Consulting and Management
Clinovations
Optimizing Your EHR to Engage
Providers in HCC Capture
MGMA National Conference
Nashville, TN
2
Learning Objectives
This session will provide you with the knowledge to:
•
Discuss optimization solutions for your existing EHR system to
automate and streamline HCC code documentation
•
Examine potential annual net revenue opportunities after
implementing an optimization strategy
•
Discuss workflow strategies to engage clinicians and set your
practice up for success
©2015 The Advisory Board Company • advisory.com
3
Introductions
John Trudel, MD
Dr. Trudel is a Assistant Medical Director for Informatics, Medical Director for Risk Revenue, and a
primary care physician employed at Reliant Medical Group (FKA Fallon Clinic), a multi-specialty group
practice in central Massachusetts. He graduated from Holy Cross College in 1984, Albany Medical
School in 1988 and completed his Family Practice residency 1991 at the Charleston Naval Hospital.
After military service, he joined Reliant Medical Group in 1993. In 2006, Reliant began implementation of
the Epic EMR and Dr. Trudel became involved in informatics, initially on the selection team then with
implementation and support. Over the last several years he has become certified in many aspects of the
Epic product, including Chronicles Programming and Epic Ambulatory. He enjoys creating and designing
new tools and systems in Epic, including cache programming. He has made significant contributions to
his organization winning the 2011 HIMSS Davies Award and achieving HIMMS Stage 7 in 2013. He was
named "Innovator of the Year" by Reliant and "Top 25 Informaticist" by Modern Healthcare magazine in
2012.
Steve Strode, MS
Mr. Strode is a Senior Vice President who leads the ambulatory sector and co-leads the Optimization
Service Line at The Advisory Board, Consulting & Management. Mr. Strode brings more than 23 years
of health administration and management consulting experience to the Clinovations team. His expertise
is focused in the areas of practice management, outpatient strategy and operations, system
implementation and optimization, revenue cycle redesign, and mergers and acquisitions. Prior to
joining, he served as the Vice President of Ambulatory Services for Rockford Health System in
Rockford, IL. Earlier in his career, he served as a Senior Manager in the healthcare consulting practice
of Deloitte Consulting, LLP and as an Administrator at Henry Ford Health System (Detroit, MI). He
received his Master of Science in Health Systems Management from Rush University and holds a
Bachelor of Science from the University of Iowa
©2015 The Advisory Board Company • advisory.com
4
The Growing Allure of Medicare Advantage
Outlook for Medicare Advantage
Ever-Rising
Enrollment
Increasing Share of
Medicare Population
Faster Growing
Payments (vs other Plans’)
22M
15M
2014
2022
3x
1.25%
Enrollment tripled
since 2004
Average increase vs
benchmark payments
in 2016
Projected
Source: “CMS proposes 2016 payment and policy updates for Medicare Health and Drug Plans,” The
Centers for Medicare and Medicaid Services , available at http://www.cms.gov/; “Medicare Advantage:
Take Another Look,” Tricia Neuman and Gretchen Jacobson, available at: http://www.kff.org; “CMS
pitches 1.1% boost to Medicare Advantage payment,” Bob Herman, available at:
http://www.modernhealthcare.com
©2015 The Advisory Board Company • advisory.com
5
The CMS Model
A Premium on Managing Patient Details
Background on Hierarchical Condition Categories (HCC)
• Risk adjustment model implemented by CMS beginning in 2004
• Allocates appropriate reimbursement for patient complexity by condition category, or HCC
• Only direct patient care activities related to HCC-related diagnosis in a particular timeframe are
used to adjust the following year’s PMPM
Provider
MA Plan
CMS
Captures ICD diagnosis
codes from patient treatment
Maps relevant ICD codes to one of 70+
HCC values for each patient
Includes supporting
documentation for HCCrelated diagnoses
Follows a multistep process to submit risk
adjustments to the MA contractor and CMS
Submits codes and claims to
medical plan
Health Status
(HCCs)
Demography,
Geography
Makes adjustments
(normalization) and
calculates new
PMPM payment
Other Factors
Entitlement
Reason
Risk Score for
Each Patient
Pays some portion of delegated risk or
FFS + incentive based sum to contracted
providers
Begins paying plan
based on new
payment
©2015 The Advisory Board Company • advisory.com
6
Four Prevailing Implications for Owners of Risk
Feature of Payment Scheme
1
Implications
Capped
Pay
Regular, pre-determined payment
amounts are not based on services
rendered
Pressure to accurately account for (if not
manage) cost burden of covered population;
margin must be managed against an established
revenue ceiling
Severity
Adjustment
Payment amounts reflect the type and
severity of diseases that are being
actively managed among beneficiaries
Pressure to appropriately document care;
improvements to patient identification, evaluation,
and documentation specificity inflect care quality
and reimbursement
Primary Care
Focus
Payment amounts reflect care that is
delivered and documented as primary
care
Pressure to further enable primary care
providers; decision support tools, performance
transparency, and incentive alignment all are
required to optimize performance
Annual
Reset
Payment amounts adjusted based on
complexity of provider’s managed
population vs. benchmarks and trends
Pressure to consistently and aggressively
manage trend; consistent, systematic efforts to
reduce documentation errors and omissions
needed to deliver steady financial outcomes
2
3
4
©2015 The Advisory Board Company • advisory.com
7
A System of Many Parts…and Failure Points
Sample Root Causes
Possible Points of Failure
Obstacles at Every Turn
Pre-Encounter
Pre-Encounter
Point of Care
Member with HCCrelated diagnosis
does not visit
provider
!
!
!
!
Post Encounter
Provider does not
appropriately document
condition
Coding and/or
Billing process
breaks down
HCCs not submitted
to CMS / HHS
Inadequate provider education and engagement
Lack of patient activation
Patient is new to Medicare/MA and does not yet have provider
Patient has difficulty scheduling an appointment
!
!
!
Provider not aware of care and diagnosis gaps; no easy access to relevant history
Provider not aware of minimum documentation standard
Physician incentives not aligned and/or tracked
!
!
!
Coding error
Limitations on number of diagnosis fields
Backlog in A/R prior to submission deadlines
!
!
!
Data warehouse limitations
Data lifecycle
Edge server/submission errors
©2015 The Advisory Board Company • advisory.com
8
Inconsistent / Incomplete Documentation
Patient Background
•
•
•
•
Past Medical History
85 year old white female, urinary tract
infection (UTI) symptoms
Patient is tired, less energy, and poor
appetite; has mild malnutrition
Urinalysis performed shows white cells,
leukocyte esterase, and microalbuminuria
She reports some mild claudication
Stable diabetes mellitus (DM); chronic
kidney disease (CKD) exacerbated by
diabetes; stable left great toe
amputation due to non healing ulcer;
UTI w/ serum GFR 29, 6 months ago
lab findings revealed CKD stage 4 but
it hasn’t changed on repeat today
Plan
Billing Scenario 1
•
•
•
•
•
•
•
•
Diabetes Mellitus
UTI
Glipizide 5 mg b.i.d. for DM
Cipro for UTI
Ensure supplements for malnutrition
Return to clinic (RTC) in 3 months
Referral to nephrologist for CKD4
Walking program for claudication
Billing Scenario 2
•
•
•
•
•
•
Diabetes Mellitus
UTI
CKD Stage 4 due to
Diabetes
Mild Degree Malnutrition
H/O Toe Amputation
PVD due to Diabetes
Modified from original industry example:
http://www.anthem.com/ca/shared/f2/s2/t4/pw_e181334.pdf
©2015 The Advisory Board Company • advisory.com
9
Revenue Impact Due to Inconsistencies
Billing Scenario 1
• Diabetes Mellitus
• UTI
Condition
Diabetes Mellitus
CMS
Risk
Score
Demographic
Score
0.677
UTI
Billing Scenario 2
Condition
•
•
•
•
•
•
Diabetes Mellitus
UTI
CKD Stage 4 due to
Diabetes
Mild Degree Malnutrition
H/O Toe Amputation
PVD due to Diabetes
1) $800 per member / per month (illustrative purposes) X RAF score
©2015 The Advisory Board Company • advisory.com
Diabetes Mellitus
UTI
Total RAF Score
PMPM Payment1
0.118
0.795
$636
0.0
CMS
Risk
Score
Demographic
Score
Total RAF Score
PMPM Payment1
-0.0
DM with
complications
0.368
CKD Stage 4
0.224
Mild Degree
Malnutrition
0.713
H/O Toe Amputation
0.779
PVD
0.299
0.677
3.06
$2,448
Modified from original industry example:
http://www.anthem.com/ca/shared/f2/s2/t4/pw_e181334.pdf
10
Today’s Plans Face Heightened Scrutiny
November 2014
“We will review the medical-record
documentation to ensure that it
supports the diagnoses organizations
submitted to CMS for use in CMS' riskscore calculations and determine
whether the diagnoses submitted
complied with federal requirements.”
Were patients really sicker? Lawsuits say
Medicare Advantage plans inflated
diagnoses to boost payments
…The lawsuits allege that providers and Advantage
plans, some operated by the nation's largest
insurers, have defrauded the Medicare program by
manipulating Advantage members' medical data to
make the members appear sicker than they were to
get higher capitation payments.
Office of Inspector General
2015 Work Plan
Source: “Were patients really sicker? Lawsuits say Medicare Advantage plans inflated diagnoses
to boost payments,” Lisa Schencker, available at: http://www.modernhealthcare.com
©2015 The Advisory Board Company • advisory.com
11
Reliant Medical Group Summary
Case in Brief
• 450 provider multi-specialty group practice based in the Northeast with more than 70%
capitated population and 30,000 risk adjusted patients
Background and Approach
Solution
Results
Challenges existed with
identification and capture of
outstanding HCC Dx
HCC header to identify
outstanding HCC diagnosis
Dramatically improves RAF
capture rate as well as
auditing compliance
Original awareness and BPA
made progress but was not
enough
Joint educational,
technological, and reporting
solution developed
Without intervention, 2013
RAF score would have
remained low
SmartForm embedded in Epic
and integrated in the normal
workflow
Increased “Raw” (2013) RAF
by 30% from baseline (2010)
2010 final RAF score: 0.899
to 2013 final estimated RAD
score 1.327
Suppression of captured Dxs
One click, add of base
compliant documentation,
supporting data, and adds HCC
diagnoses to the claim
Increased net revenue: Multi
million dollar annual impact
Robust reporting of performance
and prospective reviews
©2015 The Advisory Board Company • advisory.com
12
A Comprehensive Approach
A proven strategy accelerates
the achievement of benefits
1
2
3
People
Process
Technology
• Create compliance
and capture through
engagement,
education, and
training
• Target and optimize
key documentation
capture workflows
• Optimize existing EHR
and other clinical
information
technologies to make it
easy to do the right
thing while ensuring
accurate and complete
documentation capture
+
Stakeholder
Outreach &
Assessment
©2015 The Advisory Board Company • advisory.com
+
Workflow &
Documentation
Enhancement
=
Technical
Optimization
Results
13
Think of Technology an Essential Enabler
Performance Goals in HCC Optimization
Impact of
Technology Component
Clinical Performance
•
Increased accuracy of medical record
•
Improved identification of care and
overall chronic disease management
•
Optimized workflow with ‘automated’
processes where possible
•
Reduced time for physicians to spend
on documentation
•
Ability to capture and stratify patient
risk
•
Creation of a compliant method
for clinical documentation and
billing
Operations
Regulatory
Compliance
Enhanced reporting and
decision support
capabilities
More efficient EHR
documentation
workflows
Coding to the highest
level of specificity but
still compliant
©2015 The Advisory Board Company • advisory.com
14
Enlist Adequate Representation Early
Comprehensive Stakeholder Assessment, Engagement
System
Executives
Physicians
Coders Programmers/
Build Staff
Other?
Sample Components of Outreach Strategy
Create an Executive Summary on HCC to capture
relevant items for stakeholder groups
Develop provider-specific training plans and materials
Educate on implications of accurate Problem List
documentation for MA patients
Frame the issues for providers in clinical terms
Include incentives as part of larger engagement plan
Identify physician champions
©2015 The Advisory Board Company • advisory.com
15
Building a Product that Works for Providers
Notable Features of the Technology
Relevant
Displays
 Delivers specialty-relevant content; HCC capture opportunities are shared only with practitioners

who are qualified to evaluate the patient
 Eliminates alert redundancies; SmartForms fire only for HCCs that have yet to be captured

 Eliminates false positives; logic focuses on active diagnoses rather than encounter histories

 Presents actionable guidance at point of care; proposes options for the provider’s clinical

judgement
Actionable
 Allows one-click documentation; pre-loaded templates speed the documentation process
Information 
 Hard-wires participation; decision checkpoints drive provider participation

It’s
Easy
It’s
Accurate
 Uses existing EHR; no new interfaces to learn

 Embeds in existing workflows; no significant addition of process steps; no “bolt-ons” and extra

views within the technology
 Minimizes additional clicks; alerts and decision-making content displayed in full view

 Presents an intuitive interface; visual wayfinding and color-coding make next steps clear

 Updates clinical data and guidance daily; updated daily based on information in the patient record

 Applies rigorous clinical and compliance standards in regular releases and updates; builds are

tested, inputs are vetted, compliance standards are observed, and RAF values and normalization
ratios are updated by Clinovations
 Promotes continuous problem list cleaning; providers alter, refresh, and add problem list content

as a structured documentation exercise
©2015 The Advisory Board Company • advisory.com
16
No Out-of-Box EHR Solutions
Technical Optimization
HCC Value left = .78
The HCC Header identifies
when outstanding chronic
conditions have not been
addressed in the current
calendar year
The HCC clinical documentation
form is embedded in the EHR,
integrated in the normal workflow, and
obvious in the visit navigator.
The HCC Header Window
shows a diagnosis list report,
housed in the patient header.
Appears when patient in the correct
insurance has an HCC diagnosis with
remaining RAF value appropriate for
the appointment specialty.
Through a data link, adds a list
of the actual diagnoses that
make up that HCC value.
©2015 The Advisory Board Company • advisory.com
17
Transforming Intelligence into Action
Lots of Reporting Options for Physicians and Leadership
RAF improvement gaps by specialty,
facility, group, physician, patient
Trend performance and comparison to
likely performance without the initiative
1.293
1.256
1.219
1.345
1.249
Dec Jan Feb Mar Apr
Custom Report
Features*
Prioritized lists of patients for outreach
and appointment scheduling
•
Reports for compliance/auditing
•
Provider-specific report-carding
•
Financial planning/forecasting
models
* Illustrative only.
©2015 The Advisory Board Company • advisory.com
18
Performance Monitoring
Real time and retrospective reports support process improvement and demonstrate access
Reporting Options Support:
• Identification of suspect codes/patients for providers (for
problem list abstracting and patient outreach)
• Reports for compliance/auditing
• Evaluation of provider performance for feedback
• Financial planning/forecasting models
% HCC Chronic RAF by
Department -All Patients
1.00
93.1%
91.5% 89.8%
93.0%
93.9%
% HCC Chronic RAF by
Provider -All Patients
93.1%
91.3%
89.8% 90.0%
0.80
0.60
0.40
41.8%
Dept Dept Dept Dept Dept Dept Dept Dept Dept Dept
A
B
C
D
E
F
G
H
I
J
©2015 The Advisory Board Company • advisory.com
1.00
0.95
0.90
0.85
0.80
0.75
0.70
95.9%
93.2%
94.8%
91.2%
89.5%
86.6%
73.3%
Provider Provider Provider Provider Provider Provder Provider
M
N
O
P
Q
R
S
19
Expected Benefits of HCC Optimization
Regulatory
Initiatives
Stakeholder
Satisfaction
Financial
Success
Creation of a
compliant method
for clinical
documentation and
billing
Increased
accuracy of
medical record
Increased revenue
capture
Clinical
Excellence
Improved chronic
disease
management
Operational
Efficiency
Use of EHR
technological
capabilities and
automation
Increased
accuracy of the
medical record
©2015 The Advisory Board Company • advisory.com
20
Lessons Learned From Successful Deployments
HCC is like a marriage
• Making HCC “easy” is hard work
– Although the end result is simple for the provider, the infrastructure behind it is multilayered
and sophisticated. Don’t underestimate the complexity of doing it well. 1000+ parts to the
solution.
• It is all about commitment!
– The most important thing the organization can do is agree from the CEO down to the provider
that HCC is a priority, not an afterthought.
– Provide the resources and infrastructure to make it work right, measure success/failure and
hold managers and providers accountable
• The work never ends
– Every year the model changes, ICD-10 is coming, new patient come and need to be
abstracted. There is always maintenance.
• Give them what they want
– Give them the info (diagnoses) they need at the right time (in the encounter) and a tool in the
right place (the SmartForm in the EMR) that does the right thing (bills and documents)
• Someone needs to be the boss (just ask our wives!)
– Having a trained, educated and reimbursed champion with a clinical and technical focus will be
invaluable
©2015 The Advisory Board Company • advisory.com
21
Contact Information
John Trudel, MD
Director of Risk Revenue Programs
Assistant Medical Director for Informatics
Reliant Medical Group
John.Trudel@ReliantMedicalGroup.org
Steve Strode, MS
Senior Vice President, Clinovations
The Advisory Board Company
strodes@advisory.com
©2015 The Advisory Board Company • advisory.com
22
Questions & Discussion
©2015 The Advisory Board Company • advisory.com