In the era of value-based care (VBC), Hierarchical Condition Category (HCC) coding is crucial for accurately assessing patient risk, optimizing care, efficiently allocating resources and maximizing financial reimbursement.
Sparrow Health recognized the need to adapt to the evolving healthcare landscape and aimed to improve their HCC coding performance. The health system strategically implemented PINC AI™ Stanson's HCC alerts, focusing on provider buy-in, persistency in coding and comprehensive education to improve their risk score.
As a result, Sparrow Health documented over 1,300 suspect codes since October 2022 and maintained a 45 percent follow rate with the PINC AI™ Stanson HCC alerts.
In the age of value-based care (VBC), where quality and efficiency drive healthcare, Hierarchical Condition Category (HCC) coding is the linchpin. As health systems transition towards value-based models, understanding HCC coding becomes pivotal. It enables accurate patient risk assessment and is vital for optimizing care, proper resource allocation and appropriate financial reimbursement.
Sparrow Health, a nonprofit organization serving Central Michigan, realized the need to align with the evolving healthcare landscape. The organization had traditionally focused on retrospective data from payers and clinical documentation improvement (CDI) teams, but with the shift towards risk-based contracts and total cost of care, they recognized the urgency to keep up with the times. “We were fairly reliant on HCC recapture that was queued up by information coming from either payer gap reports or payer CDI tools, which is not very well ingested into the provider workflows to say the least,” said Deanna Bachman, Manager of Program Development at Sparrow Health. “So, we realized that we needed to do something more powerful, more impactful to catch up with the times, especially as we were exploring moving into some higher risk- based contracting.” The health system aimed to improve their overall risk scores and increase awareness and engagement among clinicians.
Navigating VBC with PINC AI™ Stanson’s HCC Alerts
Sparrow Health sought a solution that heightened awareness of the profound impact accurate HCC coding has on patient care. Historically, Sparrow Health had refrained from using interruptive alerts due to providers frequently disagreeing with the clinical decision support (CDS) content. In this pursuit for improvement, the health system turned to PINC AI™ Stanson for a CDS solution integrated in the electronic health record (EHR) environment. The PINC AITM Stanson HCC alerts, with their AI-enabled capabilities, are designed to be actionable and built to limit the provider’s administrative burden. “What our providers were really looking for was something that took time away from chart mining. They really wanted a solution that put discrete data, concrete, reliable information in front of them so that they could make those decisions very quickly. So, we did elect to move forward with PINC AI™ Stanson alerts since that really allowed us to dig into the suspect condition opportunities that we knew we were missing,” said Bachman.
The alerts are driven by evidence-based, clinician-designed logic, ensuring that an alert will only be triggered if the patient meets a specific profile and only provides recommendations that are relevant to the clinician’s decision. “We wanted to provide our physicians with alerts that aligned with clinical decision-making and added value. The providers needed to feel that the alerts were accurate and genuinely helped them in patient care decisions,” said Bachman.
Securing Provider Support and Enhancing HCC Coding Knowledge
With the right technology in hand, Sparrow Health aimed to build provider buy-in. They initiated the rollout of PINC AI™ Stanson’s HCC alerts, starting with primary care physicians (PCPs). They selected a group of engaged providers who were willing to experiment and had a population health mindset. “Our physician champions shared their positive experiences with their peers, making the transition smoother and providing real-world insights into the benefits of PINC AI™ Stanson’s HCC alerts,” said Bachman.
One of the challenges Sparrow Health faced was ensuring that providers understood the importance of HCC coding beyond just risk scores. To address this, they emphasized "persistency" instead of solely increasing risk scores. Persistency focused on the accurate and ongoing recognition of patients' conditions, with an emphasis on documenting resolved conditions.
Their incentive distribution model was designed to promote persistency by emphasizing that coding accuracy and documentation should align with the patients' actual health conditions. This marked a significant shift from incentivizing more work for additional compensation to a model that valued persistency, recognizing resolved conditions and encourages accurate capture. The delicate balance of providing information for decision-making without pressuring providers to increase risk scores became a cornerstone of Sparrow Health's incentivization strategy. This approach aimed to make informed decisions about care rather than merely pursuing higher scores for financial gain, aligning with the goals of their Accountable Care Organization (ACO).
Education played a crucial role in their approach. Sparrow Health provided comprehensive training and feedback to their pilot groups and held regular ad hoc sessions to support practices struggling with adoption. They also integrated risk capture discussions into their quarterly provider engagement meetings. "We educated providers on interoperability, stressing how their problem list precedes patients in collaborations and referrals. Emphasizing the revenue impact on risk stratification, we highlighted supporting services like care management and behavioral support, underscoring the value of risk capture for patient outcomes during our pilot," said Bachman.
Sparrow Health’s efforts have been successful, with their ACO achieving the highest risk score of all of their populations and programs. In the first eight months of 2023, providers have added >1k HCC codes (suspect/not documented previously) at the point of care, from the Stanson HCC alerts, driving ‘millions’ in new/appropriate reimbursement, necessary to deliver high quality care for those patients. “We've maintained throughout almost a year now of our work with this tool, approximately 40 to 45 percent follow rate with the alerts. So that really breaks down to just over 1300 previously unaddressed or uncaptured HCC conditions here in less than a year,” said Bachman. Furthermore, Sparrow Health is now rolling out recapture alerts with multiple practices, demonstrating their dedication to improving HCC coding accuracy and persistency.
“We are currently piloting interruptive recapture alerts with two practices and will be moving to more in the near future. I do believe that it’s because of our work with PINC AI™ Stanson our providers are not apprehensive about this change. Stanson has made our providers feel comfortable-- their team makes it very easy.”
An unexpected positive outcome of Sparrow Health’s HCC coding improvement initiative is that it allowed clinicians to normalize difficult conversations about healthcare concerns. “The alerts provided language and guidance for discussing sensitive topics, such as obesity, benzodiazepine use and mental health with patients,” said Bachman. “Clinicians not only documented these concerns but also engaged in meaningful conversations with patients, fostering a deeper understanding of their health needs.”
Sparrow Health plans to expand their success by rolling out the same process to more specialists. This expansion ensures continued growth and improvement in HCC coding while fostering patient-centered healthcare conversations. Sparrow Health's journey with PINC AI™ Stanson showcases how a health system can adapt to changing healthcare models, overcome initial barriers and improve coding accuracy while ensuring that providers are comfortable and confident in the process.
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Ryan M. Nellis
Vice President & General Manager, Stanson Health, a Premier (PINC) company
Ryan leads a team of clinicians, engineers and data science experts who work together to deliver AI-infused solutions to improve patient care and health costs via a growing client network of over 650 hospitals and 400,000 physicians.
Mr. Nellis is a growth-oriented leader who delivers business value in investor/venture and PE-backed, high-growth, public and private companies. He has developed and executed strategies in the health analytics and real-time clinical decision support solution markets – from both the provider and payer perspectives.