Rebecca Welling wants to get sick people to the doctor already

Rebecca Welling has worked in risk adjustment since the Centers for Medicare and Medicaid Services (CMS) launched a payment model based on hierarchical condition categories (HCCs) over 20 years ago. She’s risen through the ranks and now serves as VP of Risk Adjustment for Intermountain Health and Select Health, a nonprofit health system that encourages healthy behaviors in its patients and members.

Each HCC represents a chronic condition associated with higher ongoing healthcare costs. CMS compensates Affordable Care Act (ACA) and Medicare Advantage plans at higher than the normal per-capita rates for members with HCCs—adjusting the risk that plans take on by insuring sicker people. Plans have a financial incentive to identify those members and encourage them to see a physician to get their risk adjustment coding right.

It’s not easy.

And for Rebecca, it’s about much more than a regulatory obligation and a boost in reimbursement: patient outcomes are demonstrably improved with more proactive care. It’s all about healthier people leading longer, more fulfilling lives.

We love her perspective on tackling this problem and wanted to hear more.

Sounds like your entry into risk adjustment was a trial by fire. Tell us how you got here.

I have a degree in health information management, and I became a coder. Back in 2005, I worked for Providence; I did all their clinical editing and handled their payment policies. Risk adjustment was new then; my boss literally handed me a new regulation and said, “I don’t know what any of this means, but I think it will affect us financially. Can you please figure it out?”

At first, risk adjustment just applied to Medicare. We began doing retrospective reviews to ensure that the diagnosis codes that we submitted were accurate and supported in the medical record. It just grew from there. Then the ACA came on. It’s all risk-adjusted, based on the plan-level risk score.

So, you were on the job as the new rules came in. Did you notice any instances in which the law of unintended consequences took effect? That often seems to happen—perhaps especially when the rules in question govern payment.

Unfortunately, some of the largest payers have engaged in code-harvesting activities that have driven up risk scores in ways that may not reflect the disease burden of their population. I’ve been lucky that I’ve always worked for nonprofits, reporting directly to a medical director or to a head of quality assurance. I’ve gone in under the banner of, “We need to get this work done, not only for financial reasons, but also to accurately reflect our population.”

Back in 2009, we were one of the first plans to delete diagnosis codes that were not supported in the medical records—we did that even before CMS required it. Conceptually, ensuring that plans were paid appropriately for sicker patients, rather than just receiving a capitated rate, was a great idea. I’m involved with the Medicare Payment Advisory Commission and the Alliance of Community Health Plans. Those organizations are trying to rewrite the regulations in ways that will reduce waste and drive better patient care.

Obviously one challenge of applying risk adjustment in a high-turnover business is that so many members are new at any given time. How do you handle that?

We look closely at our own claims data, so we might find ourselves saying, “Hey, we’ve got this member that just filled a prescription for a hemophilic medication, and we don’t have a code showing that they’re a hemophiliac. We need to reach out to them and make sure we get them in and connected with their doctor.”

The biggest challenge in the ACA market is that we start every year knowing nothing about 40% of our members. That’s where we collaborate with Milliman IntelliScript. Your Curv Risk Adjustment model allows us to identify high-risk members early, enabling proactive outreach to connect them with primary care. Without it, we might be stuck waiting to find out what the claims show us. Obviously, we don’t get diagnosis codes, but it’s valuable to know who we need to reach and get connected with their doctor. This focus on early intervention has become essential; in 2022 and 2023, three major payers exited the Colorado market because of challenges in managing risk adjustment.

Identifying which new members are most likely to have HCCs is obviously important, but it’s only the first step. You then have to get them to in to see a primary care physician (PCP). Have you found differences between younger ACA members and older MedAdvantage members when it comes to responding to your outreach efforts?

Definitely. Reaching members and getting them to engage can vary widely by age group. My younger population is like, “Don’t call me; I’ll see you when I’m ready”—and that’s when I can even get them to answer the phone! My older population is a little bit more amenable to coming in.

I’m also reaching out to my doctors saying, “Hey, Dr. Smith, can you call Jane Doe? We think she has HIV. Can you get her in?” The physician’s attitude is often, “I don’t want to call. If she wants to see me, she’ll call herself.” Data’s a big help, but there’s more to it. You need an incentive plan in place to get patients and physicians to close these gaps.

It’s a hard problem to solve but at least knowing where to put our energy is helpful. We don’t want to spend all this time on someone who’s 30 years old and has nothing wrong with them. And it’s not even just from a risk adjustment perspective. It’s about quality of care for people who really should be seeing a doctor.

Since you enjoy hiking in Utah’s Wasatch Mountains, let’s close with a little blue-sky thinking. If you could solve any and all bureaucratic or regulatory impediments, what kind of system would you create to ensure that ACA members were accurately coded and getting optimized care?

I would love to reinvent the way new members find and interact with primary care physicians. Currently, plans have a provider tool that allows members to select a PCP, but often that PCP never knows or reaches out. Meanwhile, plans try to contact members for care but are often unsuccessful. Ideally, members would receive outreach directly from their PCP’s office, and new members with chronic conditions could be linked directly with a PCP who’s aware of their needs from day one.

Of course, current HIPAA regulations prevent this level of information sharing, but it would be great if we could sit down with new members, discuss their treatment needs, help them choose a PCP, and then pipe their information right into the doctor’s electronic medical record. Then a scheduler could book a preventive visit and the doctor could immediately see what conditions need attention.

I really believe approaches like these can help transform risk adjustment into a means of driving better health outcomes. When we get creative and innovative, we can make sure people receive not just the coverage they need but the care that can truly improve their lives.