More on Revenue Cycle Management

Mercy Family Medicine risk-adjusts patients to achieve Triple Aim

Both objective and intuitive elements must be considered to paint the truest picture of a patient's needs and calculate the risk, expert says.

Beth Jones Sanborn, Managing Editor

Risk adjusting patients must include both objective elements like the number of visits, and subjective information like pyscho-social issues.

That's the word from an expert with Mercy Family Medicine, a family practice group of 17+ providers in Durango, Colorado.

Mercy, which is part of Centura Health, has been involved with the Comprehensive Primary Care initiative for the last four years.

HIMSS20 Digital

Learn on-demand, earn credit, find products and solutions. Get Started >>

Tamra Lavengood, clinical performance coordinator for Centura, said the payer groups gave the clinics revenue up front with Per-Member-Per-Month payments that allowed for building the infrastructure in the clinics to provide comprehensive primary care.

"It was a multi-payer collaborative that put its bet on Primary Care to meet the Triple Aim, and it did," Lavengood said.

[Also: Critics blasts ACA risk-adjustment program for unfairly rewarding high administrative costs, premiums]

The first task was for all 500 clinics to come up with a methodology to risk stratify their patient population. The biggest lesson learned, she said, is that risk stratifying based on claims doesn't give clinics the true picture of who their sickest patients are in order to manage care. It's about more than just the numbers of visits, diagnoses, numbers of medications and hospitalizations that the EHR is able to pull. There are the psychosocial determinants of health, the things that you know only when you talk with the patient. These are the subjective elements that make up a person's true healthcare needs or risk, Lavengood said.

"If clinics can identify and focus intensive care management on their highest-risk patients and keep them out of the ED and hospital then there will be a cost savings," she said.

Lavengood explained that vendors need to build a risk stratification methodology within the EHR that accounts for objective elements as well as subjective or intuitive elements.

Like Healthcare Finance on Facebook

When the 500 clinics began to develop a risk stratification methodology, for instance, 71 percent of the clinics stated that risk stratification requires an intuitive element.  As such, they developed a tool that does just that, and has proven to be highly effective in determining their highest risk patient population. In fact, she said their highest level patients, known as level 6, make up one percent of their population, The high risk, levels 5 and 4, make up about 20 percent of the population, depicted by their tool. 

This correlates to the fact that 20 percent of our population use 80 percent of our healthcare dollars and the top one percent utilize 50 percent of our healthcare dollars. 

"It only makes sense to target care management to those at highest risk," she added. "This is where you will get the most cost savings."

Lavengood, along with Will McConnell, Mercy's vice president of operations and outreach strategy at HIMSS17. Their session, "Leveraging health IT to risk adjust patients," is scheduled for Sunday, Feb. 19, 2017 at 9:30 a.m.-10:30 a.m. EST in room 208C.

HIMSS17 runs from Feb. 19-23, 2017 at the Orange County Convention Center.

Twitter: @BethJSanborn