Andrea S. Danes Director, Healthcare and Human Services August 21, 2012

Transcription

1 ICD-10 Is Never Simple: Challenges and Solutions from Two States: Leveraging a Dynamic Strategy Andrea S. Danes Director, Healthcare and Human Services August 21, 2012

2 Strategic Planning Establish the vision Involve key stakeholders and decision makers Infuse both reality and optimism Understand the current environment Be realistic about the landscape Identify opportunities to improve Create the roadmap Document the process to get from here to there Acknowledge the level of effort (staff, time, and money) Obtain agreement Ensure that all levels within the organization support the plan and are equipped to execute their responsibilities within the plan 2012 CSG Government Solutions 2

3 Anticipate What could possibly go wrong? Replicate ARM Yourself for Success How can we model the potential failure to determine if the threat is real? Mitigate Is there a way to avoid this failure or does the strategy need to change? 2012 CSG Government Solutions 3

4 IN Family and Social Services Administration 2012 CSG Government Solutions 4

5 FSSA ICD-10 Project Timeline Awareness Awareness, Communication, and Education/Training May 2011 Mar 2014 Assessment Remediation Transition Plan for ICD-10 Activities Develop Change Requests and Requirements Implement Policy, Perform an Impact Assessment Develop Policy Updates, Process Updates, and Process, and System Develop a Remediation System Updates Changes Strategy Execute Systems Testing Finalize APDs Jul 2013 Oct 2013 April 2011 Sep 2011 Sep 2011 Sep 2012 End-to-End Testing Conduct Internal End-to-End Testing (Level I) Conduct External End-to-End Testing (Level II) Start Program Impact Assessment Completed Core ICD-10 Strategies Developed Remediation ICD-10 Changes Completed Oct 2012 Oct 2013 ICD-10 End-to- End Testing Completed ICD-10 Implemented and Live April 2011 Sep2011 Sep 2012 Oct 1, 2013 Window for developing policy, process, and system updates 2012 CSG Government Solutions 5

6 Indiana s Current DRG Landscape Diagnosis-Related Groupers (DRGs) are used to process inpatient claims for Indiana Medicaid Indiana Medicaid s current DRG Grouper is a 3M product; Version 18 Neither the current or most updated version of the Indiana Grouper is ICD-10 ready A native ICD-10 APR-DRG product will not be available until late 2012 ICD-10 related claims history will be unreliable for several years 2012 CSG Government Solutions 6

7 2011 Decision Point #1 Should Indiana Medicaid migrate to a new Grouper? Current DRGs are outdated Current process requires mapping from ICD- 9 to ICD-9 CMS is not a proponent of mapping from ICD-10 to ICD-9 as a permanent solution for ICD-10 compliance A native ICD-10 DRG Grouper should offer greater payment specificity Recommendation for Indiana: migrate to a new DRG Grouper 2012 CSG Government Solutions 7

8 2011 Decision Point #2 What type of Grouper should Indiana Medicaid migrate to? All Groupers are not the same; several types exist such as: All Patient Refined DRG (APR-DRGs) Medicare Severity DRG (MS-DRGs) All-Payer Severity-adjusted DRG (APS-DRGs) MS-DRGs have very limited maternal/child DRGs CMS has not stated an intent to address this gap No Groupers natively group ICD-10 codes currently with the exception of the MS-DRG; ICD-10 Groupers available Fall 2012 Migrating to more current version of ICD-9 Grouper has no return on investment (ROI) Recommendation for Indiana: utilize a native ICD-10 APR-DRG 2012 CSG Government Solutions 8

9 2011 Decision Point #3 When should Indiana Medicaid migrate to a new Grouper? Timing is important: no ICD-10 Grouper available before October 2012, limited timeframe for Grouper implementation AND no ICD-10 claims to process through the DRG in test Migrating to a new Grouper without adequate ICD-10 claim history has risks Optimally, the goal would be to perform one rebasing/recalibration of the DRGs based on quality claims data Initial recommendation for Indiana: implement a native ICD-10 APR or APS- DRG 2-3 years AFTER the ICD-10 compliance date (eg, October 1, 2013) 2012 CSG Government Solutions 9

10 Anticipate Replicate ARM for Indiana Initial vision included implementation of an ICD-10 native grouper after the compliance date Initial strategy included mapping Would the maps work? Would the results be accurate? Created subgroup to examine the assumption Included key stakeholders: Dr. Pelezo, HP, OMPP, Myers and Stauffer (rate setting) for planning and execution Managed Care Entities were also invited when results were discussed Developed mock 10 data using real 9-claims, the GEMs, and the CMS Reimbursement Map Established a test lab for the analytics project Executed over 3 to 4 months Mitigate How would the results impact the decision? 2012 CSG Government Solutions 10

11 Test Data Generation Methodology Developed by Dr. Tony Pelezo in collaboration with HP 2012 CSG Government Solutions 11

12 Caveats Results Results Summary GEMs are not perfect but they are the best available Producing native 10-claims would be markedly labor intensive and require provider collaboration; sufficient volumes would be challenging Permutated claims will not reflect real life coding Examined patterns for top 25 DRGs 50% were reasonable matches 50% included statistics as low as 1/3 reasonably mapped Significant potential risks due to lack of clinical and financial equivalency Potential for ungroupable DRGs and less than optimal clinical grouping Verification Wellpoint partnership with similar actions and conclusions 2012 CSG Government Solutions 12

13 Updated Strategy When should Indiana Medicaid migrate to a new Grouper? Timing is important: no ICD-10 Grouper available before October 2012, limited timeframe for Grouper implementation AND no ICD-10 claims to process through the DRG in test* Migrating to a new Grouper without adequate ICD-10 claim history has risks Optimally, the goal would be to perform one rebasing/recalibration of the DRGs based on quality claims data Mapping process may result in high risk to both clinical and financial equivalency Recommendation for Indiana: implement a native ICD-10 APR-DRG on the ICD-10 compliance date (eg, October 1, 2013) *Indiana is currently working with key external stakeholders to obtain natively coded ICD- 10 claims and would encourage other Medicaid agencies to do the same CSG Government Solutions 13

14 Create a comprehensive strategy Final Thoughts Establish a strong foundation for project execution Set the expectation for flexibility Leverage knowledge and resources to identify assumptions Test all critical assumptions! Allow adequate time to adjust Revise the strategy accordingly 2012 CSG Government Solutions 14

15 Contact Information Thank you! Andrea S. Danes Director, Healthcare & Human Services Direct: (217) Mobile: (217) CSG Government Solutions 15