2021 Q2

Clinically Integrated Network News

A primer on value-based care 
by Samuel Eby, MD, Nephrology Associates of Northern Indiana

What is a RAF and why should I care?

If your inbox looks even a little like mine, there are disquietingly frequent messages, links, references to white and gray papers, webinars, lectures etc. about value-based care. Further, I’d wager sight unseen that the first line – if not the title – has at least one acronym that is, well, unfamiliar. My goal in this CIN News feature is to begin the demystification of value-based care jargon—distilling it down to what you, the already overtaxed clinician, need to succeed in this environment.

Background

Not so long ago, doctors and hospitals provided a service, a bill was generated, submitted, and someone paid it, or at least part of it. The business mavens call this model “transactional.” The rest of us call it “fee for service.” It was the standard for decades but there were problems. Among them:

• Reimbursement was proportional to volume and to pricing.
• Hence, there was no incentive for practitioners to be efficient or consider cost.
• Inevitably, care was fragmented, often redundant and utilization and quality, if considered at all, were afterthoughts.

Then came 1965 and Medicare and Medicaid. This introduced a new player to the board—the federal and state governments. Organized medicine and hospital groups took to the media with dire predictions for the future of healthcare but, other than more red tape, nothing much changed. The reimbursement model remained modified fee for service — the modification being that prices were no longer controlled by the provider side. There were tweaks and adjustments in the Medicare and Medicaid funding formulae but for years fee for service remained the underlying paradigm.  

In the early 1980s, diagnosis related groups (a fixed amount paid for a particular diagnosis) and bundling of services for procedures began to decouple volume and reimbursement. Now the payer set the price and controlled volume, at least indirectly, as utilization review became a fixture. What was missing, reflected in part by rising healthcare costs as a percentage of the total economy, was accountability for outcomes, including patient experience. The transactional model was broken, costs were increasing, incentives remained misaligned, and outcomes (happy, healthy patients) were difficult to demonstrate, at least in a collective sense.

This set the stage for value-based care. The concept (described as transformational opposed to transactional) was to estimate what it cost to provide healthcare for a group of persons, design metrics to assess outcomes, including patient experience, and ask providers to assume some of the financial risk of caring for those individuals. The estimated cost for the group, based on demographics, divided by the number of persons in the group equals cost per person, per a given period. A percentage of that is paid to the physician as a capitation payment to provide that individual’s care. If the cost of delivering that care is lower, then the provider does better. If the cost of delivering care is higher, then not as well. The model aligns incentives for the provider and the patient — efficient and effective care. The delivery machinery for this model of reimbursement evolved into Medicare Advantage programs and increasingly into Medicare Shared Savings programs attached to accountable care organizations, where providers are paid per member per month.

Leveling the risk playing field - enter the risk adjustment factor (RAF)

If you think about it, the value-based or accountable care models are a rework of the concept of insurance at a smaller scale. A group is defined, a risk is identified, the estimated cost of that risk is divided by the number of people and paid by every member of the group. The devil, of course, is in the details. In large enough groups, individual variations in risk statistically even out. But we’re talking larger groups than all but the largest accountable care organizations. (An interesting aside is that the disparity in risk is high enough that even the government splits off extended care facility and end stage renal disease patients into their own accountable care organizations.) So, how to adjust compensation to recognize the disparity among individual patients?

The concept isn’t a new one. One of the tweaks in the Medicare reimbursement formulae that I mentioned above is called the case mix index. This is an adjustment factor for hospitals based on the severity of illnesses treated. ICD codes are linked to another layer of coding called Hierarchical Condition Categories (HCC), which in aggregate generate an adjustment applied to reimbursement. Applied to individuals, the case mix index becomes the risk adjustment factor, or RAF. Some but not all ICD diagnosis codes are mapped to Hierarchical Condition Categories, which generate a RAF score. These are added to the baseline RAF score based on patient demographics (age and gender) — the sum is the multiplier used to adjust the expected annual expenditure for that individual. The differences are, as you might expect, not trivial. For example, a 75-year-old man with no comorbidities has a baseline RAF score of 1.062, which when multiplied by the expected annual cost of care of, to make the math easy, $10,000, adjusts to $10,062. If the same patient also has COPD, acute myocardial infarction and CKD stage IV and those comorbidities are documented, an adjustment for each HCC/comorbidity is added to the baseline. The sum is 1.929 or an expected annual cost of care of $19,290. The example is deliberately dramatic but even a few tenths increase in RAF scores across an entire accountable care organization becomes a big number.

My point is not to bore you with the details but to suggest some relatively low effort ways to assure that you’re getting the credit you deserve for the work you do. We all recall the problem oriented medical record that’s been around since the 1960s and in some form or other still informs our thinking, or at least our charting. We all know that the key component of the POMR is the medical problem list. We also all know that there are considerable discrepancies in how we as individuals compile problem lists.  There are the “lumpers,” those who simplify (maybe oversimplify?) the problem list and the “splitters,” who list everything that could now or ever be considered a medical problem. The phenomenon is called “diagnostic intensity.” Peaceful coexistence between the camps (and those who fall in between) has been the rule. Now, however, we have a more than philosophical incentive to be more inclusive in listing problems. As the example above illustrates, the better we document problems, the patient care team benefits in providing less fragmented, more coordinated care but we are also given credit for the effort expended to care for more complicated patients.

I tend toward the lumper camp and, “Sounds like a pain in the, ah, neck,” is bouncing around my brain when I read what I’ve written. Here’s the easy part. We have people and we are privy to a top-of-the-line electronic medical record that makes this not exactly effortless, but seamless. If you read down the history portion of an EPIC record, you’ll find a list of prior medical problems. Further, next to some of the diagnoses on the list is an HCC code. There are individuals within the system whose job is to take what we put in the assessment and/or plan portion of our notes and convert them into HCC codes that in turn become part of the RAF score that in turn becomes a key component in the estimated cost of care for that patient.  It’s all contingent on the practitioner giving the coders what they need to do a thorough and accurate job. EPIC maintains an ongoing problem list, which requires little maintenance.

There are a couple of caveats. The more descriptive we are in our assessments (within reason) the better. For example, type II diabetes with complications maps to a different HCC code than type II diabetes withoutcomplications. Each major disease grouping (diabetes, for example) is allowed only one HCC code but there are degrees of severity within the group. Staying with diabetes, an acute diabetic complication (hyperosmolar state, foot ulcer, etc.) can’t be added to other problems attributed to diabetes — it is still diabetes with complications. The process would ideally be “sticky” with changes in the problem list, HCC codes and RAF score carrying forward and they do — sort of. As of now, the process must be refreshed annually. Things change, diseases progress, so this makes sense. The problem is, at present, there is no mechanism for identifying those codes logically not requiring restatement—prior amputations come immediately to mind.

To summarize:

• Value-based care as a payment model is here and is going to be for the foreseeable future.
• Individuals within a value-based cohort can have widely disparate problems, which affect the estimated cost of providing care to that person. The RAF score is the mechanism to account for this disparity.
• As practitioners, we drive the process by our documentation, providing the data needed to compile accurate and thorough risk adjustment factors.
• The goal is to provide coordinated, integrated care to our patients — and to be fairly compensated for the effort that takes.

Back to Top

Consider diagnoses that are pre-charted by the Clinically Integrated Network (CIN) team for your Medicare Advantage patients.

The CIN continues to do outreach to Medicare Advantage patients. The goal is to assist providers and staff by calling and scheduling patients without a visit (or scheduled visit) in 2021 and pre-chart HCC diagnoses to be considered for redocumentation. This effort is to help accurately capture the acuity of your patients.

Back to Top

The 2020 CIN outreach was a great success! COVID-19 posed challenges for patients with scheduled appointments or new, undiagnosed reasons to see their PCP, affecting volumes and leading to the possibility of not achieving our value-based care (VBC) contract thresholds. This scenario presented an opportunity for the CIN to assist not only patients, but also providers, while at the same time increasing performance with our value-based payers. 

In short, the CIN team began reaching out to patients who had not been seen in 2020, nor were scheduled later in the year. Those patients were scheduled and the HCC diagnoses from the prior year were pre-charted to be considered for redocumentation. 

We are pleased to report, although the numbers are not quite final for 2020, we have met our VBC contract goals with an average of 83% of VBC patients having completed PCP office visits, making Parkview eligible for shared savings. This success would not have been possible without the willingness of providers and office staff to allow the CIN to support them and we’d like to express our appreciation. We look forward to continuing to support you throughout 2021, as we expand our efforts to include additional VBC payers, as well as Ohio providers.

Back to Top

Thank you to Dr. David Reinhard and Elia Hoekstra, PA, for speaking to the importance of diabetic eye exams for patients and the use of the established PPG workflow to obtain and properly document results during our January Collaborative Learning Session (CLS).  

Thank you Tink Nikirk on Dr. Paul Kaplanis’ team for discussing some fun tips and tricks they use in their office to get patients better engaged in their care during our March CLS.

Dr. Paul Rexroth and his care team work diligently to consistently follow workflows that encourage care gap completion for their patients. Their efforts are reflected in an overall CIN score above 60% throughout the past year. 

Back to Top

Primary Care: What should we do with the HCC diagnoses information that has been added by the CIN team?

When the care team sees “CIN Outreach: HCC/RAF visit diagnosis added” to the appointment notes, this means that the CIN Outcomes team has pre-charted on diagnoses that had been charted on the year prior. This information is added to the visit diagnosis section when pre-charting. The ask is for providers to review these diagnoses and determine whether they are still applicable.

If the provider DOES NOT agree, then the condition can be removed from the visit diagnosis section.  

If the provider DOES agree, it should remain in the visit diagnosis section and the care team should input supporting documentation that the condition was re-addressed. 

Can “.follow” be used in telephone and documentation encounters to obtain diabetic eye exams?

As of Mar. 1, 2021, “.follow” used in a telephone or documentation encounter will be sent to the CIN Outcomes team to obtain diabetic eye exams.

Back to Top

In 2020, the CIN team reconstructed its site on Pulse, Parkview Health’s intranet, with the intent of housing a number of documents that care teams and providers may find helpful. Here is a summary of what you can find:

• Specialty-specific documentation guides
• Quick guides
• Primary Care appeals guide 
• Meet our Team
• Collaborative Learning Session information
• Newsletter archive
• Value Report archive
• Community resources
• Contact information

Please note if you are an independent group outside of Parkview Health, you will be unable to access this information. Your Provider Relations Specialist is happy to provide you with any requested materials. 

Back to Top

If you have questions or suggestions about measures, appeals, scorecards or other CIN tools, please contact your provider relations specialist. You may also contact Katrina Koehler, RN, CIN supervisor, at 260-266-6530 or Katrina.Koehler@parkview.com.

If you would like to join or have general questions about Parkview Care Partners, please contact Nicole Krouse, CIN director, at 260-266-3709 or Nicole.Krouse@parkview.com.

Back to Top