Accountable Care Organization

Episode 39: MA Star Ratings & Precise Documentation

July 2022

As the ACO prepares to enter into two-sided risk contracts with Medicare Advantage (MA) plans, we bring you two relevant interviews from previous episodes. The first features the ACO’s Lauren Purcell on the intricacies of MA plan star ratings; the second features Brett Loffredo, MD on improving the precision of clinical documentation.

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

Mike: And I'm Mike Clark. Julie and I are practicing physicians and liaisons with the MaineHealth ACO.

Julie: In this episode, we'll bring you two interviews from the past that still have special relevance today.

Mike: Yes. For the remainder of this calendar year, MaineHealth and the ACO are placing special emphasis on increasing primary care's capacity to succeed in value-based care contracts.

Julie: That's right. And in particular, the focus is on a subset of value-based care, the Medicare Advantage contract. So, our BACON segments this month will focus on the star rating system that's central to Medicare Advantage and diagnosis coding and central to value-based care in general.

Mike: So first, you'll hear our producer, Paul Santomenna, interview the ACO's, Lauren Purcell on the nuances of the star rating system. That's from April of last year. And second, we'll bring you Paul's interview with Dr. Brett Loffredo from last October, describing just how crucial, accurate and precise clinical documentation is and how to improve the accuracy of your own documentation.

Julie: Sounds good. Let's get to it.

Lauren: So star ratings are essentially a quality rating system created by CMS or the Center for Medicare and Medicaid Services to help beneficiaries or individuals looking to enroll in a Medicare Advantage plan to choose among competing insurance plans. So essentially, there's a five star rating system, so the highest star is a five star, which is excellent, and then it goes all the way down to a four star is above average, three stars average and then two and below is below average and probably at risk of being terminated by CMTS. And these ratings are based off of about 48 measures that evaluate that plan. So what that translates to for the ACO and why the ACO is focused on this and creating an AIP around it is some of these measures are clinical measures and relate to the clinical work that we're doing, such as A1C control for diabetic patients or breast cancer screening, for instance. So Medicare Advantage plans, you know, they're motivated to perform well on these star measures because their rating, you know, four or five stars, directly impacts how much CMS, the Center for Medicare and Medicaid, will pay them. So they get quality bonus payments based off of how they're rated. They also get other incentives that they're eligible for if they're a highly rated plan. So five star plans, you know, they can advertise their plan all throughout the year and get new membership. And then new membership also adds to the financial gains that they can earn. So that's really like how the Medicare Advantage plans are motivated to do well in these star ratings. And because they're motivated to do well, they kind of pass that responsibility to us through our value based care contracts. So since many of the star measures are clinical measures, payers hold the ACO responsible for these metrics by embedding them in our value based care contract. So through pay for performance or for shared savings,

If we in turn do well on the clinical measures, if the providers that are participating in the ACO do well, is there a financial benefit for them and the ACO in general?

Lauren: Yeah. So, you know, value based care contracts work in all sorts of different ways. One of the ways is shared savings, so our performing well on these star measures increases how much shared savings we're eligible to earn and then the ACO kind of distributes through the distribution model that money back out to the regions accordingly and then also through pay for performance. So, you know, if we hit certain targets on these quality measures of breast cancer screening, for instance, if we hit a certain target, then we're paid a fee, typically a per member per month fee for doing above average or excellent work. And so that's kind of how those incentives trickle down to the ACO and then the providers in terms of earning incentives tied to these start measures.

Paul: What can a provider do or a practice do to have some kind of influence over these star ratings?

Lauren: Yeah, I think the biggest thing is that providers can do to help influence the star ratings is doing your best to try and get patients in to have the annual wellness visits every year. It really just opens up the opportunities to address any quality or health maintenance items that might be outstanding. Another thing is just supporting your patients in getting any preventative screenings or tests necessary to monitor their chronic illnesses, such as, you know, A1C labs or supporting them and getting their colon cancer screenings or anything that might be outstanding, that will really support those quality measures, the star measures as well. And then just making sure when a patient is in the office or if you're seeing a patient via telehealth, if you're seeing them with video and audio, you can document all the codes that we might need to be recaptured. So that really just helps with risk recapture and making sure that we have a full picture of that patient from a documentation standpoint. And then lastly, is prescribing long term medications on a 90 day basis, wherever it's appropriate. There is evidence that shows that this improves medication adherence for patients. So, you know, those things will really help improve star ratings long term.

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: Thanks for listening to BACON this month. You can find all our episodes on your podcast app and at our web page, And if you have questions, comments or suggestions, let's hear them. So please email us at That's

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.