FOCUS MORE ON CARE AND LESS ON HCC CODING COMMUNITY HEALTH NETWORK SEES FINANCIAL IMPACT OF NEARLY $13 MILLION.¹

From a population health perspective, one of the goals within many organizations is to deliver value-oriented care. Medicare beneficiaries have doubled in the past decade as fee-for-service continues to downtrend and value-based care programs uptrend. Through the transition from fee-for-service to value-based care programs, hospitals must consider quality scores, risk adjustment and utilization management. Proper coding and documentation are key to optimizing success and ensuring accurate reimbursement.

Current Hierarchical Condition Category (HCC) coding approaches include manual, time-consuming processes, including sticky note reminders and retrospective review after visits. In most cases, the physicians are pulling charts prior to a patient visit to look for conditions that should be captured.

New HCC coding approaches provide real-time software using chart data where information is automatic during the encounter, recommendations are delivered based on chart evidence in the existing electronic health record (EHR) workflow and clinicians are only alerted when there is a suggestion that may help guide the provider to improve coding accuracy.

Community Health Network is an integrated health system based in Indianapolis and central Indiana with a focus of innovation in care delivery. Despite financial hardships from COVID-19, Community Health Network was able to obtain a positive financial impact of nearly $13 million with actionable HCC alerts.

“The HCC alert was followed 64%, and if you are familiar with alerts in an EMR, a follow rate of 64% is nearly a miracle. We shoot for 40-50% as a gold standard, so to have it at 64% tells you that providers really were accepting of this workflow and the alert when appropriate.”

Patrick McGill, M.D., EVP, Chief Transformation Officer | Community Health Network

SOLUTION AND IMPLEMENTATION

Community Health Network began to focus on HCC in 2019 with the shift to risk-based contracts as a significant driver. Prior to focusing on improving HCC coding, their risk scores fell below the national averages. Launching their PINC AI™ Clinical Intelligence HCC content in 2020, Community Health Network focused on three HCC categories – 18, 19 and 22 – which encompasses diabetes with chronic kidney disease, hyperglycemia neuropathy and then morbid obesity. Although they wanted to start small, they knew that these categories would have a huge impact on their risk scores.

INTEGRATION GOALS

The goal for their implementation was to provide cognitive activity within the workflow when it makes sense – the right time, the right place and the right provider. With the clinical decision support (CDS) engine evaluating over 30 elements per code, it’s helping alleviate the extra burden of clinicians having to search through charts and making sure their codes are accurate.

KEY INSIGHTS AND IMPACT

MORE SPECIFIC DIAGNOSIS CODE INTEGRATED INTO PROVIDER WORKFLOW

+ CDS logic evaluates 30 elements.

+ More accurate diagnosis available.

+ Codes are added to visit diagnosis and problem list.

$700 PMPM MEDICARE ADVANTAGE, $800 PMPM NEXT GEN ACO

+ 10 percent of attribute lives throughout primary care provider base using 85 percent historical recapture rate. Looking at 10 actionable HCC codes resulted in 25,000 alerts triggered in 2020 – average 57 percent follow rate.

NEARLY $5 MILLION IN FINANCIAL IMPACT IN 2020 DESPITE COVID-19 AND NEARLY $8 MILLION IN IMPACT IN 2021²

+ Accurate coding documenting the disease burden while allowing clinicians to manage complicated codes and report them accurately in the EMR.

RESULTS

With the transition to focus more on HCC coding, Community Health Network has been able to optimize success in providing value-based care and increasing their financial impact. Stanson Health, a PINC AI™ solution offers HCC guidance enabling them to provide more accurate coding across 10 actionable alerts in 2020 and 37 alerts; nearly $13 million in positive financial impact starting January 2020 through December 2021. With their continued partnership with PINC AI™ HCC alerts, Community Health Network can continue to focus on improving patient care, risk score outcomes and optimizing Medicare Advantage reimbursement.