This is Part 2 in the 4-part series on plausibility-testing and measuring ROI of wellness-sensitive medical events. No vendors or consultants are being “outed” in this posting, so if you read TSW for the shock value, you’ll be disappointed.  But of course you don’t do that — you read TSW to gain insight and knowledge.  Yeah, right, and you used to subscribe to Playboy for the articles.

In the previous installment, which should be reviewed prior to reading this one, we listed the ICD9s and ICD10s used to identify and measure wellness-sensitive medical events.  You want to count the number of ER visits and inpatient stays across these diagnoses, the idea being that this total should be low and/or declining, if indeed wellness (and disease management) are accomplishing anything.

This total is never going to fall to zero — people will always be slipping through the care and especially self-care cracks — but the best performing health plans and employers can manage the total down to 10-15 visits and stays per year. To put this in perspective, incurring only 10 ER and IP claims a year per 1000 covered people for wellness-related events is a great accomplishment, given that you have about 250 ER and IP claims/1000 covered people for all-causes combined. That would mean only about 5% of your claims are wellness-sensitive.  If hospital and ER spending is about 40% of your total spending, that would mean your spending on events theoretically avoidable by wellness programs represents about 2% of your total spending.  (So much for the CDC’s rant that 86% of your claims are associated with chronic disease. This from the people who are head-scratchingly alarmed by the “arresting fact” that “chronic disease is responsible for 7 out of every 10 deaths.” And yet these guys somehow wiped out polio…)

When you count these codes, there are a number of mistakes you could make, but shouldn’t, if you follow this checklist.  It’s really very easy, meaning that many mistakes are the result of overthinking the analysis.

Think of it this way: if you were estimating a birth rate, you wouldn’t look at the participants in your prenatal program, or count how many women made appointments with obstetricians. You’d simply tally the number of babies born and divide that figure by the number of people you cover. Each potential mistake on this list is avoidable by keeping that example in mind.

I’ve got a little list

1. Do not “count” the number of people (two discharges for one person equals one discharge for two people), and do not take into account whether people were in a disease management or wellness program.
2. Do not count people for whom you are secondary payer.
3. If someone has an event straddling the year-end, count them in the year of discharge
4. Don’t be concerned with taking out false positives; they will “wash”
5. If someone is transferred and has an applicable primary diagnosis both times, they count twice. (This should happen automatically.)
6. If someone has (for example) a heart attack and an angina attack in one hospitalization, only the primary code counts
7. Admissions following discharges count separately if they generate two different claims forms
8. Interim submissions of claims or claims submissions replaced by other claims submissions should only be counted once (since they represent only one hospital stay)
9. Admissions made through the ER, of course, do not count as ER visits
10. Claims may include facility and professional.  Remember to only count facility and not professional claims – otherwise it is double-counting
11. Urgent care is not the same as ER.  ER includes just (1)  ER PLACE OF SERVICE and (2) OBSERVATION DAYS.
12. All ACUTE CARE hospital admissions count, including <24 hours, and EXCLUDING observation days, which we count with ER.
13. Allowed claims, not paid claims
14. Fiscal year or Calendar year is fine — most people use fiscal year
15. Be careful that your case-finding algorithm notes that sometimes IP admissions from the ER take place the day after the ER admission (like at night)!
16. Go back as many years as is conveniently trackable.  The more years you go back, the more insight you will glean from the analysis.
17. For ER discharges, include all submissions whether non-emergent or emergent
18. Do NOT count members >65 in the “commercial” category even if you are primary-pay. (That would mess up your comparisons.)
    

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    Coming up next time: how to present and interpret your results.