Caveat on “PY” Risk Scores
Despite being called the PY risk score, events that occur during the performance year will not actually have an impact on the PY risk score.
Risk scores for a given PY are always calculated using claims from the year prior to the PY. For example, 2021 final risk scores will be calculated using claims from 2020. Therefore, when making an effort to improve your risk scores, it is important to remember that any changes implemented now will benefit the ACO in the next PY.
How are Risk Scores Calculated?
There are tons of different filters and conditions that are applied to claims to determine what exactly counts towards risk scores, but they are out of the scope of this article.
The most important thing to know here is that there are approximately 10,000 HCC eligible ICD-10 codes, and coding any of them will result in a beneficiary getting one HCC that the ICD-10 code gets mapped to. For example, there are very many codes that relate to diabetes, but all of them (that are HCC eligible) will result in the beneficiary either receiving the “Diabetes without complications” or “Diabetes with complications” HCC.
These HCCs are then used in combination with demographic factors to calculate a risk score.
A Simple and High ROI Method for Increasing Risk Scores
Increasing the updated benchmark boils down to increasing your PY risk score, which boils down to having more HCCs get coded.
Perhaps the simplest and most effective way to do this with the least possible effort is to close chronic HCC gaps.
A “gap” refers to HCCs that have been coded in prior years and has not been coded in the current year, and “chronic” refers to conditions that are… chronic.
For example, say we have a beneficiary that has HCC 111 (COPD) in 2021 (coded some time in 2020). That means we know that this beneficiary should also have HCC 111 in 2022 (coded in 2021) because COPD is chronic.
This sounds simple, but from the data we’ve seen, a lot of these chronic conditions are left uncoded year to year. Making sure these HCCs actually get coded is the simplest way we’ve found to improve risk scores.
Prioritizing High Impact Beneficiaries
The impact of any given beneficiary’s chronic HCC gaps on the total ACO risk score can vary wildly. Thus it is important to identify those with the biggest potential impact to the ACO risk score.
We do this by calculating what risk scores would be given current claims data, identifying the chronic HCC gaps, and then recalculating the risk scores as if those gaps had all been closed. This allows us to see, at a beneficiary level, how much of an impact gaps are having on the risk scores.
In our experience, closing the chronic gaps for a small fraction (usually 10-20% or so) of actionable beneficiaries when prioritized as outlined above can lead to a risk score improvement big enough that the ACO can hit the risk ratio cap (1.03 or 3%, e.g. BY3 risk score is 1.0 and PY is 1.03).
Example Using on Real Data
Below is a simplified chart made from data from real data.
Out of 1,980 patients we classified as actionable, just closing the gaps for the top 200 (~10% of actionable beneficiaries, <5% of total beneficiaries) achieved a lift in the risk score of 2.8%.
Most of the time, risk ratios aren’t terribly far from 1.0, as risk in patient populations often stays relatively steady, as does coding practices. In the case of a 1.0 risk ratio by default, a 2.8% increase in the (next) PY risk score of 2.8% means a risk ratio of 1.028, which means a 2.8% increase in the updated benchmark. A 2.8% increase for putting a bit of extra care into the coding for just 200 beneficiaries.