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Comparing Risk Assessment Between Payers and Providers: Inconsistent Agreement in Medical Comorbidity Records for
John R Hobbs1, Justin A Magnuson1, Erik Woelber1
1Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania.
Insights
Payer and institutional records show poor agreement on comorbidities for total hip (THA) and knee (TKA) replacements. Only diabetes showed strong agreement, impacting value-based care models and patient optimization.
Area of Science:
- Orthopedic surgery
- Health informatics
- Healthcare economics
Background:
- Accurate comorbidity assessment is crucial for risk adjustment in total hip arthroplasty (THA) and total knee arthroplasty (TKA).
- Discrepancies between institutional and payer data can affect financial and clinical outcomes.
- Understanding these differences is vital for effective healthcare management.
Purpose of the Study:
- To evaluate the agreement between comorbidities tracked by an institution and those reported by payers for THA and TKA patients.
- To identify specific comorbidities with high or low agreement between data sources.
- To assess the relationship between institutional risk scores and payer-reported risk scores with healthcare costs.
Main Methods:
- Retrospective analysis of 876 patients undergoing primary THA or TKA between January 2021 and March 2022.
- Comparison of 8 common medical comorbidities from institutional records against payer records using Fleiss Kappa tests.
- Evaluation of 4 institutional medical risk calculations against a payer's insurance member risk score.
Main Results:
- Significant discrepancies were found between institutional and payer comorbidity reporting for both THA and TKA.
- Diabetes was the only comorbidity with strong agreement (Kappa > 0.75) for both procedures.
- Payer's insurance member risk score showed the strongest association with total cost and surplus.
Conclusions:
- A notable lack of agreement exists between institutional and payer comorbidity data for THA and TKA.
- These data inconsistencies may disadvantage institutions in value-based care models.
- Improved data alignment is necessary for accurate patient risk assessment and perioperative optimization.
Background:
The proper risk adjustment for total hip arthroplasty (THA) and total knee arthroplasty (TKA) relies on an accurate assessment of comorbidity profiles by both the payer and the institution. The purpose of this study was to determine how strongly comorbidities tracked by our institution agreed with the same comorbidities reported by payers in patients undergoing THA and TKA.
Methods:
All patients of a single payer undergoing primary THA and TKA at a single institution between January 5, 2021 and March 31, 2022 were included (n = 876). There were 8 commonly collected medical comorbidities obtained from institutional medical records and matched with patient records reported by the payer. Fleiss Kappa tests were used to determine agreement of payer data with institutional records. There were 4 medical risk calculations collected from our institutional records and compared with an insurance member risk score reported by the payer.
Results:
Comorbidities reported by the institution differed significantly from those reported by payers, with Kappa varying between 0.139 and 0.791 for THA, and 0.062 and 0.768 for TKA. Diabetes was the only condition to demonstrate strong agreement for both procedures (THA; k = 0.791, TKA; k = 0.768). The insurance member risk score demonstrates the closest association with total cost and surplus for THA regardless of insurance type and for TKA procedures paid for with private commercial insurance.
Conclusion:
There is a lack of agreement between medical comorbidities within payer and institutional records for both THA and TKA. These differences may put institutions at a disadvantage within value-based care models and when optimizing patients perioperatively.
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