Overview

Strategy allows you to model and examine networks of providers. In order to facilitate creation of and evaluation of networks with high needs patients, we have four metrics that focus on high needs patients.

This article provides detailed information on those metrics.

  Where can I find these metrics?

On the Explore page, click on the "Add Metrics" button

This will open the Add Metrics dialog box.

Click on the "Beta" button near the top left.

type in the word, "high" into the search field. This will limit the listed metric choices to only high needs metrics.

Click on the plus sign to the left of any metric to add it to your selected metrics.

When you click on the "View" button, the dialog box will close and you will see your chosen metrics in the Explore page table.

Understanding the metrics

As you can see from the image above, there are four "high needs" metrics to choose from. To show the difference between the four metrics, (and to make it really easy to understand what these metrics are about,) let's remove the clutter from the metric name so that

"All ACO Eligible High Needs Patients with Impaired Mobility – Rolling 12 Months​"

becomes

"Patients with Impaired Mobility."

After we do that, our four metrics are:

• Patients with Impaired Mobility
• Patients with Risk Score 3.0+
• Patients with Risk Score 2.0-3.0 AND 2 or more unplanned hospital admissions
• Patients [with] Signs of Frailty

As an FYI, "rolling 12 months" does not have any extra special meaning. Like all Trella Health patient counts, the reporting period is the one year period preceding the data set ending in the listed quarter.

And another : For those of you who are not data scientists, "Patient Cohort" means "we used claims for patients with the following list of criteria to calculate this metric."

Patients with Impaired Mobility

Metric Type: a count of distinct patients

Types of Claims Analyzed - Linking Physician to Patient:

On most recent 12 months of data, physician listed as the attending physician on any of the bene facility claims or the performing physician on any of the bene professional claims

Patient Cohort: 

• All FFS patients that are eligible for an ACO program during entire PY2023 (7/1/2020 – 12/31/2021) – Updated Quarterly Until 6/30/2022 data is included in Strategy (Approximately May 2023)
  ​
• Eligible Patients Criteria During Entire 12 Months​
  • Alive – We remove any patients that have passed away​
  • Enrolled in Medicare Parts A & B ​
  • Not enrolled in Medicare Advantage or other Medicare managed care program​
  • Do not have Medicare as a secondary payer
  • Not enrolled in a 2021 MSSP

Clinical Measurement Period (CMP):

Patient Prospective HCC Risk Score 3.0+ is based on

• Impaired Mobility patient having qualifying DX codes from all CMS claims (not just this physician) on most recent 12 months of data (currently 1/1/2021-12/31/2021)
  • 1 inpatient claim with qualifying DX code, OR 2 non-inpatient claims on different dates with qualifying DX code
  • DX Codes on page 40 - here
  • Once a bene meets this criteria, they are considered eligible for remaining performance year even if they cease to meet high needs criteria

Exclusions

This metric does not take plurality of care or claims alignment into consideration (this metric is meant for voluntary alignment)

All ACO Eligible High Needs Patients with Risk Score 3.0+ - Rolling 12 months​

Metric Type: a count of distinct patients

Types of Claims Analyzed - Linking Physician to Patient:

Physician listed as attending on any facility claim or performing on professional claim on most recent 12 months of data (currently 1/1/2021-12/31/2021)

Patient Cohort:

• All FFS patients that are eligible for an ACO program during entire PY2023 (7/1/2020 – 12/31/2021) – Updated Quarterly Until 6/30/2022 data is included in Strategy (Approximately May 2023)
• Eligible Patients Criteria During Entire 12 Months​
  • Alive – We remove any patients that have passed away​
  • Enrolled in Medicare Parts A & B ​
  • Not enrolled in Medicare Advantage or other Medicare managed care program​
  • Do not have Medicare as a secondary payer
  • Not enrolled in a 2021 MSSP

Clinical Measurement Period (CMP):

Patients w/HCC Risk Score between 2.0-3.0+, AND 2 or more Unplanned Hospital Admissions​

• Prospective HCC Risk Score 2.0-3.0+ is based on: ​
  • All CMS Post-Adjudicated Claims (not just this physician's)​
  • Patients costs during the 12 months PRIOR to the most recent 12 months – Updated Quarterly​
    • Ex: Most recent 12mo of patients (Q1 2021 – Q4 2021) and then we look at the risk score from the prior 12 months (Q1 2020 – Q4 2020)​

Exclusions:

Does not take plurality of care or claims alignment into consideration (this metric is meant for voluntary alignment)

All ACO Eligible High Needs Patients with Risk Score 2.0-3.0 AND 2 or more unplanned hospital admissions – Rolling 12 months​

Metric Type: a count of distinct patients

Types of Claims Analyzed - Linking Physician to Patient:

Physician listed as attending on any facility claim or performing on professional claim on most recent 12 months of data (currently 1/1/2021 – 12/31/2021)

Patient Cohort:

• All FFS patients that are eligible for an ACO program during entire PY2023 (7/1/2020 – 12/31/2021) – Updated Quarterly Until 6/30/2022 data is included in Strategy (Approximately May 2023)
  ​
• Eligible Patients Criteria During Entire 12 Months​
  • Alive – We remove any patients that have passed away​
  • Enrolled in Medicare Parts A & B ​
  • Not enrolled in Medicare Advantage or other Medicare managed care program​
  • Do not have Medicare as a secondary payer
  • Not enrolled in a 2021 MSSP

Clinical Measurement Period (CMP):

Patients w/HCC Risk Score between 2.0-3.0+, AND 2 or more Unplanned Hospital Admissions

• Prospective HCC Risk Score 2.0-3.0+ is based on:

  • All CMS Post-Adjudicated Claims (not just this physicians)
  • Patients costs during the 12 months PRIOR to the most recent 12 months – Updated Quarterly
    
    • Ex: Most recent 12mo of patients (Q1 2021 – Q4 2021) and then we look at the risk score from the prior 12 months (Q1 2020 – Q4 2020)
  • 2 or more unplanned hospital admissions during most recent 12 months
    
    • Code on inpatient claim indicating unplanned

Exclusions:

Does not take plurality of care or claims alignment into consideration (this metric is meant for voluntary alignment)

All ACO Eligible High Needs Patients Signs of Frailty – Rolling 12 months​

Metric Type: a count of distinct patients

Types of Claims Analyzed - Linking Physician to Patient:

Physician listed as attending on any facility claim or performing on professional claim on most recent 12 months of data (currently 1/1/2021-12/31/2021)

Patient Cohort:

• All FFS patients that are eligible for an ACO program during entire PY2023 (7/1/2020 – 12/31/2021) – Updated Quarterly Until 6/30/2022 data is included in Strategy (Approximately May 2023)
• Eligible Patients Criteria​
  • Alive – We remove any patients that have passed away​
  • Enrolled in Medicare Parts A & B ​
  • Not enrolled in Medicare Advantage or other Medicare managed care program​
  • Do not have Medicare as a secondary payer
  • Not enrolled in a 2021 MSSP

Clinical Measurement Period (CMP):

• Patient having qualifying Signs of Frailty Claim from any provider Codes on Table B.6.2 (Page 40) - here

  • All CMS Post-Adjudicated Claims (not just this physician) – Most recent 5 Years – Updated Quarterly

Exclusions:

Does not take plurality of care or claims alignment into consideration (this metric is meant for voluntary alignment)