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Bulk Claims for Value Based Care

This is a public repository describing the "Bulk Claims for Value Based Care" initiative in North Carolina. Its is overseen by the "Duke-Margolis Center for Health Policy". This public repository contains general information about the project such as links to relevant standards and sample data. All project participants may contribute to this repository or its wiki. See CONTRIBUTING.MD for more details.

Objectives

  • To create a standard way for health providers to download claims information from payers (insurance providers). Payer to provider data flow is the initial focus.
  • To adopt or profile existing standards and profiles to facilitate risk stratification.

Ongoing Work

  • Identify exactly what fields are needed for risk stratification models.

Dignosis\conditions and comorbidities are the most common\important data elements used in most risk stratification models. Age, gender(sex), maritial status, and other demographic data are also used in some models.

  • Answer this question. Are fields needed for risk stratification already covered in the CPCDS format and corresponding FHIR profile? Use the table below to support your answer.
Risk Statification Model Key Elements Links
Hierarchical Condition Categories (HCCs) Diagnosis/Conditions https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Risk-Adjustors.html
Adjusted Clinical Groups (ACG) Diagnosis/Conditions https://www.hopkinsacg.org/
Chronic Comorbidity Count (CCC) Diagnosis/Conditions https://www.ncbi.nlm.nih.gov/pubmed/21473661
Elder Risk Assessment (ERA) Diagnosis/conditions, age, gender, marital status, number of hospital days over the prior two years, and selected comorbid medical illness https://www.ncbi.nlm.nih.gov/pubmed/21441764
Minnesota Tiering (MN) Diagnosis/Conditions https://www.health.state.mn.us/facilities/hchomes/legreport/docs/hch2016report.pdf
Charlson Comorbidity Measure Diagnosis/Conditions https://www.sciencedirect.com/science/article/pii/0021968187901718
Vermont Blueprint for Health Diagnosis/Conditions https://blueprintforhealth.vermont.gov/

Sample Data

We will continue to improve the sample data to make it as complete and realistic as possible. If you encounter any issues or want the data adjusted please reach out. Check back here for updates / additional data samples.

Links to Relevant Technical Documentation

Participants

The Duke-Margolis Center for Health Policy functions as convener of participants. The participants are:

  • UNC Health Care
  • Wellcare/Centene
  • Blue Cross Blue Shield of North Carolina
  • North Carolina Department of Health and Human Services
  • AmeriHealth Caritas
  • Optum/United Healthcare
  • Duke Health

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Describes the Bulk Claims for Value-based Care Project in North Carolina

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