2021-05-13 Risk Adjustment Use Case Meeting

FHIR Risk Adjustment PSS 

• Currently under eVote by the Clinical Steering Division
• The CDS WG is interested in becoming at least an interested party, if not a co-sponsor (minutes)
  • Suggested Wed Q5 at WGM for discussion

eVote still going on and ends this week. 

CDS WG reviewed the PSS and are interested in this use case and would like to become an interested party and perhaps a co-sponsor. They would like to meet with us on Wed Q5 at the WGM. 

Continue discussing Risk Adjustment Report data elements requirements from Payer to Provider and operation requirements

FHIR analysis discussion

Last discussion on the Initial Diagnosis state- we had thought to remove this, as it may not be required. 

Start looking to see how to represent this in FHIR. Added new column in the report confluence page to list FHIR Analysis. 

Patient- decide to see which of these US Core Patient, QI-Core Patient, ATR patient may work best.

• US Core patient resource  https://www.hl7.org/fhir/us/core/StructureDefinition-us-core-patient.html
  • has resource for race, ethnicity, birth sex
  • requires identifier (value needs to be unique within system), gender
  • additional must support resources
  • few has added bindings to some resources
• US QI patient resource http://hl7.org/fhir/us/qicore/StructureDefinition-qicore-patient.html
  • includes US Core profile requirements
  • has additional items to quality measures
• ATR patient http://hl7.org/fhir/us/davinci-atr/2020FEB/StructureDefinition-davinci-atr-patient.html
  • also build from US Core
  • has different types of identifiers

Member ID- This comes through the Payers as identifier and would be mapped on the provider side.

• may need to include the MBI for the medicare advantage
• provider can have its own identifier and may mask the MBI
• payers may mainly send patient name, birthday and MBI if medicare related
• payers may use subscriber ID but will be more geared with commercial insurance
• Mother/newborn ID under Medicaid may temporarily use the Mother ID
• all of these ID have effective dates- does that get communicated in the report?
  • may be needed to look at effective gap report, ie looking back at previous gaps or historically

HCC can come in within a 25 months period and can trickle in for a long time. 

Chat comment: 

fyi, the current APIs for CMS, e.g. Blue Button ,BCDA, etc provide historical and current MBIs in the identifier element of the patient resource (for cases where the MBI has switched due to fraud, etc) 

If MemberID is changed during the evaluation period, may need to know effective time of the memberID. 

May need to review how CARIN Blue Button. CMS Blue button API (FHIR R3) does it, actually as an extension- codeable concept that says if code is historic or current) 

this is the url for the extension: https://bluebutton.cms.gov/resources/codesystem/identifier-currency/

Cancel meeting 5/27/21 due to HL7 WGM.