As health plans and other organizations prepare for Health Reform – including meeting Health Exchange requirements and preparing and competing for the expansion in government program business – there is a renewed focus on meeting accreditation and quality measurement requirements. These requirements are promulgated by organizations such as CMS and state regulators and administered by the National Committee on Quality Assurance (NCQA), URAC and other auditors that are certified by these government agencies.
For experienced health plans with generously staffed Quality Management departments this is old hat to them. To others – newer health plans, provider-sponsored health plans and community-based organizations – the language of the requirements can be foreign and the work required to meet them can seem ominous.
There tends to be theme songs to some of the key quality regulations and requirements. What data do you have that shows your knowledge of the population? How do you use the data to identify opportunities in the population? And how do you measure that your initiatives have had any impact?
Tools like MedInsight, with its clinical analytic and the risk scoring capabilities can be very effective in addressing the needs of some of these requirements. Most organizations are using these tools to identify preventive care gaps and address those gaps but many are missing opportunities to address other critical accreditation and quality improvement areas.
Some of these opportunities include:
- NCQA Health Plan Quality Improvement Standard 7 – requires the ability to identify members with complex illnesses and comorbidities, establish identification methods and conduct an annual population evaluation to determine the continued validity of those methods.
- NCQA Health Plan Quality Improvement Standard 8 – requires the ability to identify condition populations for disease management and implement a stratification approach for selective intervention.
- CMS Special Needs Plan (SNP) Model of Care (MOC)- requires the ability to define the needs of the population, identify frail and high need members and provide interventions based on analysis of population needs.
MedInsight and the Milliman Advanced Risk Adjuster (MARA) provide the ability to efficiently and consistently identify candidates for case and disease management, identify comorbidities and stratify members for targeted intervention. As quality managers and care management leaders gain access to this information these teams will find strong evidence of their ability to meet these accreditation requirements and a solid source of qualified members who will benefit from their programs.
The CMS diagnostic related groups (DRGs) have undergone numerous refinements since first introduced in the early 1980s, but they remain essentially a tool to support the CMS prospective payment system. What would a grouper that focused on clinical categories rather than payment look like? For the answer, take a tour of our new product – Guideline Analytics.
Guideline Analytics uses standard claims data elements — diagnosis/procedure codes and patient demographics, for example — to assign each inpatient admission to an Optimal Recovery Guideline (ORG) or General Recovery Guideline (GRG) category drawn directly from our acute care content —Inpatient & Surgical Care and General Recovery Care. Each admission is categorized by a principal ORG or GRG code, subsidiary ORG codes, and a severity category based on the comorbidity methodology developed by CMS for its DRG system, complication/comorbidity (CC) and major CC.
The results are easy-to-manipulate data warehouse analytics and/or an Excel spreadsheet report that allows you to analyze performance against optimal outcomes, compare yourself to peer organizations, and identify clinical areas where you can provide care more effectively.
Why not simply use the MS-DRGs to accomplish this analysis? The short answer is that the MS-DRGs were built for a different purpose. For the long answer, let’s say you’re the medical director at a medium-sized health plan. (The data that follows is actual 2010 data from such an organization.) You’re trying to understand how your network is addressing obesity using surgical procedures. Specifically, you want to know how many surgeries are being performed on an inpatient basis that – under optimal conditions – could be performed on an outpatient basis. The DRGs provide three categories for Operating Room Procedures for Obesity. However, two of those categories are for cases with significant complications and comorbidities– unlikely candidates for outpatient surgery, and in practice, only about one-sixth of cases. That leaves one large category (DRG 621) for analysis. Not much granularity.
Guideline Analytics breaks DRG 621 into seven MCG™ guideline categories (see chart below), including S-515 – Gastric Restrictive Procedure without Gastric Bypass by Laparoscopy. Why is S-515 so interesting? According to current medical literature, given optimal conditions, patients can receive this procedure on an outpatient basis. Yet 28% of such procedures are being performed on an inpatient basis at an overall cost of $1.3 million. Is that a reasonable percentage? Should you dig deeper into the data? Guideline Analytics provides risk-adjusted benchmarks – covering different lines of business, different regions of the country, different degrees of medical management, and different delivery systems – so you can assess where that 28% places you compared to peer organizations. Guideline Analytics are linked to MCG™ guideline categories in terms of their foundation only, the Guideline Analytics are not dependent on a client having a license to MCG™ products. Due to the linkage of the Guideline Analytic categories to MCG™ we know that the recent medical evidence on this procedure, S-515, includes five published studies showing the safety of outpatient treatment and four articles describing situations in which inpatient care may be required. This unique combination of statistical data and medical evidence from peer-reviewed sources allows you to decide your next step with confidence.
2010 Inpatient Medical Claims Analysis for Medium-Sized US Health Plan
Health Plan (Plan) medical management functions are designed to provide solutions to a wide range of objectives including, controlling utilization, improving clinical quality, credentialing physicians and facilities, complying with regulatory requirements and meeting market expectations. The Accountable Care Act’s provision limiting administrative costs has created an environment where all Plan administrative services are under pressure to credibly show value with a focus on demonstrating financial value. This has brought increased pressure on medical management executives to show the value of all medical management functions. Some functions meet regulatory and market demands and therefore are basic business requirements. For these services the emphasis should not be on demonstrating financial value but on demonstrating best practice efficiency meaning the basic business requirements are being met at the lowest cost. Other medical management functions directly target controlling utilization and claims cost and are expected to result in a quantifiable financial return on investment (ROI). Reliable tools and metrics for measuring the ROI for medical management have not been readily available so Plan executives have had to rely on a variety of non-standardized and often unreliable methods.
This blog post explores the characteristics an idea medical management ROI tool or tools would have and shares Milliman research progress towards developing a portfolio of tools designed to provide solutions for Plan executives wanting to credibly measure ROI of medical management.
Future blog posts will describe each tool in detail.
We believe the ideal medical management ROI tool would have these characteristics,
- Calculates ROI using credible methods that do not over or under value the financial impact of medical management
- Does not credit medical management with value produced by non-medical management interventions such as plan design, provider contracting and others
- Accepted as credible and valid by key internal and external audiences including,
- Plan executives
- Plan actuarial and finance functions
- Plan marketing
- Employer groups
- Providers in risk arrangements where the Plan provides medical management services
- Uses industry standard metrics allowing benchmarking and credible comparison with other Plans