Episode 30 – October 2021: Clinical Documentation & Pediatric Behavioral Health

Julie: This is BACON brief ACO news from the MaineHealth Accountable Care Organization, a FARM-TO-TABLE monthly podcast for health care providers. I'm Julie Grosvenor

Mike: And I'm Mike Clark. Julie and I are farmers. Well, not really. I'm sorry, I'm just trying to go with what you were saying. Julie and I are actually practicing physicians and liaisons with the MaineHealth ACO.

Julie: In this episode, we'll explore a project to train PCPs in pediatric behavioral health.

Mike: But first, we talked to MaineHealth's champion of clinical documentation improvement Dr. Brett Loffredo. That's our Meaty Topic for this month, so grab a fork and let's dig right in.

Speaker5: Meaty Topic.

Julie: Mike, I think it's fair to say that none of us got into medicine because we relish sitting in front of a computer typing in ICD 10 codes. Is that why you got into medicine?

Mike: Yeah, yeah. I used to lay awake and dream of sitting in front of a computer. No, this was not what I...

Julie: No, no. And no, no, we can't even try to pretend that we like it. But many of us do spend a good portion of our day doing just that.

Mike: That is absolutely true. And you know, it is not fun and it may not feel much like medicine. But the truth is, the way we code encounters has a major impact on our patients, on our practices, and, quite frankly, the entire health care system.

Julie: That's true. Our clinical coding is factored into all kinds of complex calculations that determine insurance benefits that a patient might be eligible for, quality goals a provider needs to achieve, and much more.

Mike: So to learn more about the impact of coding, our producer, Paul Santomenna, talked to Dr. Bret Loffredo. He's a family medicine physician and really an important leader in MaineHealth's efforts to improve clinical documentation.

Paul: So, Brett, you're a champion of improving clinical documentation, I think it's fair to say, and on the surface, it's maybe not the most compelling topic in the world. So what drives you to spend time and energy on this?

Brett: Thanks, Paul. Many things, actually, if you look under the surface, it is actually one of the most compelling subjects that we could involve ourselves in. So, you know, it's important for our patients. I think that comes first and foremost to any clinician. So when we do a better job of clinical documentation, our patients demonstrably get better services. And so any MA plan is sort of obligated to reinvest the monies they make from the federal government for the plan that they offer back into the services that their patients receive. So, for example, a patient will get free dental care, free ophthalmologic care, they'll get reduced med costs. And so that resonates deeply with me as a health care provider. And patients get better health care when we do a better job of documenting because, you know, we communicate better among care team members, right? So when I put an illegible note into Epic about my patients, people don't know what's going on. And when I have better documentation, you know, it translates into better communication with care team members. When we address HCCs as we address other care gaps or tend to at least, right? So when we bring someone in for an annual wellness visit, we address their HCCs. We're also looking at their A1C and we're ordering their colonoscopy and blah, blah, blah. So it's like all ships rise with the tide there, so it's better care in that respect. And then, you know, we live in a world of big data, right? So when we collect this data on our patients, our pop health teams have a better idea of what's going on. So people don't fit into a pool of just diabetes not otherwise specified. They're diabetic with vascular disease or without ophthalmologic issues. And so we're better able to allocate scarce resources. And then finally, a care team members like, you know, our MAs, our CTAs are able to do PaaS and get durable medical equipment without resorting back to me to say, Hey, what did you mean in this note that didn't really say much? We have better documentation, you know, leads to better stuff there.

Paul: It's hard to talk about this topic without getting a lot of acronyms thrown in. So one that's already come up is HCCs. So for those who don't know what an HCC is or don't quite get the full picture, can you try to describe what those are?

Brett: It's a great question. It took me a couple of years in the job to figure it out, right? So it's not hepatocellular carcinoma. That's a common mistake, right? It's not high-calorie cola. It’s hierarchical condition categories. And so in layman's terms, that's diagnoses, right? So someone has diabetes type two with or without insulin, with or without comorbidities. And if they have a comorbidity, what type of comorbidity? When you enter all that information in, you're entering in and HCC and Epic, which we're basically all on or will shortly be on at this point, HCCs are identified as such. Now there might be a couple at the margin that are falsely identified as HCCs is because our Epic upgrade hasn't happened and timing with when CMS changes their HCCs. But that's a handful of folks on an annual basis. So if you look at Epic there identified it, says CMS dash HCC next to the diagnoses. And so again, hierarchical condition categories their diagnoses. And essentially, what they do is when you put them on a claim, right? These diagnoses tell CMS about how sick a patient is, OK, and so every HCC carries a risk score with it. Those risk scores a CMS sums for a patient and for a population on an annual basis and they reimburse us within programs like Medicare Shared Savings Program and Medicare Advantage based on how sick those patients are. And so if we do a bad job of capturing those HCCs, CMS is going to reimburse us accordingly. And you know, in my opinion, if I look at the math, it seems to me that CMS pays fairly based on what the risk scores are, right? So if you capture the diagnoses, you're going to get reimbursed fairly. You're actually going to be able to cover the cost of care for those patients that you document accurately against. It's the ones that we don't document accurately against who end up in the hospital, who incur expenses based on their comorbidities that we're unable to pay for the care of and for a health care system that's committed to caring for everybody all the time, regardless of their ability to pay. That's make or break for us, right?

Paul: Right. Yeah, that's a great point. I think there's a little confusion, too, because not every code is in HCC, right, there's a selection of certain ones that sort of trigger CMS to say, Aha, that's great. That's what I'm going to use to figure out how, how sick your patient is.

Brett: Absolutely. That's true. So of the, you know, something like sixty-eight thousand ICD 10 codes that somewhere around eight or nine thousand of them or HCCs to give you a perspective on it.

Paul: And we can be more certain that we were capturing HCCs the more specifically, we code, essentially.

Brett: That is true. It's a good general practice to be in. It's hard. You know, I live that pain every day, right? But it's worth it when you do the math on why we're asked to do it right. So, yeah,

Paul: So you also mentioned another term, which is risk. Can you? I challenge you to briefly define what risk means in this context.

Brett: Yeah. Brevity being the soul of wit, I'm not that funny these days, right? So, risk. What they mean in terms of risk in this particular context is the risk of future health care expenditures, right? So what CMS did when they were developing this methodology is they looked at a whole bunch of diagnoses and they asked the question which of the diagnoses are predictive of future health care expenditures and then how predictive are they? And so we'll give a risk score to a diagnosis based on the degree to which it predicts future health care expenditures and how much it predicts. You know how much expense is attributed to that diagnosis, right? So, for example, you know, someone with diabetes without complication, it might be a 0.13 or something like that, and someone with diabetes with complications, it might be a 0.303 or something like that, right? So. So it's depending upon how sick you are. So risk of future health care expenditures.

Paul: Ok, and obviously HCCs and risk are tightly connected.

Brett: Yeah, so HCCs carry with them a particular risk score. You'll see that referred to as a RAF score, a risk adjustment factor. Now there are a couple of places where that comes into play a RAF score could be used to describe a population score. So of our ten thousand Medicare Advantage patients in a certain insurance vehicle, the RAF score might be 0.7 For that population, or it might be 1.0. And similarly, for an individual patient, you might have a risk score of 1 or 2 or 0.7, which people will call a RAF score interchangeably.

Paul: What practical tips do you have for capturing HCCs?

Brett: You know, there are a few, right, so I think we in years where half of our year isn't, you know, sort of access severely impaired due to a global pandemic type of thing, we would say adopt the marathon, not a sprint approach, right? So if you know you're going to see a patient a half dozen times in the course of a year, you don't have to close all their HCC gaps at that first visit in January. Although if you can great, you never know what's going to happen in the future, as recent history has told us, right? But the marathon, not a sprint approach, is great. Use every opportunity to capture HCCs when you can. So if someone you haven't seen in three years comes in for a strep pharyngitis and they happen to have diabetes, and nobody's documented on it in three years, and you have an opportunity to capture that fantastic right? And that applies for specialists as well. So if you're seeing a consult from St. Elsewhere, you don't know whether HCCs have been captured for that patient. And if they haven't, and you're the only provider that provides care for them that year or you deliver the preponderance of care in the absence of any primary care, you're going to be on the hook for attribution for that patient in Medicare shared savings program. And so, it's really important all of your downstream quality measures in terms of, you know, surgical site infection rates, overall readmission rates, quality work related to things like total knees, and things like that. That's all going to be driven by their risk score and the risk score is going to be driven by what you do at that office visit to address their HCCs. So, addressing them is really important. Leverage annual wellness visits, take advantage of them as a visit where we tend to have more time to do the work, you know, do the work. Otherwise, you may be confronted with addressing it at an acute visit where you have to deal with strep throat. And then on top of that. Think about doing the HCC, clean up the problem list. So once you pull the Band-Aid off on this work right, it's there in the problem list and the work is better. So I think we all kind of went through the conversion from ICD 9 to ICD 10 with a survival strategy of entering really generic diagnoses like at least I'm guilty of that. So it was diabetes and it was depression, right? And it was obesity. And those aren't going to cut it in the eyes of CMS. So when I have the opportunity now changing that diabetes to DM two with or without comorbidities, yadda, yadda, yadda. Changing that depression to major depressive disorder. Changing that obesity to obesity stage two with or without comorbidities. Once you do that work, it's in the problem list and then you're left to incrementalism year over year. So the first year is the hardest. Remember that? And then the final thing I'd urge people to do is reflect on how far we've come as a health care system, right? We have done the work. And so from here on out, I truly believe that the work that we need to do is incremental in comparison to the heavy-lift we've done so far. And so that's, you know, that's helped for me to look at it and say, Hey, if we can look at this like we've put two-thirds of this work behind us, it's helpful to know what lies ahead.

Paul: Well, Brett, thanks for taking the time. I don't want to take you away from really good coding, which is what you really want to spend your time doing.

Brett: I would characterize mine as improving, right? You know, I work in close proximity to really good coders. So thanks for your time.

Paul: All right. Thank you, Brett.

Julie: To check out the ACO's clinical documentation improvement resources, including toolkits and coding cards, visit Mainehealthaco.org/cdi.

Speaker5: The sizzle.

Mike: Ok, folks, it's time for the sizzle. Our segment featuring MaineHealth ACO participants doing good things inside or outside of work.

Julie: This month, our producer Paul Santomenna talks to Dr. Melissa Keeport and Dr. Amy Mayhew about training PCPs in pediatric behavioral health. Melissa is a MaineHealth pediatrician in Damariscotta and Amy is a psychiatrist at Maine Medical Center.

Paul: So you're both involved in the Maine Pediatric Behavioral Health Partnership, which is an effort to help primary care providers address pediatric behavioral health. So Amy, how would you describe this effort to a busy clinician, for example?

Amy: So I would say that what I hear a lot from clinicians in primary care is that they are being asked to treat conditions for which they don't have adequate training. And so they're having to kind of on the fly, learn the training. And so really, the purpose of this partnership is to give primary care more access to child pediatrics and psychiatry because we understand that they're managing a lot of things that they feel overwhelmed with. And so that could mean that they are connecting with us about diagnostic questions, about treatment recommendations, maybe interim management. Maybe they're sending someone to us and they really want us to manage them, but they're waiting to be seen by us. And so we can kind of help in between just treatment recommendations in general. And then sometimes it's just reassurance. Sometimes they've come up with a good plan, but they just want to talk to us and make sure that they're making good decisions. We can also talk about resources with them. Really, it's a way for them to feel more confident and managing the cases and primary care that may or may not be suited to be managed in primary care, so that we ultimately, as the specialists, can see more of the cases that really should be managed by child psychiatry.

Paul: Ok, so there are some specific components right to this initiative. There's a training part and a consultation. Can you just go into that briefly?

Amy: Sure. Yeah. So we are doing some trainings around general psychiatric questions and topics that are available through a variety of means. We're doing some statewide through the estate partnership where we and Northern Lights, who's the other partner in this grant, are providing trainings on general topics, eating disorders, understanding psychiatric conditions and primary care depression, ADHD, and those are available to anyone in the state that wants to like, come on. We are also doing trainings within practices, so we know some of that. We've been doing just talking, you know, having sessions within practices or within MaineHealth, for example. We're basically just trying to provide these trainings in whatever form makes sense for people. So that's one part of it. But really, to me, the part that's probably most important is that the ability to set up a relationship with primary care providers so that if they have a question that they can ask us, I think that sometimes they feel like in the moment they may want to talk with one of us but don't really know how to reach us. And so it's to kind of strengthen those bonds, really at the base.

Paul: Ok. So Melissa, you're a provider who's taken part in this, can you? A primary care provider. So what? What motivated you to get involved and what's it been like? What have you learned?

Melissa: What's really cool about this is how quickly I can get connected to a specialist in child psychiatry. It can take as quickly as one day where I've seen a patient on Thursday, for example. And then the next day I'm talking to Dr. Mayhew or another child psychiatrist, and I have 15 to 30 minutes to run, to go through the whole case with them. And it's been really helpful, both because if I have something that's an atypical presentation of a common diagnosis or an atypical presentation of an uncommon diagnosis, or another scenario might be I've tried three first-line medications and three first-line therapies. And now what to do when I'm getting out of that, the initial steps in management that I'm more familiar with. And then it's also really helpful that it's not asynchronous. A lot of the eConsult models are I would write something in the electronic health record and then the specialist responds asynchronously. This is a dialogue and going back and forth, and I think that really makes a big difference in finding a good solution and kind of getting into some of those deeper questions.

Paul: Yeah, great. And in general, what kind of outcomes are you seeing? Melissa described her sort of some great outcomes for her at her practice, but what are you seeing kind of across the board?

Amy: Yeah. So it's on several different levels. I think one level is that we are building these relationships with our pediatric and primary care partners so that we can kind of get a sense of who they are and what they're comfortable with and be better able to help them manage. Everybody has their own style and kind of comfort level with different conditions, so just getting an understanding of that is helpful for us because then we kind of set up our own dialogue and communication that can help them manage their patient panels and know when they reach out to us what kind of things are going to be dealing with. I also find that within our outpatient clinic, it's helping us kind of with flow because we're able to kind of manage more quickly some of these conditions that maybe don't need to be seen in our clinic. And so then we can really dedicate more time to the cases that we need to spend more time and energy with. What we do also offer some asynchronous I hear Dr. Keeport that I agree that the dialogue is more helpful in some ways because we can more quickly come to a solution. But you know, for people that can't make the time or set aside a half-hour, we also are doing some asynchronous stuff. But really, we're just. Trying to set up a model where all entry points are welcome and we're just trying to figure out a way so that we can better manage things as a group of providers, which is who we think of ourselves as that are all trying to take care of kids. So, you know, I'm just hoping to be able to strengthen that relationship and be able to better manage populations of patients.

Paul: So who's eligible to participate at this point? Is the program still enrolling folks? What's involved in getting started? Can you kind of go over that basic logistical stuff?

Amy: Yeah, yeah. So anybody, any provider in the state is eligible to participate in the program. So as I mentioned earlier, there are two main entities currently MaineHealth and Northern Lights. We work together to cover the state at this time. Anyone who is interested in being involved in the program can reach out. It does involve signing an MOU, which basically just states that we are offering advice, but we're not taking care of the patient that the care of the patient is still being managed by the primary care provider. And we have a website that people can access. They can access this through either of those organizations, through MaineHealth or Northern Lights. We have phone numbers where people can call if they want to. So for our part of this, Julie Carroll is our coordinator extraordinaire. That's been helping us, and she has a line that people can call: the number is 207-661-2771. Now Julie is going to be inundated with phone calls, but that is a way to both get connected with us. And also, if somebody needs help more urgently, they can reach out through her during business hours. We have an email address, which is MPBHP, so that's Maine Pediatric Behavioral Health Partnership, MCBHP@MMC.org. We can also send messages, it's open to any provider across the state.

Paul: Great. Well, thank you both for taking the time for filling us in, and we'll put information that you shared the phone numbers, et cetera, up on our web page for this episode as well. So. Thanks so much.

Melissa: Thank you.

Amy: Thanks so much for having us.

Julie: Thanks for listening to BACON this month. You can find all our episodes on your podcast app and at our web page MaineHealthACO.org/BACON. And if you have questions, comments, or suggestions, we'd love to hear from you. Please email us at bacon@mainehealth.org. That's bacon@mainehealth.org.

Mike: Bacon is produced by the MaineHealth Accountable Care Organization with help from MaineHealth Educational Services. Thanks for joining us. See you next month!

Julie: See you next month!