How do you think healthcare organizations and other entities will use HCC data going forward?
Hierarchical Condition Categories (HCCs) are utilized by Medicare Advantage and Affordable Care Act payers for approximately 30 million individuals currently. Use of HCCs is projected to grow significantly in coming years and individuals with in-depth knowledge and command of the HCC system will be needed to ensure coding is accurate, supported by documentation, and that reimbursement is appropriate. We asked six experts what they thought about the challenges and opportunities provided by the accelerating move toward risk adjustment payment models.
In the sixth and final installment of this discussion, the experts answer the question, “How do you think healthcare organizations and other entities will use HCC data going forward?” (See the series in its entirety here.)
“The CMS HCC model is perfectly suited to assess the complexity of care across the continuum, and it will integrate nicely with ICD-11.”
-Rose T. Dunn
DUNN: Risk adjustment could eventually become the only reimbursement system for the United States, completely replacing DRGs. We could also see a weighting system for the HCCs based on inpatient vs. outpatient services.
The best thing the United States could do is adopt the CMS HCC model because this model is not proprietary. Proprietary models layer another level of cost on providers as they try to understand how the models differ. The CMS HCC model is perfectly suited to assess the complexity of care across the continuum, and it will integrate nicely with ICD-11. With one model, we would have cleaner data and more accurate profiles across the United States.
“HCCs ultimately provide a snapshot into patient severity, giving payors valuable information they can use to assess outcomes, predict costs, and gauge overall hospital performance.”
-Bonnie S. Cassidy
CASSIDY: HCCs ultimately provide a snapshot into patient severity, giving payors valuable information they can use to assess outcomes, predict costs, and gauge overall hospital performance. Hospitals are vulnerable in this new world of HCC scrutiny, so they need to assess their own HCC data to build strong revenue integrity audit programs.
MALONE: We’ll see more alignment between payers, organizations, and physicians. Also, the evaluation and management code changes that may take place will align with value-based care given the codes are heavily weighted toward the assessment and plan. CMS is encouraging physicians to document HCC conditions as they consider them when formulating a treatment plan. The data will also assist population health to better manage the population. This will allow for better chronic condition management with positive outcomes and improve quality of care and quality of life.
“HCC data and population health will become more intertwined.”
TAYLOR: HCC data and population health will become more intertwined. For example, we may see higher insurance premiums in certain geographic areas due to a higher disease burden.
MURPHY: ACOs will create more robust algorithms to stratify patient risk based on HCC data. I agree that there will be more of an effort to link social determinants of health with HCC data.
JOHNSON: We’ll see further refinements of risk adjustment payment methodologies just like we saw with DRGs and MS-DRGs. I also think we’ll see the coding system expand on the chronic condition side for additional specificity.
Bonnie S. Cassidy, MPA, RHIA, FAHIMA, FHIMSS, President of Cassidy & Associates
Rose T. Dunn, MBA, RHIA, CPA, FACHE, Chief Operating Officer, First Class Solutions, Inc.
Laurie M. Johnson, MS, RHIA, FAHIMA, Senior Healthcare Consultant, Revenue Cycle Solutions, LLC
Donna Malone, CPC, CRC, Director of Coding and Provider Education, Enterprise Risk Adjustment, Tufts Health Plan
John Murphy, MBA, Principal, Risk Adjustment Consulting
Earshler Taylor, RHIA, RHIT, CCS, CDIP, CPC-I, COC, CPC, Chief Executive Officer, Earshler Taylor Consulting
Lisa A. Eramo, MA, moderator and freelance writer
Fundamentals of HCC Coding
Go beyond just the diagnoses — really understand the methodology behind HCCs! Prepare for the future of healthcare reimbursement with “Fundamentals of HCC Coding,” by nationally recognized HCC authority Rose T. Dunn, MBA, RHIA, CPA, FACHE. Learn more here.