benchmark is based on its historical performance—more specifically, its population risk adjustment factor defined by hierarchical condition categories (HCCs). For Medicare Shared
Savings Program (MSSP) ACOs, this threshold remains in
place for a minimum of five years with a potential risk score
growth of three percent during that timeframe. However, per
the “Pathways to Success” final rule, there is no defined limit
on risk score decreases over the agreement period. Documentation must accurately reflect disease complexity because this
information translates to medical codes that convey the financial resources the ACO needs to function properly.
If an ACO isn’t able to communicate the resources it needs
to effectively serve its population, it could face years of insufficient reimbursement. Interestingly, a recent survey of 43 Track
1 MSSP ACOs conducted by the National Association of ACOs
prior to the release of the Centers for Medicare and Medicaid
Services’ (CMS) Pathways to Success final rule found that 71
percent of these entities will likely leave the MSSP as a result of
assuming risk in a t wo-sided model. 1 Could subpar documentation be one reason why? Quite possibly. These ACOs may not be
able to sustain the care they provide because their documentation doesn’t justify their costs. Creating a population health CDI
program can help solve this issue and others for an ACO.
Justifying the Need for Population Health CDI
Obtaining executive-level buy-in is the first step in creating a
population health CDI program because it ensures there will be
resources dedicated to the effort. However, demonstrating an immediate return on investment (ROI) can be challenging because
ACO reimbursement is based on retrospective data. Even if an
ACO improves its risk adjustment factor (RAF) scores in the short-term, it won’t see a potential increase in its benchmark immediately, as is realized in inpatient or fee-for-service models. Even
then, the ACO would still need to contain costs and meet quality
metrics to drive a shared savings payment. Instead, health information management (HIM) professionals can articulate the following to hospital executives:
1. While adding dollars to the ACO benchmark does not
mean we have improved our bottom line, it does make it
easier for the organization to meet the MSR.
2. By improving our organization’s outpatient documentation, we’ll also improve our inpatient documentation
specificity. This will help with prior authorizations, cost
justification, medical necessity, risk adjustment for hospi-tal-centric outcome measures, star ratings, and more.
3. By improving our organization’s outpatient documentation, we can reduce denials in our system-owned physician practices.
4. Having complete, accurate, and detailed provider documen-
Forming a Population Health CDI Team, Strategy
tation is key to ensuring patient safety and providing consis-
tent quality care. This documentation also informs payers
and system leaders when making strategic business decisions
(e.g., whether to participate in a bundled payment model).
A population health CDI team should exist at the corporate
level and include the following individuals:
Ambulatory coding and/or CDI director
Executive director of HIM
Hospital coding and/or CDI director
Vice president and/or manager of population health and
chief transformation officer
The team should also include at least one physician cham-
pion. Depending on the size of the ACO, multiple physician
champions may be necessary. However, rather than strive to as-
sign a physician champion for each specialty or region, focus on
finding the right individual for the role. A physician champion
should be someone who is enthusiastic about CDI, respected
by their peers, influential within the medical community, and
whose documentation can serve as a model for others.
Together, a population health CDI team can answer the following strategy-related questions:
What HCCs will we target, and why?
What HCCs have not yet been captured in the current
year? Are we able to capture these HCCs during and before each visit? For example, can nurses and medical assistants obtain and present pre-visit planning information
to physicians before they meet with patients so physicians
can monitor, evaluate, assess, or treat the conditions during the visit? Can we incorporate point-of-care technology into the provider workflow to assist with this process?
How will we streamline CDI efforts across disparate providers to prevent physician burnout and improve physician satisfaction and engagement? For example, how can
we align messaging from CDI, coders, care coordinators,
compliance, legal, and others to reduce the documentation
burden as much as possible? Can we leverage our inpatient
CDI program in any way? In many cases, targeted diagnoses will overlap.
How will we provide ongoing education to all physicians,
including those working in independent practices? How
will we track new providers who are onboarded into the
ACO so they don’t fall through the cracks?
How can we work with I T to develop documentation tools
that integrate easily into physician workflows?
How will we continually measure and communicate the
ROI of our program?
Understanding Baseline Documentation
Identifying the quality of baseline documentation enables an
ACO to track its progress and identify high-risk areas to target
Population Health CDI
Generates ACO Shared Savings