According to the U.S. Department of Health and Human Services, one in four adults in the US, and three in four adults aged 65 and older, have multiple chronic conditions. Further, CMS found that in 2014, 30.1% of Medicare beneficiaries had two or three chronic conditions, 20.9% had four or five chronic conditions and 14.5% had six or more chronic conditions.
Medicare beneficiaries account for at least 15% of total emergency department (ED) visits, utilizing the ED at rates twice that of individuals with private insurance. Following ED visits, these Medicare beneficiaries are particularly at-risk and have an average mortality rate of 10%, an average ED readmission rate of 24% as well as an average post-discharge hospitalization rate of 24% within the first three months following an ED visit.
HEDIS FMC Measure
Patients with multiple chronic conditions often receive care from disparate providers across the care continuum, and often these providers operate on different platforms, resulting in poor care coordination that leads to adverse healthcare outcomes. To improve cross-continuum provider collaboration and mitigate communication lapses between the ED and outpatient providers, the NCQA’s Follow-Up After Emergency Department Visit for People with High-Risk Multiple Chronic Conditions (FMC) HEDIS (Healthcare Effectiveness Data and Information Set) measure seeks to ensure follow-up within seven days of ED discharge for members 18 years of age and older who have multiple high-risk chronic conditions.
The HEDIS FMC measure is currently a display measure and has been proposed for addition to the Medicare Advantage Star Ratings program as early as Measurement Year (MY) 2022. Though CMS has not yet finalized its addition to the Star Rating program, nor a definitive date for its addition, health plans should act now to be ensure success when the measure is added to Star Ratings.
How Can CarePort Help Payers?
Most Medicare Advantage (MA) plans lack sufficient workflows, data and interventions triggered by ED visits, and lack real-time data to support plan-based monitoring and management of patients visiting the ED within the seven-day time frame defined by the HEDIS FMC measure.
To succeed under the HEDIS FMC measure, plans need to know when members have discharged from an ED to ensure the scheduling of follow-up appointments within seven days of a patient’s discharge from the ED. Claims data are not fast enough to support the necessary timelines, and coordinating with utilization management may be complicated and incomplete. Real-time data via hospital ADT feeds can help guarantee that plans have enough time to deploy the necessary interventions to support their members and reduce readmissions.
Using CarePort, health plans can leverage real-time, contextual clinical updates and ADT alerts via text or email to monitor patient ED discharges, as well as to follow specific patients or cohorts defined by patient worklists – in this case, members over 18 years old with multiple chronic conditions. CarePort’s real-time data exchange enables care management teams to locate, contact and monitor patients following ED discharge to ensure each patient receives the follow-up care required.
Leveraging real-time data, health plans can achieve improved HEDIS FMC measure scores and decrease costs, as an estimated 75% of healthcare is spent on patients with high-risk multiple chronic conditions. Health plans can also realize reduced admissions and readmissions – and improved Plan All-Cause Readmissions (PCR) measure scores resulting from actions measured by more adherence to evidence-based care continuum. Further, discharge notifications enable providers to proactively schedule post-discharge inpatient and ED follow-up visits without requiring staffing costs on part of the health plans.
This is the third and final post in our series covering proposed changes to the Medicare Advantage Star Ratings program. In case you missed it, learn how CarePort can help health plans succeed under the HEDIS Transitions of Care (TRC) measure and the PCR measure.
CarePort can help your health plan organization succeed under the FMC HEDIS measure. Contact us to learn more.