CIRCULAT in Chronic Ischemic Heart Disease - 20 Pat, Diabetic Foot and Gene Expression
Prepared for AAHCP and constituents of the IAH Coalition ...€¦ · 250.6 diab w neurologic manif*...
Transcript of Prepared for AAHCP and constituents of the IAH Coalition ...€¦ · 250.6 diab w neurologic manif*...
Prepared for AAHCP and constituents of the IAH Coalition by Bruce Kinosian, MD Associate Professor of Medicine University of Pennsylvania
Objectives
Prepare for Independence at Home implementation
Describe the context of risk-adjusted payments
Explain relationships of ICD-9 codes to HCC groups
Demonstrate the ability of risk adjustment to accurately predict costs for IAH-eligible patients
Discuss potentially relevant requirements of PCP documentation and ICD-9 coding
• IAH retains Fee for Service payment structure
• Incorporates incentives of Capitation (“risk”) • Rewards come from reducing utilization
• Quality must be maintained
• Covers the added Interdisciplinary Team cost
• Savings will be shared by payer and providers
• Guaranteed to be less expensive than current arrangement (minimum 5% savings guarantee)
Final I.A.H. Regs. Not Public
Known Shared savings will be provided
CMS will measure what “costs would have been” to calculate savings
Risk adjustment will be involved
HCC scores are often used in this context
Risk adjustment using HCC scores accurately measures what “costs would have been”
Unknown How CMS will calculate “what costs would have been” and determine the gain sharing amount
Some adjustment is essential to payment models involving very high cost patients
One approach is prospective modeling such as we will show using HCC scores (later)
Another is matched controls – must be matched on disease burden and expected costs
You will need to understand your patients’ co-morbidities and how those relate to costs
Widely used with Medicare Advantage (MA) payments ◦ Also, used in P.A.C.E. and S.N.P.
Ensures more accurate payments to MA organizations based on health status of enrolled beneficiaries rather than demographic data
Involves funds from Part D as well as Parts A and B
Risk adjustment is based entirely on diagnosis coding, therefore: encounter data are key
Fee for Service rewards CPT coding, not ICD-9 coding ◦ Accordingly, provider diagnosis coding is often inaccurate
and/or incomplete
BBA 1997 mandated accurate payment to Medicare Advantage plans based on risk adjustment
In March 2002, CMS chose a model based on selected chronic conditions – the CMS- Hierarchical Condition Category (or CMS-HCC) payment model
BBA required initial implementation by 2004 ◦ full implementation by 2007/2008
Physician coding is the main source (90%) of diagnostic data that drives the HCC (and Rx HCC) payment models
Key diseases broadly organized by body system, using ICD-9 codes (~ 3,100)
87 disease groups (HCC), each with assigned scores, plus disease interactions
Hierarchy logic for certain disease groups ◦ Payment for most severe manifestation of a disease
when less severe manifestation is also present
◦ “Sicker” participants with more diagnoses may
trigger more HCCs
HCCs are additive HCC models are recalibrated periodically (annually)
using more recent cost data
ICD-9-CM codes (~18,000)
Qualifying codes
(~3000+)
HCCs (87)
HCC Disease Group Score 1 HIV/AIDS 0.945
2 Septicemia/Shock 0.759
5 Opportunistic Infections 0.3
7 Metastatic Cancer or Acute Leukemia 2.276
8 Lung, Upper Digestive Tract, and Other Severe Cancers 1.053
9 Lymphatic, Head and Neck, Brain, Other Major Cancers 0.794
10 Breast, Prostate, Colorectal, Other Cancers and Tumors 0.208
15
Diabetes with Renal or Peripheral Circulatory Manifestation 0.508
16 Diabetes with Neurologic or Other Specified Manifestation 0.408
17 Diabetes with Acute Complications 0.339
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Diabetes with Ophthalmologic or Unspecified Manifestation 0.259
19 Diabetes without Complication 0.162
21 Protein-Calorie Malnutrition 0.856
ICD-9 Description HCC
250.4 DIAB W RENAL MANIFEST* 15
250.40 DMII RENL NT ST UNCNTRLD 15
250.41 DMI RENL NT ST UNCNTRLD 15
250.42 DMII RENAL UNCNTRLD 15
250.43 DMI RENAL UNCNTRLD 15
250.6 DIAB W NEUROLOGIC MANIF* 16
250.7 DIABETES W CIRCULAT DIS* 15
250.60 DMII NEURO NT ST UNCNTRL 16
250.61 DMI NEURO NT ST UNCNTRLD 16
250.62 DMII NEURO UNCNTRLD 16
250.63 DMI NEURO UNCNTRLD 16
250.70 DMII CIRC NT ST UNCNTRLD 15
250.71 DMI CIRC NT ST UNCNTRLD 15
250.72 DMII CIRC UNCNTRLD 15
250.73 DMI CIRC UNCNTRLD 15
If HCC in this
column
. . .Then Drop the HCC in this
Column
15 Diabetes with Renal Manifestations 16,17,18,19
16 Diabetes with Neurologic Manifestation 17,18,19
17 Diabetes with Acute Complications 18,19
18 Diabetes with Ophthalmologic Manifestations 19
67 Quadriplegia/Other Extensive Paralysis 68,69,100,101,157
81 Acute Myocardial Infarction 82,83
82 Unstable Angina, Acute Ischemic Heart Disease 83
95 Cerebral Hemorrhage 96
100 Hemiplegia/Hemiparesis 101
104 Vascular Disease with Complications 105,149
111 Aspiration and Specified Bacterial Pneumonias 112
130 Dialysis Status 131,132
EXAMPLE: beneficiary triggers both Disease Groups 148 (Decubitus Ulcer of the Skin) and 149 (Chronic Ulcer of Skin, Except Decubitus). DG 149 will be dropped.
Current HCC models use ICD-9 diagnosis codes ◦ CMS HCC (Medicare Part C)
◦ ESRD
◦ New Enrollees
◦ Community/Long Term Institutional versions
◦ Rx HCC (Part D)
CMS-HCC and ESRD models ◦ 70 HCCs (there will be 87 HCCs in 2012)
◦ 6 disease interactions (there will be 12 in 2012)
Demographic Component (~.7 HCC points) ◦ Gender, Age, Medicaid status ◦ How person entered Medicare, disability ◦ LTI and LIS multipliers (for Part D)
Frailty Factor(~.2 points and <0.05 in 2012) ◦ Predicts Medicare expenditures for functionally
impaired not explained by CMS-HCC model ◦ Based on self-reported ADL dependency -- HOS-M
HCC Component (~1.7 points)
• Original HCC model V.12 – Recalibrated in 2007, adjusted frailty factors
– Modest reduction in some high-volume, high cost factor weights (pvd, ckd, pcm, pressure ulcer)
• For 2012, V.12 would produce average
HCC score 2.12 /Risk score 2.216
For 2012, V.21 will produce an average
HCC score 2.24/Risk score 2.282 Frailty factor average .102 for V.12; .047 for V.21
• Major drops in areas targeted for enhanced provider coding by large MA plans • Diabetes with complications • Depression • Oxygen • CKD
• With provider attention to coding, severity/cost thresholds dropped, leading to reduced factors
• Attention to accurate coding for graded conditions is important for next recalibration: CKD and Pressure Ulcers
Condition Group
Predicted/Observed $ V.12
Predicted/Observed $ V.21
Diabetes 1 1
Cognitive .858 1
Psych 1 1
CVD 1 1.002
Cardiac 1.003 1.002
Skin 1 1
Infections 1.003 1.004
Neuro 1.005 1.001
78 y.o. AA woman, Lives independently in
neighborhood for 50 years 2-story row home Bi-polar daughter lives with
her along with her 2 children (one with autism)
Recurrent utility crisis due to poor money management
Oxygen dependent Held and personally catered
annual block party Multiple cats with fleas Medicare risk score 4.6 Personal goal to survive to
80th birthday
2004 2005 2006 2007 2008 2009
COPD
COPD/ICU COPD/ICU
COPD/ICU
COPD/ICU
COPD
Start
Housecall
ED 80th birthday
491.21 COPD 518.83 Resp Fail 02 327.3 Sleep Apnea 440.2 PVD 585.3 CKD 404.11 HTN c CKD and HF 416.8 Pulmonary Htn 428.3 Diastolic CHF 427.89 SVT 358.8 Neuropathy 274.0 gout 285.29 anemia 721.9 Cervical spondylosis 295.30 Depression 366.9 cataract 530.81 GERD 389.9 Hearing loss 250.40 Diabetes wCKD 250.70 Diabetes w PVD
HCC-V.12
108 - COPD
79 – Respiratory Failure
105 -- PVD
131-- CKD
80 -- CHF
92- Arrythmia
71- Neuropathy
55 – Depression
15 – Diabetes w/ renal or vascular comp.
491.21 COPD 518.83 Resp Fail 02 327.3 Sleep Apnea 440.2 PVD 585.3 CKD 404.11 HTN c CKD and HF 416.8 Pulmonary Htn 428.3 Diastolic CHF 427.89 SVT 358.8 Neuropathy 274.0 gout 285.29 anemia 721.9 Cervical spondylosis 295.30 Depression 366.9 cataract 530.81 GERD 389.9 Hearing loss 250.40 Diabetes wCKD 250.70 Diabetes w PVD
HCC-V.12 HCC-V.21 Weight
108-COPD 111-- COPD .388
79– Resp Fail 84– Respiratory failure .326
105-- PVD 108 Vascular disease .288
131-- CKD 138– CKD stage 3 .227
80-- CHF 85 CHF .361
92-Arrythmia 96 Arrhythmia .276
71-Neuropathy 78- Polyneuropathy .281
55– Depression 58- Depression .318
15 – Diabetes w renal or vasc 18- DM w chron comp .344
DM*CHF DM* CHF .233
CHF*COPD CHF*COPD .255
CHF*Renal*DM CHF*Renal .201
Resp. failure*COPD .42
Total HCC score 3.92
Using the CMS-HCC model, county payment amounts are determined for each enrollee
Enrollees’ demographic characteristics and diagnostic information are linked to numeric scores that add to determine individual HCC risk scores
A frailty adjuster is added to the HCC risk score for community and “new” enrollees (not LTI or ESRD enrollees)
Each enrollee’s total risk score (HCC score + frailty adjuster, if applicable) is multiplied to the appropriate county payment amount to generate a monthly payment amount
23
County payment rates are the greater of ◦ prior year’s rates trended forward or
◦ average per capita fee-for-service payment amounts
Rates vary; for example in 2011/2012 ◦ Miami, FL (Dade county): $1,237.75 / $1,301.37
◦ Portland, OR (Multnomah county): $818.86 / $816.73
◦ Big Stone Gap, VA (Wise county): $769.22 / $743.23
◦ Pittsburgh, PA (Allegheny county): $820.57 / $845.21
◦ Oakland, CA (Alameda county): $940.50 / $942.70
◦ New Orleans, LA (Orleans county): $1108.66 / $1134.37
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Community Resident in 2012 -- ◦ 82 year-old woman: .517
◦ Medicaid eligible: .213
◦ CHF (HCC85): .361
◦ COPD (HCC111): .388
◦ Dementia (HCC 51): .616
◦ CHF_COPD (INT4): .255
◦ Normalization Factor: 1.051
◦ MA Coding Intensity Adjustment: 3.41%
HCC Risk Score = (.517+ .213+ .361+ .388+ .616+
.255) /1.051 = 2.236
MA Coding Intensity Adjustment: 2.236 * .9659 = 2.160
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HCC Risk Score*: 2.160
Frailty Adjuster: 0.05
County Payment Rate: $845.21
Payment = (2.160 + .05) * $845.21 = $1,867.91 per month
* After normalization and coding intensity adjustment
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Accounts for variations in beneficiaries’ Medicare
costs not explained by CMS-HCC model
Organizational-level frailty adjuster added to HCC
risk score for community-based and “new
enrollees”
Frailty adjuster based on functional impairments
reported by organization’s enrollees on Health
Outcomes Survey - Modified (HOS-M)
Currently only for PACE, mandated by ACA to
develop frailty adjustor for Special Needs Plans
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CMS recognizes only three sources from face-to-face encounters: ◦ CMS-certified hospital inpatient
◦CMS-certified hospital outpatient
◦ “Physician”
Short-term (General and Specialty) Hospitals Medical Assistance Facilities/Critical Access
Hospitals Community Mental Health Centers Federally Qualified Health Centers/Religious
Non-Medical Health Care Institutions Long-term Hospitals Rehabilitation Hospitals Children’s Hospitals Rural Health Clinics, Freestanding and Provider-
Based Psychiatric Hospitals
Clinical Psychologist Licensed Clinical Social
Worker Nurse Practitioner Occupational Therapist Optometrist Oral Surgery Physical Therapist Physician Assistant Podiatrist Medical or surgical
specialty
Audiologist Certified Clinical
Nurse Specialist Certified Nurse
Midwife Certified Registered
Nurse Anesthetist Chiropractor “Unknown” Specialty
Concurrent vs. Prospective models ◦ 5x better prediction vs. gaming and funds flow
◦ Comparing “control” patients to estimated modeled cost as a “model correction factor”
Reconciliation and lags ◦ Time frame for diagnosis codes
◦ Expenditure data come in over time
◦ Calculation of final savings depends on the time frame for data
Adjustment for “extreme cost tail”
County Rate “skewness” for “extreme cost tail”
HCC Applied and Lessons Learned
$17 $19 $24 $32
$45 $54
$71
$98
$156
$395
$16 $19 $22 $25
$42 $54
$72
$104
$163
$396
$0
$50
$100
$150
$200
$250
$300
$350
$400
$450
Average Cost ‘00
Hu
nd
red
s
Risk Adjustment Deciles
Observed Predicted
A
$22 $24
$26 $28
$31 $35
$40
$46
$56
$88
$22 $24
$26 $28
$31 $35
$40
$47
$57
$86
$0
$10
$20
$30
$40
$50
$60
$70
$80
$90
$100
Average Cost ‘000
Tho
usa
nd
s
Risk Adjustment Deciles
Observed Predicted
B
$15
$19
$24
$29
$35
$43 $46
$58
$76
$113
$22 $26
$29
$33
$38
$42
$48
$56
$68
$97
$19
$23 $26
$30
$36 $37
$43
$49
$58
$77
$0
$20
$40
$60
$80
$100
$120
Ave
rage
Co
st
Tho
usa
nd
s
Risk Adjustment Deciles (ordered by VA-HCC decile ranges with mean CMS-HCC for each decile)
Observed Predicted Post Admission Annualized
.91 1.4 1.8 2.1 2.4 2.9 3.3 3.8 4.7 6.6
2.9
IAH-eligible patients are costly, on average $35,000-$45,000 per patient per year
CMS-HCC model is useful to determine “what costs would have been”– either to determine risk, or as part of IAH shared savings formula.
IAH-eligible patients have a high degree of disease burden which the CMS-HCC model can capture if diagnostic coding is comprehensive
This site is the Risk Adjustment Medicare Advantage homepage.
http://www.cms.hhs.gov/MedicareAdvtgSpecRateStats/06_Risk_adjustment.asp ◦ Contains a number of downloadable files containing
information on HCC and RxHCC.
CSSC operations- Customer Service & Support Center
www.csscoperations.com ◦ Contains RAPS information, and PDIC (Prescription Drug
Information Center).
http://www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/icdguide08.pdf ◦ Website for Official Guidelines for Coding and Reporting,
effective October 1, 2008.
• CMS-provider contracts • Medical fund :HCC-predicted costs less CMS’ 5% • FFS payments • Interdisciplinary Team fee (pmpm) • Pooled outlier risk (7-12% of HCC premiums) • Shared savings of Medical fund balance (after
withholds for IBNR, reconciliation). • Prospective HCC initial funding, concurrent HCC for
final reconciliation • Concurrent HCC-matched controls to obtain a
“model adjustment factor” to correct for systematic over or under-prediction of the model relative to costs to ensure savings.
Avg predicted cost
Individual IAH enrollees
A C T U A L C O S T S
Higher cost outliers
Savings that offset high cost outliers
Reserve pool, held back by CMS for IBNR and reconciliation
IAH Program share
Savings pool for distribution to IAH programs
CMS share
5 % minimum savings, off the top