The Financial Impact of ICD-10: Don t Let Risk Adjustment Be An Afterthought November 18, 2014

Transcription

1 1 The Financial Impact f ICD-10: Dn t Let Risk Adjustment Be An Afterthught Nvember 18, 2014 Presented by: Kim Brwning, CHRS, PMP, CHC Executive Vice President, Cgnisight LLC

2 Tday s Agenda 2 Why This Matters ICD Heat Map Analysis Prvider Engagement Sample Spreadsheets Lessns Learned Early Indicatins f HIX Getting Started With Yur Analysis Questins

3 Why This Matters Fr a plan r rganizatin Many items relate directly t dllars and prfitability If yu re nt practive, by the time yu realize there s a prblem, it ll be t late 3

4 ICD-10 Heat Map Analysis 4 ICD-9 t ICD-10 ICD-9 mapping t ICD-10 19% 2% 79% ICD-9 cdes that map directly t ne ICD-10 ICD-9 cdes that map t multiple ICD- 10 ICD-9 cdes that map t n ICD10 ICD-10 based n ICD-9 histry ICD-10 cunt based n ICD-9 histry 77% 23% ICD-10 cdes that may map t HCC ICD-10 cdes that may nt map t current HCC mdel

5 Tp 20 HCCs Tp 20 HCCs: 3 data cuts with highest Vlume f members RAF weight Ttal RAF value Yu ll need t react t all 3 in rder t maximize results 5

6 Highest Vlume f Members 6 68% HCC Descriptin Members HCC Factr Value Ttal RAF Weight % f ttal Tp 20 Chrnic Obstructive Pulmnary Disease % 1 Majr Depressive, Biplar, and Paranid Disrders % 2 Diabetes with Chrnic Cmplicatins % 3 Vascular Disease % 4 Cngestive Heart Failure % 5 Diabetes withut Cmplicatin % 6 Specified Heart Arrhythmias % 7 Metastatic Cancer and Acute Leukemia % 8 Schizphrenia % 9 Mrbid Obesity % 10 Acute Renal Failure % 11 Rheumatid Arthritis and Inflammatry Cnnective Tissue Disease % 12 Chrnic Ulcer f Skin, Except Pressure % 13 Seizure Disrders and Cnvulsins % 14 Lung and Other Severe Cancers % 15 Prtein-Calrie Malnutritin % 16 Septicemia, Sepsis, Systemic Inflammatry Respnse Syndrme/Shck % 17 Drug/Alchl Dependence % 18 Cardi-Respiratry Failure and Shck % 19 Ischemic r Unspecified Strke % 20

7 Highest RAF Weight 7 20% HCC HCC Descriptin Members HCC Factr Value Ttal RAF Weight % f ttal Tp Pressure Ulcer f Skin with Necrsis Thrugh t Muscle, Tendn, r Bne % 1 8 Metastatic Cancer and Acute Leukemia % 2 82 Respiratr Dependence/Trachestmy Status % Athersclersis f the Extremities with Ulceratin r Gangrene % Pressure Ulcer f Skin with Full Thickness Skin Lss % 5 70 Quadriplegia % 6 46 Severe Hematlgical Disrders % 7 71 Paraplegia % 8 9 Lung and Other Severe Cancers % 9 73 Amytrphic Lateral Sclersis and Other Mtr Neurn Disease % End-Stage Liver Disease % Majr Organ Transplant r Replacement Status % Respiratry Arrest % Amputatin Status, Lwer Limb/Amputatin Cmplicatins % Prtein-Calrie Malnutritin % Parkinsn's and Huntingtn's Diseases % Aspiratin and Specified Bacterial Pneumnias % Lymphma and Other Cancers % Artificial Openings fr Feeding r Eliminatin % Hemiplegia/Hemiparesis % 20

8 Highest Ttal RAF Value 8 68% HCC Descriptin Members HCC Factr Value Ttal RAF Weight % f ttal Tp 20 Chrnic Obstructive Pulmnary Disease % 1 Majr Depressive, Biplar, and Paranid Disrders % 2 Diabetes with Chrnic Cmplicatins % 3 Vascular Disease % 4 Cngestive Heart Failure % 5 Diabetes withut Cmplicatin % 6 Specified Heart Arrhythmias % 7 Metastatic Cancer and Acute Leukemia % 8 Schizphrenia % 9 Mrbid Obesity % 10 Acute Renal Failure % 11 Rheumatid Arthritis and Inflammatry Cnnective Tissue Disease % 12 Chrnic Ulcer f Skin, Except Pressure % 13 Seizure Disrders and Cnvulsins % 14 Lung and Other Severe Cancers % 15 Prtein-Calrie Malnutritin % 16 Septicemia, Sepsis, Systemic Inflammatry Respnse Syndrme/Shck % 17 Drug/Alchl Dependence % 18 Cardi-Respiratry Failure and Shck % 19 Ischemic r Unspecified Strke % 20

9 HCCs in Multiple Tp 20 Categries 9 HCC HCC Descriptin Members Weight Ttal RAF Highest Vlume f Members RAF Weight Ttal RAF Value 8 Metastatic Cancer and Acute Leukemia Specified Heart Arrhythmias Diabetes with Chrnic Cmplicatins Diabetes withut Cmplicatin Chrnic Obstructive Pulmnary Disease Cngestive Heart Failure Rheumatid Arthritis and Inflammatry Cnnective Tissue Disease Vascular Disease Majr Depressive, Biplar, and Paranid Disrders Lung and Other Severe Cancers Breast, Prstate, and Other Cancers and Tumrs Lymphma and Other Cancers Parkinsn's and Huntingtn's Diseases Mrbid Obesity Acute Renal Failure Cagulatin Defects and Other Specified Hematlgical Disrders

10 Nw What? We have identified the Tp 20 HCCs in all 3 categries with highest Vlume f members: 68% RAF weight: 20% Ttal RAF value: 68% Nw what? 10

11 Prvider Engagement T be successful, prvider engagement is missin critical 11 If prviders aren t dcumenting prperly yu ll lse tractin with yur clinical prfiling and crrespnding reimbursement Yu ll want t develp a spreadsheet t lk at the Tp 20 prvider grups fr each f yur data cut categries and drill dwn t the actual prvider when available We encurage plans t cnduct utreach t yur impacted prviders Let s first lk at an example f impacted prviders and then talk abut next steps

12 Grup Name Ttal HCC Value Ttal HCC Value Rank 12 Tp 20 HCC Value Grups with Tp 20 Highest RAF Value Tp 20 HCC Value Rank Ttal Distinct RAF Weight Ttal Distinct RAF Weight Rank Patients with HCCs University Prfessinal Services OSNU Hspitals and Clinics Preferred Medical Grup St Christpher s Medical Center SR Reginal Medical Center Lc. A Cmpass Onclgy St Nichlas Medical Center Vectr Memrial Clinic Preferred Place Medical Center Oneida Medical Grup Sacred Heart Physicians Meridian Park Hspital Suth Hspital Suth Health Services The Orange Clinic Red Valley Medical Center The Cmet Clinic S Hspital Radilgy Assciates Sacred Medical Center Patients with HCCs Rank

13 13 Prviders with Tp 20 Highest RAF Value Prvider ID Physician Grup Name Ttal HCC Value Ttal HCC Value Rank Tp 20 HCC Value Tp 20 HCC Value Rank Ttal Distinct RAF Ttal Distinct RAF Rank Patients with HCCs Patients with HCCs Rank xx43563 Smith, William OHNU Hspitals and Clinics xx43435 Gerge, Jean- Paul St Nichlas Medical Center xx43428 Preferred Medical Center xx43475 Suth Hspital xx43485 St Christpher s Medical Center xx43441 Hughes, Jeanette SR Reginal Medical Center Lc. A xx45719 Williams, Peter Suth Medical Center xx43419 S Hspital xx43191 Cnnr, Timthy PeaceHealth xx43487 Meridian Hspital xx36804 Legacy Labratry Services xx3414 Ridge Valley Medical Center xx51721 Mercy Medical Center xx43273 SR Medical Center xx37468 Clark, Charlene Gd Samaritan Reginal Medical Center Lc. C xx43469 Lake Medical Center xx43504 Peace Hme Services xx43461 Twnship Cmmunity Hspital xx43412 XYZ General Hspital xx43468 Grande Hspital

14 Develp a spreadsheet that Ties HCCs t diagnses, then Ties t prvider, the Maps frm ICD-9 t ICD-10 Tying t Prvider & 9-10 Mapping 14 1 t 1 1 t many Naked 9s Cannt cde frm mapping tls

15 Prvider Engagement Next Steps Cnduct webinars fr prviders with an emphasis n PCPs Cardilgists Neurlgists Nephrlgists 15

16 Lessns Learned Start nw better late than never Keep HCC infrmatin fr prviders brief just what they need t knw t imprve Data is in many places; be familiar with all f yur databases data can be anywhere! Success with queries 16

17 Lessns Learned, cnt d 17 Success with queries

18 Early Indicatins fr HIX 18

19 Early Indicatins fr HIX, cnt d 19

20 Early Indicatins fr HIX, cnt d 20

21 Early Indicatins fr HIX, cnt d 21

22 Getting Started With Yur Analysis: Medicare Advantage T Determine Tp 20 HCCs based n prevalence and weight 22 Current weights fr mdel 12 can be fund in 2013 Annuncement Plans/MedicareAdvtgSpecRateStats/Annuncements-and-Dcuments- Items/2013Annuncement.html?DLPage=1&DLSrt=2&DLSrtDir=desc ending Current weights fr mdel 22 can be fund in 2014 Annuncement Plans/MedicareAdvtgSpecRateStats/Annuncements-and-Dcuments- Items/2014Annuncement.html?DLPage=1&DLSrt=2&DLSrtDir=desc ending

23 Getting Started With Yur Analysis: Medicare Advantage, cnt d Find the number f members with each HCC frm the Part C Risk Adjustment Mdel Output Data (MODD) r Part C Risk Adjustment Mdel Output Reprt (MODR) Mdel Output Data file layut is cntained in the Plan Cmmunicatin User Guide (PCUG) Appendices 23 Infrmatin- Technlgy/mapdhelpdesk/Plan_Cmmunicatins_User_Guide.html Screenshts n next 2 pages

24 Yu need yur Mdel Output Data (MODD) Screensht: Getting Started With Yur Analysis: Medicare Advantage, cnt d 24 Recmmendatin Cnvert t Excel and label clumns Fastest way t get t prevalence

25 Yu als need yur Part C Risk Adjustment Mdel Output Reprt (MODR) Screensht: Getting Started With Yur Analysis: Medicare Advantage, cnt d 25 Participant 1 HCCs Participant 2

26 26 Find the number f members with each ICD-9 (HCC) frm Edge Server respnse files Pull RAF weights frm Getting Started With Yur Analysis: Health Insurance Exchange Fr ease, yu may want t default t the silver metal level and adult HCC mdel, unless in pediatric medicine

27 Getting Started With Yur Analysis: Health Insurance Exchange, cnt d Multiple ways t tie claims t prviders Pages

28 Questins 28 Thank yu! If yu have questins, please feel free t cntact me at: (e) kbrwning@cgnisight.cm (p)