Solventum™ Potentially Preventable Admissions (PPAs) Classification System

The Solventum PPA methodology identifies hospital admissions that could potentially have been dealt with in the outpatient setting. These hospital admissions may result from hospital and/or ambulatory care inefficiency, lack of adequate access to outpatient care, or inadequate coordination of ambulatory care services.



In many cases, Solventum PPA can uncover flare-ups of chronic conditions (e.g., asthma), which could have been avoided through adequate monitoring and appropriate follow-up procedures such as medication management. The occurrence of high PPA rates within a region or health care system may represent a failure of the ambulatory care system.

Solventum PPA can be useful to payers, employers, government agencies, researchers, integrated health delivery systems (e.g., managed care organizations and accountable care organizations), and residential nursing care facilities (e.g., nursing facilities, intermediate care facilities, and residential treatment centers).

For example, employers or government insurance programs can use Solventum PPA to measure the performance of contracted, integrated health delivery systems or residential nursing care facilities. Those integrated health delivery systems and residential nursing care facilities themselves can also use the Solventum PPA methodology to enhance their own performance by improving outcomes from year to year.

Here are a few examples of how the Solventum PPA methodology has benefited customers:

• Improving quality and managing managed care. Through concerted effort, the Texas Medicaid STAR managed care program reduced the Solventum PPA rate by 35 percent, going from 14 PPAs per 100 stays in 2012 to 9 nine PPAs per 100 stays in 2017. That reduction translated into 7,236 fewer inpatient stays in 2017. In addition, this program reports risk-adjusted Solventum PPA ratesopens in a new tab for Medicaid-managed care organizations, offering detailed drill-down capability and downloadable data files.
  
  
• Quantifying opportunities for improvement. In a 2014 report to Congressopens in a new tab on the Medicare program, the Medicare Payment Advisory Commission (MedPAC) used Solventum PPA to calculate that 28 percent of inpatient stays were defined as potentially preventable, suggesting that “ample opportunities” existed for improvement in the ambulatory care provided to Medicare beneficiaries.
  
  
• Understanding population health. In a series of 2018 reports, the Florida Medicaid program used Solventum methodologies (including Solventum PPA) to publish risk-adjusted PPA ratesopens in a new tab for every region of the state.
  
  
• Measuring outcomes in long-term care. In analyzing data for more than 400,000 Medicare nursing facility residents, Solventum researchers found considerable variationopens in a new tab both within and across states in risk-adjusted Solventum PPA rates. One implication: Medicare’s method of assigning nursing facility SNF quality scores should say more about outcomes.

While Solventum PPA classification logic is the same for every client, an organization can use different versions of the methodology and apply their own reimbursement calculation tables. Solventum always recommends that clients use the latest version of the software, but each organization can decide how to apply it (for research, public reporting, reimbursement, or a combination). Note: At present, Solventum does not offer software that replicates a specific organization’s PPA analysis.

Solventum PPA is integrated with other Solventum patient classification methodologies:

• Solventum PPA, along with Potentially Preventable Emergency Department Visits and Potentially Preventable Services, make up the core set of population-based quality of care outcomes measures known as the Solventum™ Population-focused Preventable (PFPs). All Solventum PPE methodologies are used to measure and reduce costly, clinically significant adverse outcomes.
  
  
• The Solventum PPA methodology is defined using the industry-standard Solventum™ All Patient Refined Diagnosis Related Group (APR DRG) Classification System for inpatient stays.
  
  
• The Solventum PPA methodology also relies on the widely accepted Solventum™ Clinical Risk Grouping (CRG) Software to risk adjust comparison data.

Solventum PPA are available in the following Solventum products:

• Solventum™ 360 Encompass™ System
• Solventum™ Core Grouping Software (CGS)
• Solventum™ Grouper Plus Content Services (GPCS)
• Solventum™ Data-to-Action Solution

Available to Licensees on the Solventum customer support website:

• PFP Methodology Overview
• PFP Definitions Manual
• PFP Setup Guide
• PFP Summary of Changes

Solventum experts are available to advise health plans, government agencies and other interested parties on how to obtain maximum value from the Solventum PPA. For example, Solventum consultants can help you measure the incidence of potentially preventable admissions, compare those findings with appropriate benchmarks, and help design improvement programs. Solventum consultants can also help payers and other organizations measure PPAs across health plans and other patient populations, design pay-for-outcomes incentive methods and facilitate shared learning collaboratives.

The Solventum PPA methodology can identify PPAs using standard, inpatient claims data derived from institutional and professional claims (i.e., the UB-04 and CMS-1500 paper forms and their corresponding X12N 837 electronic formats). Consistent, unique patient identifiers are essential. Comparing Solventum PPA rates across different populations requires the Solventum™ Clinical Risk Grouping (CRG) Software to perform risk adjustment by individual health status. Thus, Solventum PPA analysis typically involves creation of a static data set comprising at least one full year of data. If available, pharmacy data in NCPDP format is optional but recommended. Note: Solventum CRG and Solventum PPA methodologies do not need to be built into the claim processing systems.

Every preventable hospital admission represents both a significant cost to the health care system and evidence of an ambulatory care system failure. The challenge has been to define “preventable” with an understanding that the preventability of these admissions depends on the overall burden of illness of the individual patient. In 2012, Solventum met this challenge by releasing the Solventum™ Potentially Preventable Admission methodology as one of the three Population-focused Preventables (the others are Potentially Preventable Emergency Department Visits and Potentially Preventable Services.)opens in a new tab

As with all Solventum PPE methodologies, three core concepts are essential. First, we recognize that not all admissions are potentially preventable. Second, what matters is not the individual admission, but rather the overall rate of potentially preventable admissions. Instead of approaching quality with the mindset of “This should never happen,” we use a more realistic and meaningful approach of “This has happened too often.” Third, any comparisons across populations of patients must be risk-adjusted. In practice, that means that the actual Solventum PPA experience of a population is compared with the experience that would be expected for a population with the same case mix.

The Solventum PPA logic is divided into two phases:

1. Identify patients with potentially preventable initial admissions
   All inpatient stays are assigned to a Solventum™ All Patient Refined Diagnosis Related Group (APR DRG). For the general population, approximately 41 base Solventum APR DRGs are considered potentially preventable. For some Solventum APR DRGs, the Solventum PPA logic also takes into account individual diagnoses and patient age. In a Minnesota all-payer analysisopens in a new tab, for example, the most common Solventum PPAs were pneumonia, heart failure and COPD. When an integrated health delivery system (such as a managed care organization or accountable care organization) accepts responsibility for a specific population, then additional Solventum APR DRGs are considered potentially preventable, for a total of approximately 100. Examples of additional Solventum APR DRGs include bipolar disorder, sickle cell anemia crisis and inflammatory bowel disease. When a population is under the care of a residential nursing care facility (such as a nursing facility, intermediate care facility or residential treatment center), additional Solventum APR DRGs are considered potentially preventable, for a total of approximately 126. For example, Solventum analysisopens in a new tab showed that Solventum APR DRG 720, Septicemia and Disseminated Infections, was the most common Solventum PPA in a population of more than 400,000 Medicare nursing facility patients.
   
   
2. Determine patient risk adjustment
   In any rate-based comparison of outcomes, risk adjustment is essential to a fair comparison across populations. Although Solventum PPAs are generally preventable, they will never be totally eliminated, even with optimal care. As a result, there will be a residual rate of Solventum PPAs in even the best-performing systems. More importantly, the rate at which Solventum PPAs occur depends on the burden of illness of the population which is measured using Solventum™ Clinical Risk Grouping (CRG) Software. For example, Solventum CRG 70602 is a person with congestive heart failure, diabetes and chronic obstructive pulmonary disease, severity 2. Hospital admissions for this person would be more likely to be preventable than for a person in severity 5 (i.e., Solventum CRG 70605).

Further information on the Solventum PPA logic is available in the Population-focused Preventables Methodology Overview. Detailed information is available to licensees in the online PFP definitions manual.

The Solventum PPA clinical logic is maintained by a team of Solventum clinicians, data analysts, nosologists, programmers and economists. The methodology is updated annually to reflect changes in the standard diagnosis and procedure code sets as well as Solventum enhancements to the clinical logic.