What does national data tell us about HCC capture at this point in the year and why it matters to every ACO

By David Clain

As we head towards the Fall, ACOs are looking to improve shared savings through better acuity capture, improving HCC capture—without unreasonable time demands on already-overworked providers. This requires a targeted, data-driven approach, especially as the window begins to close. We use our privileged access to Medicare's full claims database to identify how well every ACO is capturing every HCC, compared to "digital twins"—that is, patients elsewhere in the country with similar clinical profiles. We can then suggest conditions, providers, and even patients where greater focus on HCC capture would yield an outsized return.

We built our new HCC capture dashboard to share some of these insights and help ACOs across the country understand the organizations they're being compared against. For every HCC, the dashboard highlights recapture rates at each point in the year based on the actual capture rates for patients with similar clinical histories.

A few findings struck me in reviewing this data:

Even "forever" conditions are not always recaptured. This is low-hanging fruit for many ACOs: the patient with a transplant history, missing limbs, or an uncurable condition like HIV, Huntington's, or schizophrenia. Even though these conditions do not resolve, and typically involve substantial ongoing clinical management, some patients are not appropriately coded. Consider liver cirrhosis, for example: even among patients who had cirrhosis documented as an HCC in each of the last three years, nearly one out of ten will not have the diagnosis as an HCC this year.

For ongoing conditions, most recapture happens early in the year. That doesn't mean that ACOs can't bring these patients in, manage these conditions, and get HCC credit later in the year. But it does mean that by this point, ACOs that have not recaptured ongoing conditions are behind the benchmark. Our dashboard shows, for every HCC, when in the year various national recapture benchmarks are reached. For diabetes without complications, to use one common example, 25% of patients who had that HCC in each of the previous three years and will have it again this year will have it coded by February, 50% by April, and 75% by June. By September, 90% of HCC recapture for those patients has happened.

Relying on a one-year history to prioritize recapture isn't sufficient. One-year gaps in capture—even for ongoing conditions—are common, and they shouldn't lead to a failure to recapture a condition going forward (or worse, a failure to manage it). If we look at uncomplicated dementia, for instance, we see many patients who did not have the code last year but did two and three years ago. 61% will have it again this year, but a focus on last year's codes might miss it. For patients who had a dementia code two years ago but not one or three, 36% will have it this year; for those who had it three years ago but not the last two, 28% will. Taking a longer view is important to make sure these codes are captured, and that these patients get the care they need.

HCC recapture challenges are common but fixable, at least with the right data. If you're interested in learning where your ACO's HCC capture gaps are this year—while there's still time to close them—please contact us or email info@hda-institute.com for a free assessment.