Combining Risk Adjustment and HEDIS to Improve Quality of Care. Colleen Gianatasio, CPC, CPC-P, CPMA, CPC-I, CRC

Transcription

1 Combining Risk Adjustment and HEDIS to Improve Quality of Care Colleen Gianatasio, CPC, CPC-P, CPMA, CPC-I, CRC

2 Agenda Improving primary care in today s health care environment Risk adjustment basics (using HCC model) HEDIS basics Combining efforts 2

3 CPC+: The Future of Primary Care Comprehensive Primary Care Plus (CPC+) is a five-year program that will begin in January 2017 and include up to 5,000 practices and 20,000 physicians in 14 regions. The program consists of five components: Access and Continuity Care Management Patient and Caregiver Engagement Planned Care and Population Health Comprehensiveness and Coordination 3

4 CDPHP Enhanced Primary Care (EPC) In 2008, CDPHP created EPC to address local shortage in primary care medicine Departs from traditional FFS model Moves doctors to value-based payments Offers doctors opportunity for enhanced bonus money Rewards doctors for spending more time with sickest patients 4

5 Physician Engagement Engage medical providers in the overall cost of care Review quality metrics for CDPHP members Identify members with gaps in care Engage providers in use of high-cost medications where there is a lower cost alternative with equal therapeutic effectiveness Repeat messaging to providers to create new prescribing habits Provide quarterly updates on patient care and site performances 5

6 Care Health Cost 6

7 200 primary care practices 900 clinicians Enhanced Primary Care 230,000 CDPHP members $20.7 million 7

8 Risk Adjustment Overview

9 Health Care is Changing Fee for Service Risk Adjustment 9

10 What is Risk Adjustment? Risk adjustment is a form of predictive modeling that assesses the relative risk that a member will incur above or below an overall average over a defined period of time. Minimizes the incentive to select or reject enrollees based on their health status Encourages competition based on quality, efficiency, and premium stabilization Assists with the financial forecasting of future medical need 10

11 What are the Benefits? Member Provider Protects patient health Prevents unnecessary medical services Aligns accurate CMS reimbursement with utilization trends Premium stabilization Drives the development of care management strategies Achieves greater accuracy in the documentation of key quality metrics associated with valuebased payment contracts Identifies and eliminates clinical documentation concerns that could pose a compliance risk Reduces the need for disruptive chart retrieval requests 11

12 HCC: Hierarchical Condition Categories HCC 86 - Acute myocardial infarction HCC 87 - Unstable angina and other acute ischemic heart disease HCC 88 - Angina 12

13 Medicare Risk Score Calculation Hierarchy and demographics applied, disease interactions added CMS calculates risk adjustment Care is delivered to patient Care is documented and coded Risk adjustment begins at the point of care. The cycle begins in January of each year. HCC codes are submitted to CMS ICD-10 codes are submitted on claim forms Codes from claims data are converted to HCC codes 13

14 Common Pitfalls Reporting only the primary diagnosis Coding generic or unspecified codes Using rule-out diagnosis codes Coding history as current Overlooking chronic conditions related to health status 14

15 Does Your Documentation Have MEAT? Monitor signs, symptoms, disease progression, disease regression Evaluate test results, medication effectiveness, response to treatment Assess ordering tests, discussion, review records, counseling Treat medications, therapies, other modalities 15

16 Example of MEAT Monitor, Evaluate, Assess, Treat Diabetes currently controlled by diet and exercise Bipolar 1 disorder, most recent episode depressed, in full remission. Patient is stable. CHF stable on Lasix. Followed by cardiology. Morbid Obesity: Has lost 5 pounds since last month. Encouraged to continue weight loss program. Weight bearing and palpation, plus wearing of foot care, elicit the expected pain and discomfort - diabetes with peripheral vascular disease 16

17 Why is a Condition Missing? The member did not have an encounter in the calendar year. The member had an encounter, but the condition was not assessed or coded. The member had an encounter and the condition was assessed and documented, but not coded on the claim. The member no longer has the condition. The condition was previously coded erroneously. 17

18 Provider Challenges Provider Challenges 18

19 What is HEDIS? HEDIS = Healthcare Effectiveness Data and Information Set Used by more than 90% of U.S. health plans Measures performance of important dimensions of care and service Allows plan comparison NCQA (National Committee for Quality Assurance) requires HEDIS results to be audited by an external organization that NCQA licenses 19

20 Examples of HEDIS Measurements Breast Cancer Screening (BCS) Description: The percentage of women ages 50 to 74 who had a mammogram any time on or between 10/1 two years prior to the measurement year through 12/31 of the measurement year (27 months total) Cervical Cancer Screening (CCS) Description: The percentage of women ages 21 to 64 who were screened for cervical cancer using either of the following criteria: age cervical cancer screening (PAP) in measurement year or 2 years prior ( ) OR age 30-64, PAP and HPV testing performed in measurement year or 4 years prior Colorectal Cancer Screening (COL) Description: The percentage of adults 50 to 75 who had appropriate screening for colorectal cancer 20

21 HEDIS HEDIS 2016 includes 88 measures across 7 domains of care Effectiveness of Care Access/Availability of Care Experience of Care Utilization and Risk Adjusted Utilization Relative Resource Use Health Plan Descriptive Information Measures Using Electronic Clinical Data Systems 21

22 HEDIS Cycle Review Physicians need to: document order the appropriate screenings and tests submit appropriate and HEDIS-acceptable codes on claims follow up with patients and specialists for results 22

23 Denominator - How to Get into the Measure Claims from all providers Total Plan membership Denominator is made up of all members who meet measure criteria for inclusion in the measure based on claims and demographics Rx claims Age CPT ICD -10- CM Gender Denominator 23

24 Numerator: How a Patient/Member Meets the Measure Denominator (minus exclusions) Numerator As the member (or provider) meets the criteria for the measure, the member becomes part of the numerator. Information is received through claims, gap corrections, and HEDIS chases. 24

25 Exclusions: How to Get Out of the Measure Certain measures have exclusion criteria, and members who meet that criteria are removed from the denominator. Example: Women who have had a TAH can be excluded from the Cervical Cancer Screening (CCS) measure. Denominator Remove Exclusions 25

26 How is a HEDIS Score Calculated? HEDIS metric scores are a simple equation reported as a percentage: Numerator (member met measure criteria) = Score (%) Denominator (eligible population minus exclusions) For example, using the Colon Cancer Screening measure: 75 members who had a colonoscopy 100 members ages minus those with history of total colectomy/cancer Score = 75% 26

27 Investment in Quality - Victory for All Help Everyone Develop Improvement Strategies We all win and achieve the Triple Aim Health plan Accreditation, rankings, reimbursement Providers Clinical outcomes, reimbursement for quality, satisfaction Members Improved health and outcomes 27

28 Combining Efforts Maximize use of the talent and medical records for various projects across departments Eliminate duplication of efforts Reduce disruption to our provider offices Eliminate unnecessary chases Create supplemental data streams to improve ratings, rankings, and quality incentive payments Optimize the challenge of managing multiple timelines 28

29 Congestive Heart Failure Included (not all inclusive) Cardiomyopathies Pulmonary hypertension Pulmonary heart disease Myocarditis Myocardial degeneration Not Included CAD 29

30 Congestive Heart Failure Risk Adjustment Acute, chronic, or combined Systolic or diastolic Avoid defaulting to CAD if more is known HEDIS Member should receive: Persistent medication management ACE/ARB + Digoxin + diuretics Other related HEDIS measures including blood pressure management and BMI 30

31 Diabetes without Complications Included (not all inclusive) DM due to underlying condition w/o complication Drug or chemical-induced diabetes w/o complication Type 1 DM w/o complication Type 2 DM w/o complication Long-term use of insulin Not Included Other abnormal glucose 31

32 Diabetes with Complications Included (not all inclusive) Type 1 DM with complication Type 2 DM with complication DM due to underlying condition with complication Drug or chemical-induced DM with complication Not Included DM without complications 32

33 Diabetes Risk Adjustment Type 1, Type 2 Method of control Any manifestations or complications HEDIS Member should receive: eye exam kidney attention (nephropathy) A1c 33

34 Major Depressive, Bipolar, and Paranoid Disorders Included (not all inclusive) Bipolar Major depressive disorder, single episode, mild Other persistent mood disorders Suicide attempt Not Included Major depressive disorder, single episode, unspecified Generalized anxiety 34

35 Major Depressive Disorders Depression - (not otherwise specified) Typically recorded in the medical record and is default code unless further specified Coder cannot make assumption based on medications, counseling, referrals, etc. Major clinical depression, recurrent depression, or bipolar At least one of the following Depressed mood most of the day, nearly every day Diminished interest in activities At least four of the following Weight loss or gain (>5% in a month) Insomnia or hypersomnia Agitation or retardation observed by others Feelings of worthlessness or guilt Diminished ability to think or concentrate Recurrent thoughts of death, suicidal ideation, or attempt 35

36 Major Depression Severity Markers Mild: Few, if any, symptoms in excess of those required to make the diagnosis are present, the intensity of the symptoms is distressing but manageable, and the symptoms result in minor impairment in social or occupational function. Moderate: The number of symptoms, intensity of symptoms, and/or functional impairment are between those specified for mild and severe. Severe: The number of symptoms is substantially in excess of that required to make the diagnosis, the intensity of the symptoms is seriously distressing and unmanageable, and the symptoms markedly interfere with social and occupational functioning. 36

37 Depression Risk Adjustment Mild, moderate, or severe Single or recurrent Avoid defaulting to F32.9 if more is known HEDIS Members 18 years or older seen during the intake period in an OP visit, ED visit, or IP who were diagnosed with major depression and were treated with an antidepressant. Members 18 years or older who remained on an antidepressant medication for at least 180 days (6 months). 37

38 Chronic Obstructive Pulmonary Disease Included (not all inclusive) COPD unspecified Emphysema Simple chronic bronchitis Unilateral pulmonary emphysema (Macleod s Syndrome) Unspecified chronic bronchitis Not Included Asthma unspecified Bronchitis unspecified 38

39 COPD Risk Adjustment Specify acute or chronic Link medications to diagnosis HEDIS Member should receive: Pharmacotherapy management of COPD exacerbation (bronchodilators and corticosteroids) Spirometry 39

40 Steps for Success Keep lines of communication open Work gap lists on a regular basis Develop a pre-visit planning process Code what you know at the time of the encounter Consider granting remote EMR access Keep your eye on the future and stay educated! 40

41 Helpful Links: Plans/MedicareAdvtgSpecRateStats/Risk-Adjustors.html 41