ACC22 poster.pdf
Impact of Cardiac Diagnostics in Risk Adjustment
Aniket Zinzuwadia, Nandini Nayer, Jana Goldberg, Jeffrey Wessler Heartbeat Health, New York, NY
Background
The Center of Medicare & Medicaid Services utilizes Hierarchical Condition Categories (HCCs) to reflect a patient's burden of disease and allocate payments.
Accurate risk adjustment factors (RAF) are critical for estimating expenditures and allocating care.
Cardiac diagnostics like echocardiograms provide significant diagnostic information but their RAF impact has not been quantified.
Methods
The study constituted 5,182 Medicare Advantage patients across 7 states.
Each patient underwent an outpatient clinically-indicated echocardiogram in 2021.
Diagnostic Findings
The following diagnoses with severity were collected from reports:
- Heart Failure (preserved or reduced EF)
- Pulmonary Hypertension and/or RV Failure
- LV Hypertrophy
- Aortic Disease
- Coronary Artery Disease
RAF Echo Impact on Reimbursement
Echocardiograms provide significant clinical information for risk assessment for purposes of CMS RAF calculation.
In a Medicare Advantage population, a clinically indicated echocardiogram corresponded to an average potential increase in RAF of 0.097 and annual CMS reimbursement of $926.
Further research into RAF impact is necessary given the growth of value-based care models.
Results
Low-Risk Findings
| Finding | Prevalence |
|---|---|
| Mild LVH | 49.2% |
| Moderate LVH | 14.1% |
| Moderate Valvular Disease | 8.8% |
| Mild Pulmonary Hypertension | 12.2% |
| Aortic Disease | 5.2% |
| Pericardial Effusion | 1.8% |
High-Risk Findings
| Finding | Prevalence |
|---|---|
| Severe LVH | 2.2% |
| Severe Valvular Disease | 0.95% |
| HFpEF | 13.3% |
| HFrEF | 5.6% |
| Coronary Artery Disease | 1.6% |
| Moderate/Severe Pulmonary Hypertension | 5.3% |
| Reduced RV Function | 0.87% |
Indications Prevalence
| Indications | Prevalence |
|---|---|
| Hypertension | 75% |
| Hyperlipidemia | 14% |
| Heart Failure | 11% |
| Diabetes | 10% |
| Coronary Artery Disease | 6% |
| Valvular Disease | 6% |
| CKD | 5% |
RAF Impact by Indication
$3,630* per high-risk echo (RAF:0.388)
$505* per low-risk echo (RAF:0.054)
$4.8 million* across 5,182 patients
*Annually
Conclusion
Cardiac diagnostics are a critically important risk stratification tool for care management programs.
Further investigation is warranted into other diagnostic tools.
Healthcare providers should evaluate the clinical and economic utility of expanding early screening in elderly, Medicare advantage populations.