Maximizing the Value of Risk-Adjustment Models

Medical professionals reviewing data on risk-adjustment models

Mount Sinai Medical Center, a not-for-profit teaching hospital in southern Florida, has a mission to provide high-quality healthcare to their diverse communities that is enhanced through teaching, research, charity care and financial responsibility. To commit to their mission, the medical center stays focused on new ways to improve population health.

Upon refining their population health strategy, Mount Sinai identified hierarchical condition category (HCC) coding as a major area of focus, especially during their transition to value-based care. HCC coding is a risk-adjustment model designed to estimate future healthcare costs for patients. For example, a patient with multiple chronic conditions would be expected to have higher healthcare utilization and costs compared to a patient without serious health conditions, resulting in different “scores” for each patient.

With all of this in mind, the organization set goals to improve their EMR system’s build and workflows and to increase HCC awareness and compliance among physicians following the system enhancements.

Stage 7 Success Story: Improving HCC Coding Process to Benefit Patients and Providers

To get started, Mount Sinai organized a population health task force to set and drive the strategy behind their organizational goals. The task force included staff from various parts of the organization: physicians, practice administration, managed care operations professionals, business office professionals, information technologists and project management professionals.

The first course of action the task force undertook was to update best practice alerts (BPAs) into the EMR. The new BPAs simplified the process of adding information related to diagnosis and incorporated more menu options for selection such as “not applicable.” BPAs were adjusted so they would only fire as relevant for specific types of visits—in this case, internal medicine office visits. These adjustments were integral to improving scores based on the risk-adjustment model.

In efforts to better align with payer reporting, the task force turned on claims external data mapping using various reporting tools in the EMR. To increase awareness and improve score visibility, they started displaying the score both on the EMR multi-provider schedule and within the patient chart.

Thanks to the work of the task force, they immediately observed positive results in provider engagement. Simplifying the BPA alerts led to a nearly 90% drop in unnecessary notifications, helping physicians stay focused on the EMR alerts and BPAs that were most relevant to a patient’s diagnosis.

After including more interactive action buttons to alerts and restricting notifications to internal medicine, 50% of patients had a diagnosis added from an alert, and 5% had a problem added or resolved directly from an alert. Data was constantly reviewed and shared with the individual provider, which helped close gaps and improve performance.

Based on internal reporting on the HCC risk-adjustment model, HCC scores increased from 0.74 in 2017, to 1.04 in 2018, and to 1.08 in 2019; and the minimum potential score increased from 0.87 in 2017, to 1.18 in 2018, and to 1.22 in 2019. Overall, the coding compliance efforts resulted in more accurate resource allocation, with an average increase in premium payments from the Centers for Medicare and Medicaid Services (CMS).

This in-depth learning experience helped Mount Sinai leverage the full capabilities of their EMR to provide high-quality care and promote physician awareness and compliance with these changes.

Achieving O-EMRAM Stage 7 Validation

HIMSS is pleased to recognize Mount Sinai Medical Center of Southern Florida for their HIMSS Outpatient Electronic Medical Record Adoption Model (O-EMRAM) Stage 7 validation.

“It was a pleasure to visit Mount Sinai Medical Center and witness the commitment to improve the health and lives of their patients,” said Philip Bradley, regional director, analytics, HIMSS.

“We strive each day to achieve our mission,” said Robert C. Goldszer, MD, MBA, FACP, chief medical officer, Mount Sinai Medical Center. “Key to all of our achievements are the people who work together at Mount Sinai Medical Center. Our HIMSS Stage 7 recognition is a recognition of the commitment and work of our leadership, our information technology team, physicians, nurses, practice administration and many others.”

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