Presentation on theme: "2004 DxCG ®, Inc. -1- Rong Yi, Senior Research Associate, DxCG Inc. Academy Health Conference June 6, 2004 Better Provider Profiling: Adding Patient Risk."— Presentation transcript:
2004 DxCG ®, Inc. -1- Rong Yi, Senior Research Associate, DxCG Inc. Academy Health Conference June 6, 2004 Better Provider Profiling: Adding Patient Risk Adjustment to Episodes
2004 DxCG ®, Inc. -2- Questions Keeping Us Up at Night: How much do patient comorbidities affect episode costs? Could we use the DCG Relative Risk Score that measures patient risk along with Medstats Episode Group method to more accurately determine expected costs? How do severity and risk-adjusted episodes change our provider profiling results? The credibility of a provider profiling initiative depends largely on how well we can respond to the my patients are sicker objection.
2004 DxCG ®, Inc. -3- Presentation Outline Project objectives Proposed methodology Application to BCBS of South Carolinas provider profiles Conclusions
2004 DxCG ®, Inc. -4- Look-backEpisodeClean Period Office Visit Office Visit PrescriptionLabHospital Admission Office Visit MEGs Medstats Episodes Grouper Links together a patients claims into a clinically meaningful episode across care settings Calculates summary episode cost and utilization metrics Assigns a managing physician to the episode to support profiling Determines the disease stage of the episode (highest)
2004 DxCG ®, Inc. -5- Diagnosis Information Age/Sex DCG Model Clinical Categories Patient Risk Scores DxCGs DCG/HCC Models Developed using regression methods on Medstats MarketScan database (commercial model) Model input includes demographic information and all diagnosis information (and/or drug information) for a patient for a period (typically a year) Assigns a set of risk scores to the patient that measures current and future risk (used for adjustment in profiling and predictive modeling).
2004 DxCG ®, Inc. -6- Member ID: Name: John Smith Age: 54 Sex: M Rel Risk Score: year old male Condition Categories 5.71Diabetes with renal manifestation 1.84Congestive heart failure 0.90Acute myocardial infarction 0.89 Vascular disease with complication 0Vascular disease hierarchy 18.09Dialysis status … …… 0.46Diabetes & congestive heart failure interaction ______ 29.34Relative Risk Score DCG – Calculating a Patients Risk Score
2004 DxCG ®, Inc. -7- How Much Should an Episode Cost? - Depends on the patient! Average Episode Cost DCG Risk Score (Health Burden, 1.0 = Avg) Whole Patient Cost Next Year Risk-Adjusted Episode Cost 45 year old female Healthy $ $1,500?? 55 year old male Early Chronic $ $4,500?? 64 year old female Chronic with Complications $ $12,500??
2004 DxCG ®, Inc. -8- Cost of Pneumonia and Patient Risk (DCGs) Healthier..……………… Sicker DCG Risk Score Stage # of Episodes Episode Cost Avg DCG Risk Score ,918$ , $171$246$335$378$ $ $56$166$623$368$2, $ $37$118$44$89$4,371 Overall4,069$
2004 DxCG ®, Inc Stages are not comparable across MEGs, but broadly higher stages go with higher risk scores. Ordinal Stage# of EpisodesMean Patient Risk Score Range 0409,3171.3(0.1, 56.4) 1962,9462.1(0.1, 52.5) 273,8663.2(0.1, 52.5) 310,4915.1(0.1, 52.5) Overall Relationship between Episode Disease Stage and Patient Illness Burden
2004 DxCG ®, Inc Risk-Adjusted Episodes in Provider Profiling Problem: While episodes can be severity-adjusted, without adjusting for patient risk, there is the potential to unfairly reward physicians who care for patients with few co-morbid diseases and penalize those who effectively care for patients with significant disease burden. Proposed solution: Marry the patient-level risk scores from DxCG with the severity score within Medstats Episodes Grouper to fairly evaluate physicians and pay for the best performance. Medstats Episodes Grouper Severity-adjustment within Episode DxCGs HCC Model Whole-patient Relative Risk Score Risk-adjusted Episodes
2004 DxCG ®, Inc Developing the Risk-Adjusted Episode Model MarketScan database –Only complete episodes with enough time for claim run-out –20 million episodes in 2002 Regression models incorporating –MEG –Disease Stage –DCG/HCC Prospective Relative Risk Score Predict episode cost within each MEG
2004 DxCG ®, Inc Improvements in Predictive Power (R 2 )
2004 DxCG ®, Inc Overview of BCBS of South Carolinas Profiling Efforts 1+ million enrolled members Provider Contracting deals with over 1600 physicians Profiling effort began in 1998, using the MEGs. Profile specialists with more than 100 members on episode cost and use information and compare to specialist norms
2004 DxCG ®, Inc Risk-Adjusted Episode Profile for Internal Medicine / General Practice BASEBASE + DCG Managing PhysEpisodes Mean ActualMean ExpPerf RatioMean Exp Perf Ratio Perf Ratio Change A1,199$413$ $ % B1,131$433$ $ % C1,065$451$ $ % D633$746$ $ % E704$665$ $ % F919$495$ $ % G835$514$ $ % H356$1,091$ $ % I616$629$ $ %
2004 DxCG ®, Inc Performance Ratios by Physician Performance ratios for most physicians (the ratio of actual $ / expected $) are similar between the two methods. Some physicians performance ratio changes significantly when we add patient risk to the adjustment. Physician H moved from an outlier to practicing within expected range Physician D is even more of an outlier Adjusted using episode group and stage Adjusted using episode group, stage and patient risk
2004 DxCG ®, Inc Physician D – Drill Down Episode DescriptionEpisodes Actual Payments Exp Payments (BASE) Exp (BASE+DC G) Actual RRS Expected Average RRS Other Nutritional and Metabolic Disorders91$373$260$ Essential Hypertension, Chronic Maintenance88$640 $ Other General Signs, Symptoms, and Conditions47$343$366$ Other Ear, Nose, and Throat Infections27$158$148$ Osteoarthritis25$2,443$1,462$1, Other Spinal and Back Disorders21$398$505$ Other Respiratory Symptoms19$608$776$ This physicians patients have consistently lower illness burden than expected.
2004 DxCG ®, Inc Physician H Drill Down Physician H moves from an outlier to within the norm due to treating more severely ill patients. Episode DescriptionEpisodes Actual Allowed Payments per Episode Exp Allowed Payments per Episode (MEG) Exp Allowed Payments per Episode (MEG & DCG) Actual RRS Exp Average RRS Essential Hypertension, Chronic Maintenance40$729$620$ Other Nutritional and Metabolic Disorders29$485$260$ Diabetes Mellitus Type 2 and Hyperglycemic States Maint26$1,656$1,360$1, Hernia, Hiatal or Reflux Esophagitis12$880$501$ Renal Failure9$13,110$2,992$10, Angina Pectoris9$1,180$5,189$4,
2004 DxCG ®, Inc Conclusions Episode costs increase with the severity of the disease (MEG) and disease burden of the patient (RRS) Considerable variation in episode costs leaves room for risk adjustment Organizations can improve the accuracy of provider performance assessments using risk-adjusted episodes. This is important for ensuring equitable pay-for-performance. Plans are underway to incorporate risk-adjusted episodes into the Medstats standalone episode grouper and Advantage Suite.