Value Based P4P: Risk Adjustment Methodology. Value Based P4P Webinar Series May 11, 2015
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1 Value Based P4P: Risk Adjustment Methodology Value Based P4P Webinar Series May 11, 2015
2 Value Based P4P Webinar Series Today s session is a bonus webinar in a series that digs into the Value Based P4P methodology: 101: Value Based P4P : Worksheet Review 103: Performance Gates and TCC Specifications 201: Shared Savings Calculation 202: Resource Use Measure and Specifications 203: Full Risk Organization Methodology Extra Credit: Risk Adjustment in Depth Did you miss a previous webinar? Slides and recording are now available at Integrated Healthcare Association. All rights reserved. 2
3 Risk Adjustment Accounts for illness burden of population Increasing use in health care ACA health plan premium adjustment Medicare Advantage health plan payment Pioneer and Next Generation ACO benchmarking In Value Based P4P, allows for fair comparisons on key resource use measures (1) across POs for a given point in time and (2) across time for a given PO Inpatient Bed Days (IPBD) All-Cause Readmissions (PCR) Emergency Department Visits (EDV) Total Cost of Care (TCC) 2015 Integrated Healthcare Association. All rights reserved. 3
4 Importance of Risk Adjustment Proper documentation of member risk supports more accurate measure of performance, better results Higher risk higher expected costs (or utilization) lower risk adjusted costs Observed costs Relative Risk Score Expected costs Total Cost of Care 1 (risk-adjusted, lower is better) PO A $3, $3,500 $3,500 PO B $3, $4,200 $2,917 PO C $4, $3,500 $4,200 PO D $4, $4,200 $3,500 1 TCC = Observed/Expected * Population Average 2015 Integrated Healthcare Association. All rights reserved. 4
5 Risk Adjustment Generally Statistical and actuarial models that organize and translate clinical information about members into a prediction of health care resource use (e.g. costs, bed days) Age Clinical info Gender Condition mapping Statistical model Risk Score or Predicted Utilization or Cost INPUTS Clinical info may include: Diagnoses codes Prescription fills Procedures RISK ADJUSTMENT MODEL Examples of models: HCC DCG ACG ERG OUTPUTS 2015 Integrated Healthcare Association. All rights reserved. 5
6 Risk Adjustment in Value Based P4P P4P Measure All-Cause Readmissions (PCR) Inpatient Bed Days (IPBD) Inpatient Discharges (IPU) Emergency Department Visits (EDV) Total Cost of Care (TCC) Frequency of Selected Procedures Average Length of Stay Method HCC DCG DCG DCG DCG Age and gender CMS DRG 2015 Integrated Healthcare Association. All rights reserved. 6
7 DCG used in Value Based P4P DCG developed and licensed from Verisk Healthcare. Measures run by Truven Health Analytics on data supplied by the health plans. Concurrent Uses claims and encounters for the same period as the cost or utilization being adjusted Diagnosis codes from all medical claims and encounters, except: Pharmacy claims/encounters Radiology claims/encounters Laboratory claims/encounters Two models used: IPBD, IPU, EDV Model 18 (not truncated) TCC Model 19 (truncated at $100,000, i.e. predicts costs up to $100,000) 2015 Integrated Healthcare Association. All rights reserved. 7
8 DCG Model Categorization Dx Codes ICD-9-CM codes (n = 15,000+) DxGroups (n 800) Condition Categories (CCs) (n 200) 31 hierarchies imposed for predictions Hierarchical Condition Categories (HCCs) (n 200) Each ICD-9-CM code maps to one DxGroup (clinically homogeneous). Most patients have multiple DxGroups. CCs are clinical groupings of DxGroups that are related and imply similar resource use (organized by body system or disease group) 31 hierarchies are imposed on the CCs to produce HCCs. These clinical hierarchies identify the most costly manifestation of each distinct disease Used with permission of DxCG 2015 Integrated Healthcare Association. All rights reserved. 8
9 DCG Model Categorization Dx Codes HCC hierarchy for Diabetes: An example of a hierarchy. When a patient is initially diagnosed with a condition, they may receive less severe or less specific diagnoses. As the physician learns more or the patient progresses through the disease, the Dx can get more specific. More specific means better predictive power. The higher predictive power HCC trumps the less predictive one. In other words, if you have Diabetes with Acute complications, we expect your cost to be X, regardless of whether you have another Dx of Diabetes with no/unspecified complications. HCC015 Diabetes with Renal Manifestation HCC016 Diabetes w/ Neurologic or Peripheral Circulatory Manifestation HCC017 Diabetes with Acute Complications HCC020 Type I Diabetes Mellitus If someone has both HCC 17 and 19, for example, only 17 will be used in predicting risk. HCC018 Diabetes with Ophthalmologic Manifestation HCC019 Diabetes with No or Unspecified Complications Used with permission of DxCG 2015 Integrated Healthcare Association. All rights reserved. 9
10 Risk Capture Risk scores are a function of both: Encounter/claims submission i.e., are all encounters for office visits (and other appropriate services) sent to health plan and included by health plan in ARU and TCC measure data? If encounters aren t available in the data, neither will the Dx that would have been captured in the encounters Depth of Dx coding i.e., on claims and encounters, are physician offices fully coding the member s clinical conditions? Are those codes being included in the data feeds? 2015 Integrated Healthcare Association. All rights reserved. 10
11 2013 Relative Risk Score (RRS) Risk Capture Relative risk scores are the basis for risk adjustment in the Total Cost of Care and several ARU measures. PO risk scores are strongly correlated with encounter rates (correlation of , p<0.0001). Higher risk scores reflect a sicker population and more complete diagnosis capture, resulting in higher expected utilization and in turn better performance Overall Encounter Rate (ENRSTOV) Plan-POs 2015 Integrated Healthcare Association. All rights reserved. 11
12 What you can do? Risk adjustment is only as good as underlying data Make sure the risk of your members is fully coded by providers and transmitted to health plans Ensure providers appropriately and specifically document all acute, chronic, and status conditions every year Support thorough diagnosis coding P4P uses: Up to 7 diagnosis codes on professional Up to 13 diagnosis codes on facility Confirm complete encounter and claims transmission and acceptance by health plans 2015 Integrated Healthcare Association. All rights reserved. 12
13 ARU Report - RRS Tables Available at (Measures ARU Tab RRS Information) Member Characteristics Benchmark (Population Rate) PO's Total (Across All Plans) Aetna Anthem Blue Cross Blue Shield of California Cigna HealthCare Health Net Sharp UnitedHealthcare Western Health Advantage Member Years of Enrollment Average Relative Risk Score Median Age Percent Female Benchmark (Population Rate) PO's Total (Across All Plans) Aetna Anthem Blue Cross Blue Shield of California Cigna HealthCare Health Net Sharp UnitedHealthcare Western Health Advantage Percent of Professional Claims/Encounters with Code Available Dx1 Dx2 Dx3 Dx4 Dx5 Dx6 Dx7 Benchmark (Population Rate) PO's Total (Across All Plans) Aetna Anthem Blue Cross Blue Shield of California Cigna HealthCare Health Net Sharp UnitedHealthcare Western Health Advantage Percent of Facility Claims/Encounters with Code Available Dx1 Dx2 Dx3 Dx4 Dx5 Dx6 Dx7 Dx8 Dx9 Dx10 Dx11 Dx12 Dx Integrated Healthcare Association. All rights reserved. 13
14 Questions Questions regarding P4P program and policies should be directed to 2015 Integrated Healthcare Association. All rights reserved. 14
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