Definition of Serious and Complex Medical Conditions (1999) / Chapter Skim
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1 Introduction
1 Introduction
Pages 15-33
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From page 15... ...
As He paradigm for heal has shiPced away Dom acute care interventions and reducing deans, a model to address serious and complex medical conditions has emerged. Such conditions are Dequently persistent In nature and require ~ntennittent interventions to proactively identify and resolve emerging problems and resolve acute exacerbations of illness or disability.
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From page 16... ...
Specifically, the Consumers' Bill of Rights and Responsibilities states that "consumers with complex or serious medical conditions who require frequent specialty care should have direct access to a qualified specialist of their choice within a plan's network of providers. Authorization, when required, should be for an adequate number of direct access visits under an approved treatment plan" (President's Advisory Commission, 1 998b)
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From page 17... ...
Consideration of these issues demonstrated unequivocally to the committee the challenges of caring for highly vulnerable populations such as those having serious and complex medical conditions. The challenges ranged from ensuring quality, coordination, and continuity of care for these patient populations from a wide variety of service providers to clarifying issues associated with access to specialty care, patient confidentiality, patients' right to choice and involvement in their health care, provider and plan liability, and appeal and grievance processes.
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From page 18... ...
DEFINITIONS OF SERIOUS AND COMPLEX MEDICAL CONDITIONS: ALTERNATIVES AND IMPLICATIONS Background Managed care has the potential to significantly improve the quality of health care provided to health plan members. The original promise embodied in the term "health maintenance organization" was an emphasis on preventive services, early detection of illness, close coordination of medical and nonmedical health services, and treatment care plans designed to maintain function and minimize disability.
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From page 19... ...
The following presents examples descriptive criteria for serious and complex medical conditions. It is important to recognize that these conditions may be serious and complex for some patients at some points during the course of their disease or disability.
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From page 20... ...
Serious and complex medical conditions should reflect the characteristics of the management of the condition rather than some inherent biological complexity. Although there may be some correlation between biological parameters and complexity of management, it is possible to imagine biologically complex conditions that are easy to Heat because a very simple treatment (e.g., a once-a-day prescription drug)
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From page 21... ...
The codes would typically be found in insurance claims databases. Most managed care plans would be able to use a "presence-of-codes" rule to identify patients with serious and complex conditions.
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From page 22... ...
To the extent that any of these specific problems are valid markers of serious and complex medical conditions, the ICIDH-2 system provides a clear way of assigning codes to the impairments to facilitate accurate classification. The ICIDH-2 system may represent some disabilities better than do current ICD-9 codes.
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From page 23... ...
If being described as having a serious and complex medical condition depended on being below a certain threshold, there could be an incentive to put a patient either above or below the threshold that would bias "gray area" cases. Another key problem is that the scale does not directly refer to any specific medical condition, so a serious and complex medical condition is evident only indirectly in the scale score.
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From page 24... ...
The Karnofsky scale, by contrast, is based on clinician evaluation and is easier to incorporate into a claims-based data collection process. Scale scores in and of themselves do not identify serious and complex medical conditions, but the scale scores used in combination with other information (e.g., ICD-9 codes in claims databases)
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From page 25... ...
The DRGs could conceivably be used as a means of determining whether patients have serious and complex medical conditions, and the information beyond diagnostic code may provide a more precise classification than diagnosis alone. Presumably, a diagnosis with complications or comorbidities is inherently more serious and complex than one without them.
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From page 26... ...
The DCG system was designed for a specific purpose to model annual expenses based on diagnoses and this purpose may not exactly match the description of persons with serious and complex medical conditions. If there are conditions that are not expensive but are very serious, or conditions that are expensive but not serious in any other sense, then the DCG system would yield misleading results.
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From page 27... ...
Annual expense in the outpatient setting is almost certainly correlated with the underlying descriptions of serious and complex medical conditions, but the relationship is not perfect and there may be some misleading results. Given the relatively small number of ACGs, one could expect some heterogeneity within specific ACGs on the extent to which patients really do have serious and complex conditions.
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From page 28... ...
Patients who have multiple hospital admissions in a period of time such as a year are a statistically unusual group and are probably dealing with serious and complex medical conditions. Multiple admissions reflect either persistent conditions under poor control, serious illnesses such as cancer that require frequent admissions for administration of complex treatments, serious anatomical problems that require multiple surgeries, or general frailty.
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From page 29... ...
The models are built on a statistical association between extreme laboratory test values and either risk of mortality or inpatient cost. In the inpatient context, patients with extreme lab values may be considered to have serious and complex medical conditions, although not all values would have this connotation.
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From page 30... ...
Although this information is inexpensive to obtain in a clinical context, it may be very expensive to obtain for large numbers of people to ensure proper identification of those with serious and complex medical conditions. There may be some potential for gaming for individuals at or near a threshold value.
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From page 31... ...
Individuals who are eligible for disability payments or related services through private employers, Medicaid programs, Veterans Administration programs, or other public programs may already have had to demonstrate the presence of serious and complex medical conditions. Children eligible for Medicaid benefits through the Children with Special Health Care Needs program, for example, may not need to pass any other tests to be labeled as having a serious and complex medical condition.
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From page 32... ...
Health care plans and HCFA should ensure that state-of-theart measurement techniques are adapted as quickly as possible to improve identification of patients with serious and complex medical conditions. It is also important to acknowledge that a system of screening patient populations for the presence of serious or complex conditions will be limited by the frequency with which such assessments are made.
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From page 33... ...
For example, research in correlating patient volume with patient outcomes, differentiating access to services as a function of health plan benefits, and addressing variations in quality of care has just begun to yield meaningful results about particular groups of patients. The committee anticipates that this research will continue to evolve and will provide more definitive conclusions to guide the efforts of health plans to identify patients with serious and complex medical conditions and ensure appropriate levels of treatment and care management.
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