Combining Risk Adjustment and HEDIS to Improve Quality of Care

Colleen Gianatasio, CPC, CPC-P, CPMA, CPC-I, CRC

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Agenda

• Improving primary care in today’s health care environment

• Risk adjustment basics (using HCC model)

• HEDIS basics

• Combining efforts

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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

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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

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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

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Care Health Cost

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200 primary care practices

900 clinicians

230,000 CDPHP members

$20.7 million

Enhanced Primary Care

Risk Adjustment Overview

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Health Care is Changing

Fee for Service Risk

Adjustment

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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

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What are the Benefits?

Member

• Protects patient health

• Prevents unnecessary medical services

• Aligns accurate CMS reimbursement with utilization trends

• Premium stabilization

• Drives the development of care management strategies

Provider

• Achieves greater accuracy in the documentation of key quality metrics associated with value-based payment contracts

• Identifies and eliminates clinical documentation concerns that could pose a compliance risk

• Reduces the need for disruptive chart retrieval requests

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HCC: Hierarchical Condition Categories

HCC 86 - Acute myocardial infarction

HCC 87 - Unstable angina and other acute ischemic heart disease

HCC 88 - Angina

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Medicare Risk Score Calculation

Care is delivered to

patient

Care is documented and coded

ICD-10 codes are submitted on claim forms

Codes from claims data are

converted to HCC codes

HCC codes are submitted to

CMS

Hierarchy and demographics

applied, disease

interactions added

CMS calculates risk adjustment

Risk adjustment

begins at the

point of care.

The cycle begins

in January of

each year.

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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

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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

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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

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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.

Why is a Condition Missing?

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Provider Challenges

Provider Challenges

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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

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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 21-64 cervical cancer screening (PAP) in measurement year or 2 years prior (2013-2015) 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

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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

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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

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Claims

from all

providers

Total Plan

membership

Denominator

Rx

claims

ICD

-10-

CM

CPT

Denominator

is made up of

all members

who meet

measure

criteria for

inclusion in

the measure

based on

claims and

demographics

GenderAge

Denominator - How to Get into the Measure

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Denominator

(minus

exclusions)

Numerator

Numerator: How a Patient/Member Meets

the Measure

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.

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Remove

Exclusions

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

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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 50-75 minus those with history of total colectomy/cancer

Score = 75%

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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

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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

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Congestive Heart Failure

Included (not all inclusive)

• Cardiomyopathies

• Pulmonary hypertension

• Pulmonary heart disease

• Myocarditis

• Myocardial degeneration

Not Included

• CAD

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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

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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

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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

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Diabetes

Risk Adjustment

• Type 1, Type 2

• Method of control

• Any manifestations or complications

HEDIS

• Member should receive:

– eye exam

– kidney attention (nephropathy)

– A1c

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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

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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

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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.

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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).

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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

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COPD

Risk Adjustment

• Specify acute or chronic

• Link medications to diagnosis

HEDIS

• Member should receive:

Pharmacotherapy management of COPD exacerbation (bronchodilators and corticosteroids)

Spirometry

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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!

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Helpful Links:

• https://www.aapc.com/

• https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Risk-Adjustors.html

• http://www.ncqa.org/