Documenting the patient’s Risk Adjustment Profile (RAP), a cornerstone of Medicare’s value-based healthcare efforts is integral to delivering quality value-based care and ensuring appropriate Medicare payments.
The Role of RAP in Delivering Value-based Care to Patients
In adopting a value-based healthcare approach, Medicare has moved away from reimbursing for discrete activities and toward payments based on sustained care that leads to better quality health outcomes for the patient. To do this, Medicare has adopted a new set of measures that both anticipate and document the patient’s healthcare journey.
One of these measures is the Risk Adjustment Profile (RAP).
RAP is designed to identify the state of the patient’s health by mapping their diagnoses against the Hierarchical Condition Categories (HCCs). A patient’s state of health is reported annually to Medicare using ICD-10 codes. These codes along with the patient’s demographics are mapped against the HCCs. In turn, this data gets translated into a risk profile that reflects the severity of the patient’s diagnosis and the expected level of care needed to treat or manage their health. Medicare aligns its payments with the patient’s RAP.
The basic assumption is that more severe diagnoses lead to more complex treatment plans and, ultimately, higher payments from Medicare. By matching the severity of the diagnosis with the level of Medicare payment, this approach to risk management discourages healthcare providers from cherry-picking (i.e., taking on only "healthy" patients) and lemon dropping (i.e., avoiding taking on ill) patients because payments better match the complexity of care delivered.
ICD-10 Coding, Demographics, and Hierarchical Condition Categories Determine the Patient’s RAP
A patient’s RAP is determined by their ICD-10 coding and demographics in the context of Hierarchical Condition Categories (HCCs).
The use of ICD-10 codes has been mandated since 2015 by the Department of Health and Human Services (HHS). This coding standard replaces a system that dates back 40 years with an internationally recognized system that provides more detailed and up-to-date coding—dramatically improving data quality. ICD-10 codes are consistent with current clinical practice and medical technology. And ICD-10 codes capture in greater granularity the complexity and severity of the patient’s condition.
Adoption of ICD-10 codes also makes it possible for HHS to track and compare certain health data between states, and at national and international levels.
Demographic information such as age, gender, and whether the patient lives in the community or an institution are also taken into consideration when determining their RAP.
HCCs provide the context for analyzing the patient’s condition and determining their RAP. HCCs model future healthcare costs based on the relative risk posed by a specific health condition and the severity of that condition for a patient at a particular age, gender, etc.
The HCC model takes common chronic diseases and, based on the ICD-10 codes, categorizes the healthcare risk of the specific state of health the patient is currently experiencing.
For example, with the HCC model, the patient isn’t simply diagnosed with cardiovascular disease (CVD). The diagnosis also needs to reflect whether that patient has experienced specific related events like a heart attack or stroke. Also, whether that patient is living with comorbid conditions like heart failure or peripheral arterial disease (PAD).
Each additional diagnosis adds to the patient’s overall health risk and drives their RAP, which then drives payment from Medicare. But more importantly, by looking at the whole patient instead of just discrete medical conditions this system is aimed at driving comprehensive, high-quality care for the patient.
For example, with the use of HCCs the risk of a patient with heart disease is categorized differently than a patient who has heart disease and stroke.
The second patient is seen as at higher risk and needs more complex care. Because of this, the second patient’s Medicare payment is likely to be higher and cover additional types of care. The treatment plan indicated becomes potentially more complex and more effective. The type of rehabilitative physical therapy prescribed after a stroke is informed by the patient’s heart condition. When medication is prescribed avoiding medicines with a risk of high blood pressure becomes an obvious consideration.
When the patient’s demographics are taken into consideration additional, possibly nontraditional, services might be indicated. These could be services like low-fat and low-sodium meal delivery, transportation to and from physical therapy appointments, or providing resistance bands so that PT exercises can be done at home.
Interoperable EHR Integration Support Better RAP and Patient Care by the Providers
Given the potential negative impacts imprecise ICD-10 coding can have, on both the patients’ state of health and Medicare payments, having a robust, well-integrated EHR system is all the more important for healthcare providers, provider groups, and other healthcare organizations.
These are the kind of EHR systems that enable the coding process to be streamlined. They support the sharing of patient information, such as patient history, diagnosis, claims history, and treatment plans across all the providers caring for the patient. Such systems enable patient coding to take place at a single point in the care stream, minimizing the opportunity to introduce errors. Additionally, they allow for the easy sharing of patient and care classification information with all the medical and care providers along that patient’s healthcare journey. Prescribing community resources and building relationships becomes easier for providers helping them to focus on treating patients at the right time and right place.
Mobisoft Infotech’s team is well versed with EHR integrations and interoperability rules. We understand the data points needed to help payers, provider/provider groups, and other healthcare organizations establish and manage the technical services that enable improved healthcare outcomes. We help to build interoperable healthcare applications with the full understanding of SMART on FHIR - R2/R4 and HL7 formats for EHR implementation. Our healthcare applications can integrate seamlessly with all major EHR systems and help improve clinical workflows.