Reviewing Medicare claims data is a valuable first step. CMS
provides robust, claims-level information about each ACO’s
attributed beneficiaries. This information includes beneficia-ry-level Medicare claims for hospital services, physician services, post-acute care, and other covered Medicare services.
An ACO can use this data to evaluate beneficiary cost across
the continuum of care. CMS also provides the following:
Monthly claims and claims line feed files for assigned
Quarterly reports (including an updated ACO benchmark
and list of attributed beneficiaries)
However, it’s not easy to extrapolate these results to determine
where educational resources are best spent. An external vendor
with data analytics expertise can help an ACO normalize, organize,
and understand its data so it can refine the focus of its population
health CDI program on certain specialties, practices, or physicians.
A vendor can also help articulate the impact of CDI efforts (i.e.,
how much do we anticipate the RAF score has moved?).
Using Data Analytics to Drive the Program
Where can an ACO have the biggest financial impact across
the entire system? Based on the data, it may be better to focus
on one high-impact diagnosis (e.g., diabetes without complications) rather than several lower-impact ones. However, an
ACO must be cautious when using data. Partnering with practice managers and others in operations (e.g., care coordinators and physician advisors) can help CDI specialists identify
whether they should target certain providers as early adopters
or for ongoing CDI interventions. For example, if data analytics identifies that an endocrinologist continually forgets to
document body habitus to support the body mass index and
morbid obesity diagnosis, it might not make sense to engage
this provider as an early adopter if the practice manager states
that the physician typically resists CDI efforts. When targeting
interventions, it’s important to ask these questions:
How far does the provider’s RAF scores deviate from expected scores?
How large is the provider’s patient panel?
Is the effort required to convince the provider to support
CDI worth the anticipated benefit?
Is the provider participating in other initiatives/projects
that may limit their ability to focus on CDI?
Providing Ongoing Physician Education
The success of a population health CDI program depends
largely on an ACO’s ability to provide ongoing physician education. All physicians, including primary care providers and
specialists, should strive to capture HCCs that are pertinent to
the current encounter. Be sure to include the ACO’s independent providers in HCC education. Explain to physicians that a
RAF score is assigned to a patient—not a provider. As patients
move throughout the ACO receiving care in multiple settings,
each physician must do his or her part to capture the HCCs
that cumulatively affect this patient-specific score. Establish
a baseline average RAF score for each physician, provide education regarding HCC capture, remeasure the average RAF
score, and then provide additional education as needed.
Linking Documentation with Patient Engagement
Population health CDI programs are unique in that they include
an element of patient engagement that’s typically absent from
inpatient CDI programs. That’s because population health is all
about managing the continuum of care rather than an isolated
inpatient admission. To truly enable population health management, patients must be empowered throughout their healthcare
journey to make healthy choices, participate in preventive screenings, and stay out of high-cost settings. ACOs that ultimately improve the health of their populations are those that can identify
high-risk patients (both from a clinical perspective and based on
their social determinants of health) and target them with tailored
Population Health CDI
Generates ACO Shared Savings
THE EARLIER AN ACO establishes a population health CDI
program, the better. However, ACOs can also benefit from
CDI efforts at any point in their journeys. Consider the fol-
lowing six ways in which population health CDI supports
1. Understanding costs. Accurate documentation
translates to accurate data. Without data, organizations can’t justify costs.
2. Reducing patient leakage. Accurate documentation
drives the data that helps organizations identify opportunities for new patient services, new contractual
relationships, and other changes necessary to retain
patients within the ACO by improving patient access
and the care experience.
3. Maximizing pay-for-performance reimbursement.
Accurate documentation helps providers close gaps
in care, thereby driving better outcomes through preventive medicine and an avoidance of “never events”
and hospital-acquired conditions.
4. Reducing utilization. Accurate documentation helps
organizations reduce costly hospitalizations, emer-
gency department visits, and 30-day readmissions.
5. Supporting chronic disease management. Accurate
documentation enables organizations to target and en-
gage high-risk patients with meaningful interventions.
6. Predicting individual patient health. Accurate docu-
mentation supports accurate data analytics—the ability
to predict outcomes based on the number and severity
of a patient’s comorbid conditions. Organizations can
then target these individuals with early interventions.
Six Ways in Which CDI Efforts Support
Population Health Initiatives