Docstoc

Risk Adjusted Data - sc-ahq.org

Document Sample
Risk Adjusted Data - sc-ahq.org Powered By Docstoc
					   Risk Adjusted Data

          South Carolina
Association of Health Care Quality
     What is Risk Adjustment
• Can Risk be Managed?
  – Going beyond your best guess
         Some Examples of Risk
             Management
•   Project Management
•   Any Insurance
•   Public Relations
•   Investing

    – The event causing the risk.
    – The likelihood of the event happening.
    – The impact on the plan if the event occurs
            Why Medicine?
Doctor – You have higher X when compared
  to Y
• My patient’s are more complex and sicker

• Question is this really true
  – Enter Risk Adjusted Data


• Used to compare one provider to another
   Process of Risk Adjustment
• Must have an adequate risk assessment
  tool.
• Must segment populations in meaningful
  ways.
• Develop a system to normalize the
  population.
• Reward or dissuade risky behavior.
Criteria for
assessing
   Risk
Adjustment
   tools
Mechanism of Risk Adjustment
Going National
     The Basic Tool
DRG -> Risk Adjusted DRG
                        Hx of DRG
• Developed in 1967
   – Introduction of Medicare
       • Hospitals required to implement Utilization Review
       • Also implement Quality Assurance Programs
• Intentions
   – Inclusion of all hospital services
   – Incorporate thousands of diagnoses and procedures
   – Account for multiple diseases and treatment of individual
     patients
   – Differentiate between high and low cost care
   – Create clinically meaningful catagories
• Followed ICD-9 Methodology
   – Developed 23 Major Diagnostic Categories
   – Identified patient clusters based on secondary dx, procedures,
     sex age, discharge status, complications comorbidities to sort
     out similar LOS and resource consumption
         Advent of HCFA-DRG
• Original DRG system flawed
  –   Found to be highly variable
  –   Did not capture severity of illness
  –   Relative weights based on unreliable data
  –   Too slow to keep pace with rapid change
• HCFA adopted DRG system as payment for
  hospitals in 1983
  – Took ownership of ensuring annual updates
  – Reimbursement for hospitalization based on the
    reason for hospital stay.
  – Split out procedure codes to be maintained separately
                 Refined DRG
• Soon became evident the presence or absence
  of complications and comorbities (CC) resulted
  in assignment of different DRG for certain
  patients
  – Defined a CC as a secondary diagnosis that
    specifically increases hospital resource use.
  – System modified to account for four levels of CC
     • Non, Moderate, Major, Catastrophic
  – Ran pilot studies, but never adopted this modification
     • Only utilized one CC to modify DRG to Highest level
                All Patients DRG
• Adopted by New York State as the payment
  system for all non-Medicare patients in 1987
  – Found DRG system was inadequate to classify
    resource consumption for:
     • Neonates
     • HIV infected patients
  – NY state contracted 3M to modify DRG system
     • Added Pediatric modified DRGs
     • MDC 24 for HIV infection
     • CC List modified gave rise to MDC 25
         –   Transplants
         –   Long term vents
         –   Cystic Fibrosis
         –   Nutritional Disorders
         –   High risk OB
         –   Acute Leukemia
         –   Sickle Cell Anemia
          All Patient Refined DRG
• Widely used in US, Europe, parts of Asia
• Uses Base of AP-DRG system
• Developed by 3M in 1990
• Added four subgroups attempting to describe Severity of
  Illness
• Resulted in significant change to group logic
    – All age and CC distinctions are removed
    – Replaced by two groups
         • Severity of illness 1-4
         • Risk of Mortality 1-4
• Subgroup assignment is based on the interaction
  between:
    –   Secondary diagnosis
    –   Age
    –   Principle diagnosis
    –   Presence of certain non-operative procedures
Intent of APR-DRG
                From 3M

     • Compare hospitals across
       wide range of resources and
       outcome measures
     • Evaluate the differences in
       inpatient mortality rate
     • Implement and support
       critical pathways
     • Identify continuous quality
       improvement projects
     • Form the basis of internal
       management and planning
APR DRG Classification Data Elements

                MDC Major Diagnostic Category



                          APR DRG Assignment




Four Severity of Illness Subclasses    Four Risk of Mortality Subclasses

    1.   Minor                             1.   Minor
    2.   Moderate                          2.   Moderate
    3.   Major                             3.   Major
    4.   Extreme                           4.   Extreme
Does Severity Adjustment really
      make a difference
      Mortality in Severity of Illness -- SRHS
120




100




80




60




40




20




 0

        Minor SI   Moderate SI   Severe SI   Extreme SI
      Mortality in Mortality Risk -- SRHS
120


100


 80


 60


 40


 20


  0
       Minor MR   Moderate MR   Severe MR   Extreme MR
     LOS in Severity Adjusted-- SRHS
45



40



35



30



25



20



15



10



5



0


      Minor SI   Moderate SI   Major SI   Extreme SI
     LOS in Mortality Risk -- SRHS
45



40



35



30



25



20



15



10



5



0


      Minor MR   Moderate MR   Major MR   Extreme MR
          Pattern in Most Hospitals
80



70



60



50



40



30



20



10



0
     Minor SI   Moderate SI   Major SI   Extreme SI
       SRHS Severity of Illness – All Patients
2500




2000




1500




1000




500




  0
          Minor SI   Moderate SI   Major SI   Extreme SI
       SRHS Mortality Risk – All Patients
3500




3000




2500




2000




1500




1000




500




  0
         Minor MR   Moderate MR   Major MR   Extreme MR
Big Deal, What can I do with this Knowledge
     Case Management Perspective
45



40



35



30



25



20



15



10



5



0


      Minor SI   Moderate SI   Major SI   Extreme SI
                 Discharge Planning
45%



40%



35%



30%



25%
                                                          Home DC
                                                          Home Health
                                                          SNF
20%



15%



10%



5%



0%
      Minor SI      Moderate SI   Major SI   Extreme SI
     Disposition is not an Issue
60




50




40




30




20




10




 0
        HOME     HOME HEALTH   SNF-SKILLED   Other
     DISCHARGE   AGENCY/HOSP    NURSING
                     ICE         FACILITY
                                             Age
14
                     NICU Babies                           Oncology with Surgery
                     Pre term
12
                                                                                 PSYCH &
                                                                                 GI Procedure
10                   PSYCH

 8



     6



     4



     2



     0
         0.0

               8.1

                        16.2

                               24.3

                                      32.4

                                             40.5

                                                    48.6


                                                                                           S1
                                                            56.7

                                                                   64.8

                                                                          72.9

                                                                                    81.0
         56% of Outliers in 4 Units
                                              100%   100%


70                                                   90%


                                                     80%
60

                                                     70%

50
                                                     60%


40
                                     56%             50%



30                          45%                      40%



                    32%                              30%
20
        17%
                                                     20%

10
                                                     10%


0                                                    0%


      PSYCH-3   4 TOWER NURSERY- 8 TOWER   Other
     SOUTH-EAST        INTERMEDIATE
                                      But I Admit more then others                                                                                                        100%                                                                                                                                                                                                             100%


    12
                                                                                                                                                               100%              90
                                                                                                                                                                                                                                                                                                                                    99%                                 100%
                                                                                                                                                                          90%                                                                                                                                                                                                              90%
                                                                                                                               92%                                               80
                                                                                                          85%                                                             80%                                                                                                                                                                                                              80%
    10                                                                                                                                                                                                                                                                                             82%
                                                                                                                                                                                 70
                                                                                                                                                                          70%                                                                                                                                                                                                              70%
                                                             69%                                                                                                                 60
    8                                                                                                                                                                                                                                                                                                                                                                                      60%
                                                                                                                                                                          60%

                                      54%                                                                                                                                        50                                                                                 58%
                                                                                                                                                                          50%                                                                                                                                                                                                              50%
    6
                                                                                                                                                                                 40
                                                                                                                                                                          40%                                                                                                                                                                                                              40%


    4                                                                                                                                                                            30                                        29%                                                                                                                                                             30%
                                                                                                                                                                          30%


                                                                                                                                                                                 20                                                                                                                                                                                                        20%
                                                                                                                                                                          20%
    2

                                                                                                                                                                          10%    10                                                                                                                                                                                                        10%



    0    SHAH,AMISHI                        GRAVELY,VONDA                              MEMON,MOHAMMED A         CASTON,CHRIS                                 POWELL,W S
                                                                                                                                                                          0%      0                          SHAH,AMISHI                            GRAVELY,VONDA                          MEMON,MOHAMMED A                       CASTON,CHRIS                          POWELL,W S
                                                                                                                                                                                                                                                                                                                                                                                           0%


                                                             Attending Physician                                                                                                                                                                                     Attending Physician

6                                                                                                                                                          100%           100%
                                                                                                                                                                                 100                                                                                                                                                                                                 100%100%


                                                                                                                                                                          90%                                                                                                                                                                                                             90%
                                                                                                                                                                                                                                                                                                                                                                  86%
5                                                                                      83%                                                                                80%                                                                                                                                                                                                             80%
                                                                                                                                                                                 80

         67%                                                                                                                                                              70%                                                                                                                                               71%                                                           70%
4

                                                                                                                                                                          60%    60                                                                                                                                                                                                       60%

                                                                                                                                                                                                                                                                                         54%
3                                                                                                                                                                         50%                                                                                                                                                                                                             50%



                                                                                                                                                                          40%    40                                                                                                                                                                                                       40%
                                                                                                                                                                                                                                                   37%
2
                                                                                                                                                                          30%          21%                                                                                                                                                                                                30%



                                                                                                                                                                          20%    20                                                                                                                                                                                                       20%
1

                                                                                                                                                                          10%                                                                                                                                                                                                             10%



0                      CURRAN,COLIN                                  BEARDEN,JAMES D                                                 NELSON,ERIC CHARLES
                                                                                                                                                                          0%      0    NELSON,ERIC CHARLES                       BEARDEN,JAMES D                          CURRAN,COLIN                        PATI,ASIM R                        CORSO,STEVEN W          Other
                                                                                                                                                                                                                                                                                                                                                                                          0%


                                                            Attending Physician                                                                                                                                                                                     Attending Physician
                                                                              Patient Mix
100%




80%




60%




40%




20%




 0%    CHERRY,STEPHEN R   EICKMAN,F MICHAEL   GALLAGHER,JOHN   HUEY,BARRY L    IKE,DAVID   LITTLEFIELD,RONALD H   LOPEZ,ALEJANDRO N   MACDONALD,ROBERT G   MOBLEY,JOSEPH   RODAK,DAVID J   SRIVASTAVA,NALIN K   STORY,JAMES R
                                                                                                                       Costs
30000




25000




20000




 15000




 10000




   5000




         0
             CHERRY,STEPHEN R




                                EICKMAN,F MICHAEL
                                                                                                                                                                                                                                           Extreme SI
                                                    GALLAGHER,JOHN




                                                                     HUEY,BARRY L




                                                                                    IKE,DAVID
                                                                                                                                                                                                                                          Major SI
                                                                                                LITTLEFIELD,RONALD H




                                                                                                                        LOPEZ,ALEJANDRO N




                                                                                                                                            MACDONALD,ROBERT G
                                                                                                                                                                                                                                        Moderate SI
                                                                                                                                                                 MOBLEY,JOSEPH




                                                                                                                                                                                 RODAK,DAVID J




                                                                                                                                                                                                 SRIVASTAVA,NALIN K
                                                                                                                                                                                                                                      Minor SI
                                                                                                                                                                                                                      STORY,JAMES R
   DRG Specific Cost Comparison
30000




25000




20000




 15000




 10000




   5000




         0                                                                                                                                                                      Extreme SI
                                                                                                                                                                          Major SI
             CHERRY,STEPHEN R




                                EICKMAN,F MICHAEL




                                                    GALLAGHER,JOHN




                                                                                                                                                                       Moderate SI
                                                                     HUEY,BARRY L




                                                                                    IKE,DAVID




                                                                                                MOBLEY,JOSEPH




                                                                                                                RODAK,DAVID J




                                                                                                                                SRIVASTAVA,NALIN K
                                                                                                                                                                     Minor SI
                                                                                                                                                     STORY,JAMES R
25000
          Compare Your Processes

20000




15000




10000




5000




   0


        Minor SI   Moderate SI   Major SI   Extreme SI
10.00%
                    Refine the Search
9.00%

                                                  117
8.00%
                                                  125
                                                  132
                                                  552
7.00%




6.00%




5.00%




4.00%




3.00%




2.00%
         Minor SI      Moderate SI   Major SI   Extreme SI
                    Get to the Details
• DRG 117 Revision of Pacer (Few Patients)
    – 2 docs in SI Moderate
        • 1. avg cost $3,500
        • 2 avg cost $12,300 – Higher utilization of resources Xrays, Labs LOS 5 days vs
          3
• DRG 125 Heart Dz w/o MI & wCath
    – 7 docs in Group 3
        • Avg Cost $4500
        • 1 pt with cost $15,000 complication of Malignant Htn
•   DRG 132 Atherosclerosis with CC
    – Group 3 - 1 pt expired with long LOS and MR 4
    – Group 2 – One physician Avg cost $12,500 vs, $3,000
        • Medication profile
• DRG 552 pacer w/o other major CV dx.
    – Group 2 two main physicians one uses more expensive device
    – Group 3 1 pt longer LOS
 Really Why should I care
CMS Is Changing the Rules
      Refinement of the Relative Weight
                Calculation
• Pattern of increasing Medical weights and lowering
      Surgical weights remains
• Transition period mitigates swings in payment
• Process:
   1. Standardized charges were broken into 13 cost
         buckets
   2. National Cost-to-Charge Ratio was used to convert
        charges into costs
   3. Standard methodology to create the weights was used
• Hospital Specific Relative Value (HSRV) methodology will
       NOT be used in FY 2007
• Independent contractor will evaluate charge compression
       with HSRV
      Refinement of the Relative Weight
                Calculation
Implementation of a cost-based weight methodology over
  a 3 year transition period
• Year 1 – Weights based on a blend of:
   – 33% cost based weights
   – 67% charge based weights
• Year 2 – Weights based on a blend of:
  – 67% cost based weights
  – 33% charge based weights
• Year 3 – Weights based on 100% costs
Do Severity and Risk Adjustment
     Make a Difference?
       Application of Final Rule
DRG 148 (Major small and large bowel procedures w/cc)
– CMS medical advisors felt the presence of major
  gastrointestinal diagnoses identifies patients with a
  higher level of severity.
          Pattern in Most Hospitals
80



70



60



50



40



30



20



10



0
     Minor SI   Moderate SI   Major SI   Extreme SI
Follow the Money
Severity Adjusted DRGs – On Hold
What Questions Does your
Organization Need to ask
        Present on Admission
• Deficit Reduction Act of 2005 (DEFRA)
  – Requires Present on Admission (POA) indicators to
    be collected for all Medicare patients beginning this
    Oct.

  – Requires CMS to select 2 or more infectious that are
    high cost/High volume to focus on.

  – Require CMS to begin excluding those infections
    when the are identified as not present on admission
    from the calculation of the DRG beginning Oct 1 2008
                      Case Example
                                                                      Simulated
                                              Current Payment         Payment Hosp
                      No Complication         with Complication       Acquied Infection
Principle Diagnosis     Atrial Fibrillation     Atrial Fibrillation   Atrial Fibrillation (POA)

   Secondary                                                               Pneumonia
   Diagnosis                                     Pneumonia                 (Not POA)
  Procedures          Temp Pacemaker          Temp Pacemaker           Temp Pacemaker
                                                 Mechanical                Mechanical
                                                 Ventilator                Ventilator
                      Cardiac Arrhythmia      Cardiac Arrhythmia      Cardiac Arrhythmia
 Medicare DRG         W/O CC                  W/O CC                  W/O CC

Medicare Weight             0.5227                  0.8287                   0.5227

Reimbursement               $3,839                  $6,086                   $3,839
Risk Adjustment for Quality Indicators

• Agency for Healthcare research and
  Quality released comprehensive set of
  quality indicators intended to flag potential
  quality problems.
• UCSF - Stanford Evidence based Practice
  center developed these indicators using
  APR-DRGs as the basis for risk
  adjustment
    Preparing for Report Cards
Hospitals must:
• Be proactive in evaluating data
   – Prevent surprises: Anticipate your performance ratings
   – Prepare well-planned responses to negative ratings
   – Develop improvement programs to correct any identified problem
     areas
• Invest in the quality of medical records, documentation,
  and information systems
   – Severity-of-illness and risk-of-mortality adjustments require a
     thorough reporting of patients’ diagnoses
   – Incomplete coding can negatively affect the evaluation of the
     institution on the report cards
Step One
Public Reporting of Data
       Change Pattern -- Volumes
3000




2500




2000




                                                        2005
1500
                                                        2006




1000




500




  0
       Minor SI   Moderate SI   Major SI   Extreme SI
       Yes Education Is a Good thing
         Change in percent of total
 0.4



0.35



 0.3



0.25



                                                          2005
 0.2
                                                          2006



0.15



 0.1



0.05



  0
         Minor SI   Moderate SI   Major SI   Extreme SI
       Change Mortality Pattern
0.6




0.5




0.4




                                                       2005
0.3
                                                       2006




0.2




0.1




 0
      Minor MR   Moderate MR   Major MR   Extreme MR
O
   ct
      20




              0
                  10
                       20
                            30
                                         40
                                                               50
                                                                    60
                                                                         70
                                                                              80
D        0
  ec 3
      20
Fe 03
   b
      20
Ap 04
    r2
       0
Ju 04
   n
      20
Au 04
   g
      20
O        0
   ct 4
      20
D        0
  ec 4
      20
Fe 04
   b
      20
Ap 05
    r2
       0
Ju 05
   n
      20
Au 05
   g
      20
O        0
   ct 5
      20
D        0
  ec 5
      20
Fe 05
   b
      20
Ap 06
    r2
       0
Ju 06
   n
      20
Au 06
   g
      20
O        0
   ct 6
      20
D        0
  ec 6
      20
         06
                                                                                   Total vs. Ratio (Act/Exp)



                                 Medicare Mortality
                                 Risk Adj Medicare Mortality
O
    ct




                        1


                  0.9
                            1.1
                                  1.2
                                        1.3
                                              1.4
                                                    1.5
                                                          1.6
                                                                1.7
                                                                      1.8
                                                                                   1.9
       20
          0  3
D
 ec
        20
           0  3
Fe
    b
        20
             04
Ap
   r    20
             04
Ju
  n
        20
          04
Au
   g
        20
          04
O
    ct
       20
          0  4
D
 ec
        20
           0  4
Fe
    b
        20
             05
Ap
   r    20
             05
Ju
  n
        20
          05
Au
   g
        20
          05
O
    ct
       20
          0  5
D
 ec
        20
           0  5
Fe
    b
        20
             06
Ap
   r    20
             06
Ju
  n
        20
          06
Au
   g
        20
          06
O
                                                                            Ratio of actual to expected




    ct
       20
          0  6
D
 ec
        20
           0  6
      Risk Adjustment Length of Stay
6.4




6.2




 6




5.8




5.6




5.4




5.2




 5
      Jan-Mar   Apr-Jun   Jul-Sep   Oct-Dec   Jan-Mar   Apr-Jun   Jul-Sep   Oct-Dec   Jan-Mar   Apr-Jun   Jul-Sep   Oct-Dec
       2004      2004      2004      2004      2005      2005      2005      2005      2006      2006      2006      2006
Remember Newton’s Third Law




"For every action, there is an equal and
opposite reaction."
                                                Coded Complications
3.5                                                                                                                            14


                Nervous System Complications                                                                  4.5s
  3                                                                                                                            12



                                                                                                                                               Cardiac Complication                                                           4.1s
2.5                                                                                                                            10




  2                                                                                                                            8




1.5                                                                                                                            6




  1                                                                                                                            4




0.5                                                                                                                            2




  0                                                                                                                            0
      Jan-Mar   Apr-Jun   Jul-Sep   Oct-Dec   Jan-Mar   Apr-Jun   Jul-Sep   Oct-Dec   Jan-Mar   Apr-Jun   Jul-Sep   Oct-Dec         Jan-Mar   Apr-Jun   Jul-Sep   Oct-Dec   Jan-Mar   Apr-Jun   Jul-Sep   Oct-Dec   Jan-Mar   Apr-Jun   Jul-Sep   Oct-Dec
       2004      2004      2004      2004      2005      2005      2005      2005      2006      2006      2006      2006            2004      2004      2004      2004      2005      2005      2005      2005      2006      2006      2006      2006




 4
                                                                                                                               10                                                                                                 4.0s
3.5
           Peripheral Vascular Complications                                                                            4.4s   9



                                                                                                                               8
                                                                                                                                                                      Respiratory Complications
 3


                                                                                                                               7
2.5

                                                                                                                               6

 2
                                                                                                                               5


1.5                                                                                                                            4



                                                                                                                               3
 1


                                                                                                                               2
0.5

                                                                                                                               1

 0
      Jan-Mar   Apr-Jun   Jul-Sep   Oct-Dec   Jan-Mar   Apr-Jun   Jul-Sep   Oct-Dec   Jan-Mar   Apr-Jun   Jul-Sep   Oct-Dec    0
       2004      2004      2004      2004      2005      2005      2005      2005      2006      2006      2006      2006           Jan-Mar   Apr-Jun   Jul-Sep   Oct-Dec   Jan-Mar   Apr-Jun   Jul-Sep   Oct-Dec   Jan-Mar   Apr-Jun   Jul-Sep   Oct-Dec
                                                                                                                                     2004      2004      2004      2004      2005      2005      2005      2005      2006      2006      2006      2006
     What Have We Learned
• My kids would say nothing.

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:4
posted:9/15/2012
language:Unknown
pages:66