Prevalence of Chronic Kidney Disease (CKD)

Studies indicate that over 40% of individuals over 65 have some form of Chronic Kidney Disease (stages 1-5). 70-75% of individuals with CKD are undiagnosed, primarily as a result of high rates of under-diagnosis of the early stages of CKD. For many Medicare Advantage plans, a typical range for CKD diagnosis rate is between 10-15%  across all stages of CKD.

Past Efforts to Increase Diagnosis of CKD by Medicare Advantage Plans

The HCC risk adjustment model utilized by CMS up through 2013 groups all stages of CKD into HCC 131 – Renal Failure. Up through 2012, HCC131 carried a raw risk score of .368 which was worth approximately $3,000 per year per member.  For 2013, the raw risk score was reduced to .297 which was worth approximately $2,500 per year per member.  (Financial values will vary for every plan depending on individual plan bids.) As a result of the high rate of under-diagnosis of early stage CKD (stages 1-3), some Medicare Advantage plans have actively engaged in efforts to increase diagnosis rates in part to trigger additional revenue from HCC131.

Impact of 2014 CMS Changes to HCC Model

Starting with Payment Year 2014 (based on 2013 dates-of-service), CMS no longer recognizes Chronic Kidney Disease stages 1-3 for Medicare risk adjustment purposes. Only individuals with CKD stage 4 and CKD stage 5 trigger additional reimbursement from the new HCC 137 and HCC136 respectively.

This change greatly diminishes the risk adjustment related value of early stage CKD diagnosis programs. However, the clinical value of early CKD diagnosis remains the same, as early diagnosis enables better management of the condition to slow the rate of disease progression to the much costlier later stages of this disease.

Implications for Medicare Advantage Plans

For many Medicare Advantage plans, anywhere from 85-90% of members who are currently diagnosed with some stage of CKD are in early stages 1 to 3.  Only 10-15%  are CKD stage 4 or CKD stage 5. Under the new HCC model for 2014, substantial amounts of risk adjustment revenue associated with these members with CKD stages 1-3 will be removed from HCC131 and will be re-distributed into other HCC categories, or taken away from Medicare Advantage plans altogether. This is as a result of the recalibrations built into the new HCC model.

To help ease the revenue impact of this new HCC model, for 2014 only, CMS will retain 25% weight for old model scores and give 75% weight to the new model scores.  Even with this transitional approach, for many Medicare Advantage plans the net impact of the new HCC model will be to reduce average risk scores anywhere between 2-3% for 2014.

As a result, plans need to think broadly about how to continue improving risk scores via a combination of expanding retrospective chart review operations, as well implementing extensive prospective assessment programs.

Physician abrasion is an issue that every health plan should be concerned about.  For busy physician offices, the challenge of meeting a health plan’s constant requests for additional information and understanding each health plan’s complex rules can be very frustrating.

Over time, this can negatively impact a physician’s perceptions and in turn their patients’ perceptions of a health plan, which can result in physician attrition, member attrition and lost revenue.

Learn more about how to avoid physician abrasion in Rolland Ho’s latest piece for Healthcare Payer News.

Before he lays all of his analysis and numbers talks on you, take some time to read this short interview and get to know Rolland a little better.

What is your favorite part of working at Outcomes Health?

The people I get to work with every day are definitely my favorite part of working for Outcomes Health.  Everyone on the Outcomes Health team is just so full of energy and innovative creativity that it’s a great treat to get to work with and learn something new from other team members every day.

What are you most passionate about in your professional life? What about your personal life?

Professionally, what gets me excited is getting to participate in this grand transformation happening to how health care is managed and delivered in this country.  I sincerely believe there is so much more that we as a country can be doing to use data and analytics to target and drive effective clinical interventions that improve the lives of patients while also reducing the overall cost of care.  And the work we do at Outcomes Health is front and center to these efforts to transform our health care delivery system for the better.

On the personal front, my wife and I have a beautiful little 2-year old daughter who is just so much fun to play with every day.  Getting to watch her enthusiastically learn and explore new things each day that we as adults take for granted is just a wonderful joy and helps keep me grounded on what’s important in life.

What topic do you most enjoy speaking to during conference and tradeshow sessions?

I love any topic that involves using data and analytics to help patients, providers, health plans or other organizations work smarter and make better choices and decisions.  The only way we will be able to solve our problems around quality and cost of healthcare in this country is by engaging everyone involved in the process with the right information, delivered at the right time, to make the best possible choices and decisions.

If you could possess any magic power, what would it be, and why?

It would be to stop the cycles of wars and conflict that waste so many lives and so much human potential and redirect all that energy towards finding creative solutions for making this world a better place for everyone.

What is your biggest bucket list desire?

To know that I made a positive difference in this world and in the lives of the people around me.

What exactly does a union between advanced technology and quality care mean for you? It means successfully closing those frustrating care gaps. Simple as that.

“Do more with less” – the quote Rolland Ho, SVP of Medicare Advantage, uses to explain the issue that healthcare organizations are frequently confronted with in regards to tightening budgets, yet needing to increase quality service to its patients. Rolland explains how to overcome this in a recent article for ADVANCE for NPs & PAs.

The Outcomes Health family has been helping health plans work smarter, not harder, for nearly twenty years.

What do I mean when I say working smarter? It’s a combination of being efficient in action, thoughtful in decision making and limited in extraneous guess work, so you can focus on projects that will bring the most benefit to your organization. At Outcomes Health, your success is our success. We leverage our subject matter expertise to help you drive quality and ensure revenue performance.

At Outcomes Health, we are feverously dedicated to advancing data to improve care, quality, information accuracy and security, and financial performance for our clients. We’re also committed to helping your organization stay abreast to the latest trends and changes that will impact you, while helping you prepare for these changes. We strive to arm you with the most up-to-date information regarding the ever-evolving industry so you can help your organization work as efficiently as possible, wherever you are in the healthcare industry—a health plan, a physician practice, an accountable care organization (ACO), or anywhere in between.

It’s for the reasons above that we decided the time has come to launch this blog, Outcomes Insights. We want to provide you with essential information about emerging trends, ideas and concepts that directly impact you and your organization. Some specific data-driven topics you can expect to see include:

• Leveraging data analytics to close care gaps
• Realizing the benefits of health advocacy programs
• Engaging patients in chronic condition self-management
• Capturing potentially unreported or underreported diagnoses to ensure accurate HEDIS/Star/GPRO scores
• Laying the groundwork for accountable care

With this information and some practical advice and strategies, you’ll be able to work smarter armed with better data, for better decisions. We hope you join us on our new adventure as we shed some light on who we are and why we love doing what we do.

Thanks for reading,

Wanda

You will be provided an Advocate to help you plan your daily activities. Outcomes Health will schedule and confirm all of your appointments to make your days as efficient as possible. We will also provide state-of-the-art equipment for scanning charts and medical records and transferring files to our secure file transfer site on the Web. We provide help desk assistance for both technical and medical record retrieval support.

Outcomes Health offers competitive compensation. We also provide thorough training in the use of our technology, processes, documents to be scanned or copied, and HIPAA confidentiality requirements for protected health information. If you have substantial medical records and/or chart auditing experience, a professional demeanor, and can work independently, we invite you to join the most respected name in the industry.

REQUIRED EDUCATION & EXPERIENCE

• Strong computer skills. Proficiency in MS Office, creating data files and folders.
• Must be an RN, LPN, Certified Coder, RHIT, RHIA, MA or Medical Records Professional or medical Billing and Coding Professional
• Medical terminology knowledge
  
• High-speed internet access at home (no dial-up)
• Reliable transportation, auto insurance and a valid driver’s license
• Commitment to confidentiality of patient health information
• Professional, articulate and able to work independently
• Availability at least 20 hours per week during business hours
• Ability to manage and meet deadlines
• Must be willing to travel within a 40-mile radius
• Business attire is required when visiting physician offices
• Must have a working cell phone, home computer, and printer

SUMMARY OF DUTIES & RESPONSIBILITIES

• Accurately and efficiently conduct medical record review services
• Scan relevant components of the medical record to support reviews performed
• Upload scanned medical records daily
• Maintain communication lines with assigned advocate
• Successfully complete required training, testing and quality assessments
• Communicate effectively and professionally with care provider offices, clinics, hospitals, other clinical facilities
• Travel to medical facilities in specified area of region from home to complete review services
• Abide by all HIPAA and associated patient confidentiality requirements

 

States in which Outcomes Health will be conducting reviews:

AL, AZ, AR, CA, CO, CT, DE, FL, GA, HI, ID, IL, IN, IA, KS, KY, LA, ME, MD, MA, MI, MN, MS, MO, MT, ND, NE, NV, NJ, NM, NY, NC, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VT, VA, WA,  WV, WI, WY

Outcomes Health Information Solutions, LLC (“Outcomes Health”) provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, gender, sexual orientation, national origin, age, disability, marital status, amnesty, or status as covered veterans in accordance with applicable federal, state and local laws. Outcomes Health complies with applicable state and local laws governing non-discrimination in employment in every location in which the company has facilities. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training. Outcomes Health expressly prohibits any form of unlawful employee harassment based on race, color, religion, gender, sexual orientation, national origin, age, disability, or veteran status. Improper interference with the ability of Outcomes Health employees to perform their expected job duties is absolutely prohibited.

Outcomes Health expressly prohibits any form of unlawful employee harassment based on race, color, religion, gender, sexual orientation, national origin, age, disability, or veteran status. Improper interference with the ability of Outcomes Health employees to perform their expected job duties is absolutely prohibited.

Outcomes Health Information Solutions is an equal opportunity employer.