conditions and services, which plays a critical role in receiving accurate payments for services rendered. Payers are in a position to see services and claims across multiple providers; while risk-bearing providers have ready access to the clinical documentation within their span of providers. For MA contracts, coders will be increasingly called upon to support three key priorities: clinical risk management, quality measures and severity of illness documentation.

This is a key topic for health system coding professionals that serve MA plan contracts. These plans are rated annual on a 5-star rating system, ranging from a 5-star as excellent to a 1-star as poor. There are about 30 quality measures in the five categories that are used to measure MA plan quality:

  1. Staying healthy
  2. Managing chronic conditions
  3. Member satisfaction
  4. Member complaints
  5. Customer service

These screening and care measures include breast and colon cancer screening, improving or maintaining physical and mental health, diabetes care, medication review and reconciliation, bladder, but are increasingly emphasizing care coordination measures such as transitions of care and follow-up care after an emergency room visit for members with multiple high-risk conditions.

These quality measures stem from the National Committee for Quality Assurance’s (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS) and have extensive inclusion, exclusion and case mix rules—all of which depend on complete and accurate coding. Health system and provider organization-based coding professionals must be familiar with MA stars and HEDIS measures.

A particular area of emerging focus will be on documenting CPT® category II codes. Category II codes are specific CPT codes that are focused on performance management and indicate, for example, not just a diagnosis but also value ranges for key metrics such as LDL-C<100 mg/dL or most recent diastolic blood pressure < 80mm Hg. Capturing CPT Category II codes not only simplifies HEDIS reporting but more importantly gives insights on quality of care performance.

As I mentioned, this blog looks exclusively at the quality of care arena for MA. Check out part two of this blog, where I go into detail on burden of illness and managing clinical and financial risks.

Sandeep Wadhwa, MD, MBA, is Global Chief Medical Officer at 3M Health Information Systems.

Kelli Christman is senior marketing communications and strategic communications specialist at 3M Health Information Systems.

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