Managed Care - January 2008 - (Page 44) ease, congestive heart failure, and high blood pressure. The physician is paid based on whether the visit is short, medium, or long, and she codes one diagnosis: upper respiratory infection. While the physician is paid correctly for the visit, the plan may not get paid the proper premium if the physician fails to report a code or does not provide the necessary specificity in coding to document the complexity and anticipated cost of the disease. In all likelihood, this patient will be hospitalized, perhaps incurring a catastrophic two- or three-week stay in the intensive care unit. Because this member’s risk score was never properly obtained, the plan did not accumulate the necessary reserves to provide for this event. Now let’s suppose that the physician is trained to perform a comprehensive evaluation of all relevant diagnoses and properly documents each relevant diagnosis code. The next challenge is to get that information to CMS. Under the HCC system, patients with complex medical problems are at highest risk of being scored too low in the risk assessment. Such patients can require 10 to 20 ICD-9 codes to accurately reflect their health status. Because most medical billing intermediaries (clearinghouses) truncate after four ICD-9 codes, these patients at highest risk will not have their risk adjusted properly, and, once again, the plan will not receive the appropriate payment. Financial penalty From a clinical perspective there are more serious challenges. Under Medicare+Choice, health plans were penalized financially for enrolling sicker members, because payment did not reflect complexity. Under HCC methodology, plans have an incentive to enroll sicker members. Assuming ideal circumstances, a Medicare Advantage plan has processes in place to ensure both comprehensive diagnosis and accurate submission to CMS. But those are ideal circumstances. Does the plan have access to the necessary robust resources (hospitals, nursing homes, home care, case management, disease management) to manage the complex medical needs of the population it now insures? More importantly, does the health plan have the technology to identify the patients who would benefit from additional resources and monitor their utilization and progress? Under the HCC risk system, it is essential that plans deploy all necessary resources to achieve better outcomes and avoid catastrophic events. Although the challenges of the HCC system are daunting, the system offers significant rewards and opportunities for plans willing to embrace the How soon we forget hysicians do not provide a complete and accurate listing of ICD-9 codes for members, particularly those with chronic diseases. All of the conditions listed are chronic, yet only 17 percent of members with, for instance, coronary artery disease are coded with this condition in the second year and only 11 percent are coded in the third year. P 100% 100% 100% 100% 100% 17% 11% Year 1 Year 2 Year 3 18% 10% 16% 11% Year 1 Year 2 Year 3 16% 8% 12% 7% Year 1 Year 2 Year 3 Year 1 Year 2 Year 3 Year 1 Year 2 Year 3 Coronary artery disease Congestive heart failure Chronic obstructive pulmonary disease Cardiovascular disease Diabetes Source: Reden & Anders 44 MANAGED CARE / JANUARY 2008
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