According to a release from Premier, a health system’s success in value-based care (VBC) models hinges on providing high-quality care at optimized costs while also enhancing the health of their population.
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It can seem like an impossible undertaking, but as Bellin Health found, successful hierarchical condition category (HCC) code capture can help turn what seems impossible into possible.
The Risk Adjustment Challenge
Bellin Health is a leader in VBC. The health system, based in Green Bay, WI, serves northeast Wisconsin and Michigan’s Upper Peninsula. Bellin’s journey to VBC began in 2012 when they participated in the Center for Medicare & Medicaid Innovation (CMMI) Pioneer Accountable Care Organization (ACO) program.
While the shift to a value-based payment model felt daunting at first, Bellin Health was confident this transition would improve their understanding of the community they serve. Their decision to step outside the box and welcome change was well worth it since in 2013 Bellin Health became the lowest-cost and highest quality ACO in the Pioneer program.
Not resting on their laurels, Bellin Health sought new ways to optimize and improve their VBC offerings. In 2016, the health system joined the Next Generation ACO to ensure that patients, especially the chronically ill, get the right care at the right time. After joining the Next Generation ACO, Bellin Health found that their risk adjustment factor (RAF) score did not accurately represent their patient population.
The RAF score looks at patient demographics and medical conditions to predict the costs of the patient’s care each year. A low RAF score may indicate a population is relatively healthy unless it’s documented poorly or incomplete. For example, a patient is expected to utilize an average amount of resources if their RAF score is 1.0. If a patient has a score above 1.0, it’s more likely they will have a higher-than-average use of healthcare services. “Our risk score with the Next Gen ACO was .86,” said Chris Elfner, Vice President of the Clinically Integrated Network at Bellin Health. “We were expecting it would be higher.” Elfner realized it was time to improve Bellin’s HCC coding initiatives.
HCC coding can make the difference between having an incomplete picture of your patients’ health or a full view of the complexity of chronic conditions. An accurate picture enables a health system to stay competitive by fully accounting for the cost of patient care. These expenses will have an impact on your benchmark, creating a level playing field for calculating ACO cost savings. With accurate HCC coding, a healthcare organization is demonstrating the value of the care they deliver and earning shared savings. It also allows Bellin to know and manage populations, not just individual patients.
How the PINC AI Stanson Solution, is Changing the Game
One key solution to improving HCC accuracy is an electronic health record (EHR) integrated tool that gives clinicians real-time HCC coding guidance utilizing information already documented on the patient’s chart, then surfacing those recommendations up in the form of an alert. Bellin Health turned to PINC AITM.
The PINC AITM HCC alerts are designed to be actionable and built to limit the provider’s administrative burden. What drew Bellin Health to this tool was its collaborative implementation approach resulting in alerts that are tailored to Bellin’s EHR system.
For example, when Bellin Health first began their HCC journey with PINC AITM Stanson, there were concerns that the alerts would become a nuisance to providers and cause alert fatigue. To get ahead of this potential problem, Bellin Health decided to approach HCC alerting in a “passive” manner by loading them in the navigator section of their EHR.
This move turned out to be unnecessary since they didn’t receive any complaints from clinicians about the alerts. “Personally, as a provider, I have not had issues,” said Dr. Shane Degen, Assistant Medical Informatics Officer and practicing physician at Bellin Health. “I haven’t heard any negative feedback in general from providers about getting these alerts.” Bellin Health ultimately reverted to using the best practice configuration, which is having the alerts fire in the cognitive workflow of the provider.
Through the PINC AI Stanson analytics platform, Bellin Health can track how often the alerts are triggered and the overall performance of the alerts. Alert data insights are then used to determine “follow” rates of the alerts which indicates improved HCC coding capture at the point of care. By making the switch from navigator to in-workflow alerts, Bellin Health’s follow rate rose from an 8 percent average follow rate to 26 percent. With this change, PINC AITM Stanson contributed to a 16 percent RAF improvement for Bellin Health’s target population as well as an 11 percent improvement for the CMS RAF score.
“I would say from a provider standpoint, one of the things that made a big difference comes back to the old story of data. Putting it on our provider dashboards that we use every day to look at our quality metrics and having where you stand compared to the benchmark which was set based on our peers and seeing that is enlightening for me,” said Dr. Degen. HCC enables healthcare leadership to monitor the performance of each physician, identify any areas that require improvement and take immediate corrective action. “So, I either need to continue doing what I'm doing and performing at the level I'm performing, or I need to change something. For me the change was incorporating HCC capture into the workflow,” said Dr. Degen.
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You might be missing out on shared savings if your healthcare organization does not have proper procedures in place for capturing HCC codes. “The PINC AITM Stanson algorithms appear to be more aligned with the clinical algorithms that our clinicians use, than the previous ones that payers have implemented,” said Elfner. “It really is all about helping to deliver better care to the populations we serve, not just getting higher reimbursement.” PINC AITM Stanson has proven methods and practical support to help healthcare organizations maximize their HCC coding opportunities.
