{"id":42807,"date":"2023-06-27T20:07:11","date_gmt":"2023-06-28T00:07:11","guid":{"rendered":"https:\/\/medcitynews.com\/?p=637597"},"modified":"2024-04-02T22:27:44","modified_gmt":"2024-04-03T02:27:44","slug":"a-new-approach-to-value-based-care-diagnostically-connecting-data-and-diagnoses","status":"publish","type":"post","link":"https:\/\/medcitynews.com\/2023\/06\/a-new-approach-to-value-based-care-diagnostically-connecting-data-and-diagnoses\/","title":{"rendered":"A New Approach to Value-Based Care: Diagnostically Connecting Data and Diagnoses"},"content":{"rendered":"

\"present\"<\/p>\n

One of the primary goals for Medicare Advantage (MA) and other value-based care (VBC) programs is to effectively manage patients\u2019 chronic conditions and avoid complications, including hospital admissions and re-admissions, and costly interventions. To accurately compensate providers for the care of these patients, VBC programs rely on clinical risk scores based on the diagnoses for which a patient is receiving care.<\/p>\n

However, while it may seem like a straightforward process, finding and documenting the information required for accurate VBC risk assessment is not always easy.<\/p>\n

Consider Medicare Advantage, which has defined approximately 80 categories of hierarchical condition categories (HCC) covering about 9,500 ICD-10-CM diagnosis codes. A risk adjustment factor (RAF) is assigned for each HCC category, with additional risk factors assigned based on gender, age, living situation, and other factors. These risk factors determine a patient\u2019s overall RAF score; providers qualify for higher payments for patients with higher RAF scores.<\/p>\n

To drive higher reimbursement, providers will often seek to identify diagnoses which will result in a higher RAF score. This requires focus on the coding of a patient\u2019s diagnoses, and not necessarily on how well each condition is being managed. In other words, VBC models have created an overemphasis on coding, instead of on caring.<\/p>\n

Antiquated review methods<\/b><\/p>\n

Organizations use a variety of methods to increase RAF scores. One approach is to review a patient\u2019s medical record, typically after the provider\/patient encounter, to identify opportunities for \u201cupcoding\u201d a diagnosis to raise the RAF score. For example, if a diabetes diagnosis can be coded as having neurological manifestations, the risk score will be higher, as will the provider\u2019s reimbursement. An organization might have staff review charts manually after a patient encounter to identify potential diagnoses that could qualify for higher risk. There are also a flurry of software products coming to market to help identify opportunities to \u201coptimize\u201d or \u201cmanage\u201d risk which, in reality, is just a veiled way of saying \u201cupcoding.\u201d<\/p>\n

Unfortunately, neither of these review methods provide the clinician with tools at the point of care to care <\/i>for the patient; that is, properly manage, evaluate, assess, and treat a patient\u2019s various conditions in accordance with the original intent of VBC: improved outcomes through better management of patient health. Particularly as healthcare shifts to more team-based care delivered across a variety of settings, including in-office, telehealth, home health and more, the need for tools that help clinicians efficiently and effectively deliver care has never been greater. All providers must have instant access to the information and data needed to manage and code each patient\u2019s specific diagnoses \u2013 as well as to create documentation that supports the coding.<\/p>\n

A comprehensive clinical care approach to VBC, as opposed to an approach that focuses on the transactional coding of diagnoses to maximize risk scores, requires a new set of solutions that enable any provider to quickly see the status of any known or suspected condition. Such technology empowers clinicians to act upon information immediately and helps them create accurate documentation that supports a patient\u2019s diagnosis and satisfies potential quality care and MA audits.<\/p>\n

Needed: Point-of-care decision support for VBC<\/b><\/p>\n

Consider the potential benefits when providers are empowered with point-of-care decision support, diagnostic filtering, and documentation tools geared for VBC:<\/p>\n