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	James L. Holly, M.D.

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Letters - Blue Cross Blue Shield - Allan Chernov - October 2, 2015 Risk Stratification

October 2, 2015

Allan Chernov, MD
Medical Director, BCBS of Texas

Dear Dr. Chernov:

Thank you for taking my call this morning. I am inquiring about a letter which one of SETMA’s (www.jameslhollymd.com) providers received this week about Blue Cross Blue Shield’s reviewing of a sample of BCBS Affordable Care Act beneficiaries to “appropriately report risk scores to the Department of Health and Human Service (HHS),” These charts are to be sent to Peak Risk Adjustment Solutions (Peak).

As I mentioned to you, SETMA already receives additional payments from BCBS for the Bridges to Excellence (BTE) program for Diabetes and for Cardiovascular disease. This is on the basis of our recognition by NCQA. All of SETMA’s accreditations, which include NCQA, URAC, AAAHC and Joint Commission, are listed at the following link: http://jameslhollymd.com/Accreditations/pdfs/accreditations.pdf. SETMA also has “publicly reported by provider name” for seven years on over 300 quality metrics performance; see http://jameslhollymd.com/Public-Reporting/pdfs/public-reports-by-type.pdf. SETMA’s Model of Care, which is different than three hundred others in the literature and can be reviewed at: http://jameslhollymd.com/the-setma-way/setma-model-of-care-pc-mh-healthcare-innovation-the-future-of-healthcare.

My inquiry is because SETMA completes Risk Stratification by calculating Coefficient Aggregates on all patients for Medicare Advantage, ACO and PC-MH. In fact, we calculate these risk scores based on the HCC/RxHCC system on all patients seen by SETMA. On each chart, at the Assessment sheet, the following Risk Stratification Coefficient Aggregate are displayed

For acute diagnoses for the current encounter
For Chronic conditions for all diagnoses listed
For diagnoses which have not been assessed for the year
For demographic Risk Scores which include age & gender, disease interaction and disability & poverty
Total for the aggregate of all of the above

If BCBS is using the same Risk Stratification methodology, i.e., HCC/RxHCC, I would like to show you how we are doing this assessment and discuss how we could collaborate on this process. The following link is to our HCC/RxHCC Tutorial: http://jameslhollymd.com/epm-tools/Tutorial-HCC-RxHCC-Risk. One of the unique ways we use Risk Stratification Coefficients is in auditing the appropriateness of E&M Code assessment. That is explained in the tutorial. This is not endorsed by CMS but is one more test we apply in order to increase our compliance.

I look forward from hearing from you and/or from your designee.

Sincerely yours,

James (Larry) Holly, M.D.
C.E.O. SETMA
www.jameslhollymd.com

Adjunct Professor
Family & Community Medicine
University of Texas Health Science Center
San Antonio School of Medicine

Clinical Associate Professor
Department of Internal Medicine
School of Medicine
Texas A&M Health Science Center

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