Section 1. Introduction - HHSC - DSRIP Program



DSRIP Provider ReportingPotentially Preventable Emergency Room VisitsTechnical NotesPatient Population: Texas Medicaid and CHIP Measurement Year: Calendar Year 2017The Institute for Child Health PolicyUniversity of FloridaThe External Quality Review Organizationfor Texas Medicaid Managed Care and CHIPIssue Date: March 7th, 2019Table of Contents TOC \o "1-3" \h \z \u Section 1. Introduction PAGEREF _Toc478475190 \h 1Section 2. PPV Logic and Calculation of Rates and Expenditures for Facilities1Section 3. PPV Processing for Facility Reports PAGEREF _Toc478475193 \h 2Section 4. Guide to the Facility Report2State-Wide Provider PPV Rate3State-Wide Provider Distributions3PPV Results by Category4PPV Results by EAPG PAGEREF _Toc478475198 \h 5Section 5. Glossary PAGEREF _Toc478475199 \h 6CRGs PAGEREF _Toc478475201 \h 6Reference6Section 1. IntroductionPotentially Preventable Emergency Department Visits (PPVs) are encounters that may have resulted from the lack of adequate access to care or ambulatory care coordination. Circumstances associated with PPVs are ambulatory sensitive conditions (e.g., asthma) for which adequate patient monitoring and follow-up (e.g., medication management) can often avoid the use of ED services. The occurrence of high rates of PPVs may represent a failure of the ambulatory care provided to the patient. In addition, when a PPV occurs shortly following a hospitalization, the PPV may be the result of actions taken or omitted during the hospital stay, such as incomplete treatment or poor care of the underlying problem and/or poor coordination with the primary care or specialist physician.Section 2. PPV Logic and Calculation of Rates and Expenditures for FacilitiesThe identification of PPVs begins with assignment of primary Enhanced Ambulatory Patient Groups (EAPGs) to ED visits. Based on the reason for the visit and the source of admission, the preventable status is set. Health status (CRG), determined from encounter data for the year prior to the measurement year, is used to adjust the case-mix of patients. Patients with less than 3 months enrollment in the prior year are excluded because reliable CRG assignment depends on adequate health care history. Admissions for these patients are not considered at risk for PPVs. Relative weights are assigned to each ED visit at risk for a PPV based on the primary EAPG. National EAPG relative weights for CY2017 provided by 3MTM were used to determine resource utilization. Using relative weights for PPV rate calculation is important because not all PPV have the same resource costs. Total PPV weight is calculated as the sum of the relative weights for each PPV. PPV weighted rates are calculated as the total resources utilization for PPV (sum of the relative weights for each PPV) divided by the total resources utilization for at-risk ED visits (sum of the relative weights for each at-risk PPV). PPV is risk adjusted by CRG, using the CRG assigned to the member based on the data (both MCO encounters and FFS claims) from the year prior to the measurement year. A state norm weighted rate for each CRG category is calculated using the at-risk admissions statewide. The expected weighted PPV (total resources utilization for PPV) within each CRG category for a facility is calculated as the state norm weighted rate for the CRG category times the sum of the relative weights for the at-risk admission in the CRG for the facility. The total expected weighted PPV for a facility is the sum of expected weighted PPV across all CRG levels.The actual to expected ratio for the facility is the ratio of actual weighted PPV (sum of the relative weights for each PPV) over expected weighted PPV.Expenditures calculations are determined using paid amounts per PPV instead of relative weights, but follow the same logic for determination of actual and expected amounts, and adjusting for CRG.Section 3. PPV Processing for Facility ReportsUsing the 3M? Population Focused Preventable software and methodology (Core Grouping Software Version 2018.3.2; Population-Focused Preventable Grouper Version 2.1.0), encounter and eligibility data for Texas Medicaid and CHIP for the 2017 service year was used to calculate facility rates for PPVs. Members with dual eligibility during the measurement year are excluded. Valid DOB, gender, and race information is required in extracting member eligibility data.ED visits were identified by revenue codes 045x and 0981, or CPT codes 99281-99285, G0381, G0382, G0383, G0384 and G0390. Void and denied encounters as well as informational encounters/claims are excluded. Encounters are rolled up to a single cost record by member, provider ID, and admission date.Low volume providers can affect the reliability and interpretability of provider based summary statistics such as statewide percentile rankings. Providers meeting any of the following criteria were considered low volume and are excluded from percentile calculations:Less than 40 total ED visits at risk for PPV orLess than 5 actual total PPV orLess than 5 expected total PPVThe state norms represent the experience of all eligible members with at risk ED visits. The norms are calculated using all eligible ED visits at all providers. Section 4. Guide to the Facility ReportHospitalThe hospital name associated with the NPI in the HHSC provider table.NPIThe NPI associated with the hospital, and identified as the billing provider in the encounters attributed to the provider and included in the provider results.TPIThe TPIs corresponding to the hospital NPI based on the crosswalk provided by Texas Medicaid Healthcare Partnership (TMHP) and DSRIP team.PPV Rates and Expenditures (Provider Results)Total ED visits at Risk for PPVAll ED visits that are by the 3M? software as at-risk for PPV (see section 3 for exclusion criteria). Actual Number of PPVsED visits from ‘Total ED visits at Risk for PPV’ that were identified by the 3M? PPV algorithm as potentially preventable.PPV Rate (weighted)The sum of relative weights for encounters in ‘Actual Number of PPV’ divided by the sum of relative weights for encounters in ‘Total ED visits at Risk for PPV’.Expected Number of PPVsStatewide un-weighted PPV rate times the ED visits at Risk for PPV. Calculated as an un-weighted sum across CRG categories.Expected PPV Rate (weighted)The sum of the expected weighted PPVs divided by the sum of relative weights for the ED visits in ‘Total ED visits at Risk for PPV’.Actual-to-Expected Ratio for PPV Rate (weighted)‘PPV Rate (weighted)’ divided by ‘Expected PPV Rate (weighted)’Members with PPVsNumber of unique clients associated with PPVsActual PPV ExpendituresSum of paid amounts for PPVsExpected PPV ExpendituresThe State norm PPV expenditure (sum of paid amounts divided by sum of relative weights for encounters, statewide) times the sum of relative weights for encounters in’ Actual Number of PPV’Actual-to-Expected Ratio for PPV Expenditures‘Actual PPV Expenditures’ divided by ‘Expected PPV Expenditures’State-Wide Provider PPV RateState NormThe sum of relative weights for PPV encounters divided by the sum of relative weights for at risk encounters statewide. Data from all providers is included in the State Norm.PercentilesCalculated from ‘PPV Rate (weighted)’ for all providers excluding those identified as low volume providers.State-Wide Provider DistributionsPercentilesCalculated from ‘Total ED visits at Risk for PPV’, ‘Actual Number of PPV’, and ‘Members with PPVs’ for all providers excluding those identified as low volume providers.PPV Results by CategoryCategoryCategories are identified by EAPGCategoryEAPGInfections Upper Respiratory Tract & Otitis Media00562Asthma00575, 00579COPD (Chronic Obstructive Pulmonary Disease)00574Other Respiratory00572, 00573, 00576, 00577 Diabetes00710, 00711, 00712, 00713, 00714Seizure00529HF (Heart Failure)00594HTN (Hypertension)00599Chest Pain/Angina Pectoris & Coronary Atherosclerosis00598, 00604Nausea, Vomiting, Abdominal Pain, GI00624, 00625, 00626, 00627, 00628Back and Neck00656, 00657, 00658Musculoskeletal & Connective Tissue00660, 00661Behavioral Health/ Substance Use00820, 00821, 00822, 00823, 00824, 00825, 00826, 00827, 00829OthersAll other EAPGsNumber of PPVsEncounters identified as PPVs within the categoryPPV Category Rate (weighted) per 1,000 Resource UnitThe sum of relative weights for encounters in ‘Category – Number of PPV’ divided by the sum of relative weights for encounters in ‘Provider – Total ED visits at Risk for PPV’ times 1,000.State Percentile of PPV Weighted Rate per 1,000 Resource UnitCalculated from ‘PPV Category Rate (weighted) per 1,000 Resource Unit’ for all providers excluding those identified as low volume providers.Fraction of all PPVs‘Category – Number of PPVs’ divided by ‘Provider – Actual Number of PPVs’.PPV ExpendituresPaid amounts for encounters included in ‘Category – Number of PPVs’.Fraction of PPV Expenditures‘Category – PPV Expenditures’ divided by ‘Provider – Actual PPV Expenditures’.PPV Results by EAPGColumn description are the same as for PPV results by CategorySection 5. GlossaryCRGsThe CRGs are a categorical clinical model which assigns each enrollee to a single mutually exclusive risk group based on their chronic illness burden. These groups relate the historical clinical and demographic characteristics of the enrollee to the amount and type of healthcare resources that enrollee will consume in the future. CRG can be grouped within 9 overall status categories:Healthy. Healthy status is identified by the absence of any primary chronic disease or significant acute episode disease categories or episode procedure categories Healthy status may have Minor Acute EDCs present but are otherwise healthy. The healthy status also includes individuals who had no medical care encounters.Recent History of Significant Acute Disease. History of significant acute disease is identified by the presence within the most recent six month period of one or more Significant Acute episode disease categories or significant episode procedure categories. There are no primary chronic diseases present.Single Minor Chronic Disease. Minor Chronic Disease in Multiple Organ Systems. Single Dominant or Moderate Chronic Disease. Dominant or Moderate Chronic Disease in Multiple Organ Systems. Significant Chronic Disease in Multiple Organ Systems. Dominant, Metastatic and Complicated Malignancies. Malignancy that dominates the medical care required (e.g., brain malignancy) or a non-dominant malignancy (e.g., prostate malignancy) that is metastatic or complicated (e.g., requiring a bone marrow transplant).Catastrophic Conditions. Catastrophic Conditions include long term dependency on medical technology (e.g., dialysis, respirator, and total parenteral nutrition, (TPN) and life-defining chronic diseases or conditions that dominate the medical care required (e.g., persistent vegetative state, cystic fibrosis, AIDS, history of heart transplant)Reference3MTM Health Information Systems. Population Focused Preventables (PFP) Classification System Definitions Manual v2.1. GRP-372, 2018. ................
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