Research

HCC capture: How to engage specialists and succeed in value-based care

Specialists must be part of any value-based care strategy going forward to meaningfully reduce costs and improve population health. But it’s difficult to know where to start. Begin those efforts with one ‘no regrets’ strategy—engaging specialists in accurate HCC capture.

By Ryan Furr-JohnsonClare Wirth

October 14, 2021

Overview

Specialists must be part of any value-based care strategy going forward to meaningfully reduce costs and improve population health. But it’s difficult to know where to start. Begin those efforts with one ‘no regrets’ strategy—engaging specialists in accurate HCC capture.

Hierarchical Condition Categories (HCCs) are groupings of ICD-10 diagnosis codes for active and chronic conditions. Medicare and other payers use HCCs to calculate patient risk scores and predict costs, which inform provider organizations’ reimbursement and performance benchmarks. Put simply: If ICD-10 codes aren’t coded correctly and HCCs underrepresent disease burden, reimbursement will be lower and quality benchmarks will be more difficult to achieve in shared savings programs.

And it isn’t a one-time action—diagnosis codes must be updated every 12 months. Otherwise, CMS does not count them.

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Why engaging specialists in HCC capture is ‘no-regrets’

Historically, it has been the PCP’s responsibility to accurately capture HCCs—after all, they manage many of the patients with chronic conditions upon which HCCs are built. But it’s time for organizations to move past this “first wave” of HCC capture and take the next step—by engaging specialists in HCC capture. Here’s why:

HCC capture introduces specialists to a population-based approach to care. Organizations have to start involving specialists in value-based care. Identifying complex chronic conditions helps specialists become more aware of the need to manage them to control costs and improve patient outcomes.
It gives specialists credit for the increasingly complex patients they’re treating. HCC capture is not a primary care-only issue. The chronic disease burden is growing, with the number of adults with three or more chronic conditions expected to almost triple by 2030. Provider organizations need all physicians involved to ensure appropriate compensation for the high-risk beneficiaries they’re already treating. As we know, not doing so leaves money on the table. Not only does HCC documentation drive short-term reimbursement rates (such as care management codes) but also future performance benchmarks (for MSSPs and Next Gen ACOs).

Four imperatives to engaging specialists in accurate HCC capture

The good news is it’s not all that different from what you’ve previously done with primary care. As an executive, take the lessons you learned from there—successes and failures—to help inform your approach toward specialists.

Below are four key imperatives we’ve identified for engaging specialists in accurate HCC capture:

1. Start by scoping specialists’ role in HCC capture.
The easiest way to improve HCC capture is to provide specialists with discrete lists of HCC codes for which they’re accountable. Specialists shouldn’t be accountable for all codes—just universal conditions any physician can identify—as well as their specialty-specific codes.

New York-based multispecialty group Crystal Run Healthcare has done this to great success, holding their specialists accountable to 16 core diagnoses:

Crystal Run’s core chronic diagnoses

HIV

Diabetes without complications

Protein-calorie malnutrition

Morbid obesity

Quadriplegia

Paraplegia

Respirator dependence/tracheostomy status

Cardio-respiratory failure and shock

Amputation status, lower limb/amputation complications

Hemiplegia/hemiparesis

Monoplegia, other paralytic syndromes

Vascular disease

COPD

Dialysis status

Major organ transplant or replacement status

Artificial openings for feeding or elimination

This core list has remained consistent since implemented in 2019. Crystal Run maintains specialty-specific HCC capture lists for specialties such as oncology, neurology, and endocrinology, as those specialties should record the complex chronic conditions specific to their patients.
2. Educate specialists on the importance of accurate HCC capture.

Educate specialists not just on the importance of HCCs for reflective reimbursement, but also as part of a bigger mindset shift of them to take a more population-focused approach to care. It’s easy for specialists to focus on their hyper-specialized areas of expertise. Education on HCC capture can help them better understand the costs and challenges of managing chronic conditions, encouraging them to collaborate more with PCPs to manage them.

Kettering Physician Network did so when they provided didactic and practical HCC education to their primary care and specialty physicians. These physician-led sessions included presentations on the importance of HCC capture, how it impacts reimbursement, and a “how to” walkthrough of incorporating documentation best practices into day-to-day workflows. Within four months of the program, Kettering improved HCC capture across their network by 31%.
3. Tie rewards to HCC capture.

When optimizing HCC capture in primary care, many organizations tied a portion of PCP compensation to HCC capture. This same practice can be applied to specialists. A common metric of success used is HCC recapture rate, but organizations have also paid physicians incrementally for each HCC documented. However, before implementing either approach, ensure it fits with your broader compensation philosophy.

And as your specialists become more comfortable with HCC capture, move away from financial incentives and toward a broader culture of accountability. Successful primary care programs have relied on performance transparency to create such a culture.
4. Provide specialists with coding support.

Accurate HCC capture requires significant time investment. At a minimum, provider organizations should develop a simple, easily-accessible resource featuring HCCs every physician can document—especially ones that are high-impact and often incorrectly coded. To maximize outcomes, advanced organizations invest in real-time analytic staff or technology-based coding support.

For example, Crystal Run created a tool that automatically identifies and alerts specialists to possible chronic care gaps prior to visits. The tool is fully automated and flags any patient with a chronic condition that has not yet been recorded in the current year. If a specialist believes the patient no longer has that condition, they can email the HCC team to close the care gap. Crystal Run has reaped the rewards of their HCC capture efforts. In 2020, they had an 88-90% HCC recapture rate, even during the pandemic—far above national standards.

Parting thoughts

As you engage specialists in HCC capture and iterate on solutions, continue to reflect on what’s worked and what hasn’t in primary care. Because while specialty care is a different space, the overarching lessons of engaging physicians in HCC capture remain largely the same.

HCC capture is an important first step. But it can’t stop there. Moving forward, specialists will play a critical role in whether organizations succeed in value-based care. Our team is conducting ongoing research into ambitious, yet feasible ways to involve them in that care transformation. Have thoughts? Send them to rfurrjo@advisory.com.

HCC capture: How to engage specialists and succeed in value-based care

Specialists must be part of any value-based care strategy going forward to meaningfully reduce costs and improve population health. But it’s difficult to know where to start. Begin those efforts with one ‘no regrets’ strategy—engaging specialists in accurate HCC capture.

Why engaging specialists in HCC capture is ‘no-regrets’

Four imperatives to engaging specialists in accurate HCC capture

Crystal Run’s core chronic diagnoses

Parting thoughts

Have a Question?

Our Company

HCC capture: How to engage specialists and succeed in value-based care

Specialists must be part of any value-based care strategy going forward to meaningfully reduce costs and improve population health. But it’s difficult to know where to start. Begin those efforts with one ‘no regrets’ strategy—engaging specialists in accurate HCC capture.

Why engaging specialists in HCC capture is ‘no-regrets’

Four imperatives to engaging specialists in accurate HCC capture

Crystal Run’s core chronic diagnoses

Parting thoughts

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Have a Question?

Our Company

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