Solventum™ Patient-focused Episodes (PFEs) Classification System

Solventum PFEs are a categorical, clinical model that defines episodes of care to reflect a patient’s total burden of illness and comorbidities, not merely the presence of a single disease. Solventum PFEs simultaneously quantify the patient’s acute and post-acute resource needs, taking into account both the immediate need for care and baseline health status. The methodology was designed for payment, utilization analysis and clinical insight.

Solventum PFEs are most attractive to organizations interested in improving systemwide healthcare performance, provider profiling and payment reform. Examples include payers, large integrated delivery systems, accountable care organizations, risk-bearing provider organizations, government agencies, employers and research groups.

Solventum PFEs are designed both for analysis and for creating a bundled, incentive-based payment method. Because the Solventum PFE-based payment method includes risk adjustment, it can reward provider collaboration and efficiency without requiring providers to accept insurance risk for the incidence of illness and injury. Many payers, led by Medicare, look to episodes and other alternative payment methods to reduce waste, increase coordination and improve outcomes.

Here are a few examples of the value Solventum PFEs can bring to customers:

• Meaningful communication to improve patient outcomes. To improve care, clinicians need data they can believe. Solventum PFEs are defined in clinical terms that communicate actionable information at a sufficient level of detail. High-level analysis reveals variations and areas for potential improvement, so that the categorical nature of Solventum PFE results can then lead to focused actions.
  
  
• Bundled payment. The Solventum PFE patient-centered approach greatly simplifies the administration of an episode-based payment method. It eliminates the complexity of defining which services are related to which diagnoses. This is especially important when patients have multiple diagnoses. The entity receiving the single payment is rewarded for efficiently coordinating both acute and post-acute care across multiple provider types. Solventum PFEs include severity and risk adjustment, available empirically defined relative payment weights and other features needed for a successful prospective payment system.
  
  
• Stewardship of financial resources. Solventum PFEs clearly define the episode as the comprehensive unit of service. The ability to compare actual and expected resource use can help identify patterns of systematic overuse and underuse. These results serve as a starting place for further identification of possible inappropriate care, fraud, waste and abuse. For example, if a hospital’s patients have meaningfully higher post-acute care expenses compared with peer organizations, the reason may be inadequacies in inpatient care or continuity of care.

Solventum PFE classification logic is the same for every licensee, although different organizations may use different configurations. At this time, Solventum does not offer software that replicates the PFE analysis used by specific organizations.

Solventum PFEs use Solventum™ All Patient Refined Diagnosis Related Groups (APR DRGs) Classification System as triggers for inpatient event episodes, Solventum™ Enhanced Ambulatory Patient Groups (EAPGs) Classification System as triggers for outpatient event episodes and Solventum™ Clinical Risk Groups (CRGs) Classification System both to identify cohort episodes and risk adjust all episodes for baseline health status. Readmissions are evaluated using the Solventum™ Potentially Preventable Returns to the Hospital (PPRH) Classification System. Licensees already familiar with Solventum patient classification methodologies will easily recognize and understand many Solventum PFE concepts.

Solventum PFEs are available in the following Solventum products:

• Solventum™ Core Grouping Software (CGS)
• Solventum™ Grouper Plus Content Services (GPCS)
• Solventum™ Data-to-Action (DTA) Solution
• Solventum™ Intelligent Data Asset (IDA)

Available to licensees on the Solventum customer support website:

• Solventum PFE Methodology Overview
  
• Solventum PFE Definitions Manual
• Solventum PFE Summary of Changes
• Solventum PFE Setup Guides

All data required to assign a Solventum PFE are routinely collected from institutional and professional claims, including the UB-04 and CMS-1500 paper forms and their corresponding X12N 837 electronic formats. Pharmacy data in NCPDP format are optional but recommended. Consistent, unique patient identifiers are essential. These requirements are the same as those for the Solventum CRGs.

Solventum PFE analysis typically involves creation of a static data set comprising at least one full year of data. Two years of data allow a full year of data to establish baseline health status by Solventum CRG before a one-year episode analysis window. Some users perform rolling analyses each month or each quarter. The Solventum PFEs do not need to be built into a claim-processing system.

Development

In the 1980s and 1990s, the success of the Centers for Medicare & Medicaid Services (CMS) diagnosis related groups (DRGs) for hospital inpatient care prompted widespread interest in developing similar models for other applications. Since CMS DRGs define an episode as a single hospital stay, the obvious extension was to define broader episodes. For example, an episode might also include the cost of physician services and post-acute services such as rehabilitation.

Solventum, as the contractor to CMS for Medicare DRGs, was well-positioned to develop such models. Under contract to CMS and the Medicare Payment Advisory Commission (MedPAC), Solventum prepared analyses of episodes built around Medicare DRGs that were published in 2013 in the Medicare and Medicaid Research Review¹ and in a MedPAC Report to Congress.²

In parallel to its work developing episodes around Medicare DRGs, Solventum also developed the more comprehensive, proprietary Solventum PFEs. Solventum PFEs are appropriate for all populations, include both inpatient and ambulatory care and incorporate risk adjustment for baseline health status.

Design principles

These four principles guide the Solventum PFE design:

1. Patient-focused. Most notably, the episode clinical model focuses on an individual’s total burden of illness. This approach differs from conventional disease-centered models that face the intractable challenge of separating services; for example, heart failure requires treatment and services distinct from those needed for lung disease. This is important because patients with interacting comorbidities are precisely those who are most expensive to care for and the most complex clinically.
2. Uniform categorical clinical model. Solventum PFEs are a categorical clinical model, that is, a mutually exclusive and exhaustive set of clinical categories that differentiate individuals based on their total burden of illness. The underlying categorical model applies to all episode types, creating a uniform and stable clinical language. The model also remains unchanged across all potential configurations of episodes (window lengths, included services, etc.).
3. Re-use well-established systems. Solventum PFEs are based on Solventum APR DRGs, Solventum EAPGs and Solventum CRGs, which are widely used for risk adjustment and payment systems.
4. Independent, empirically derived relative weights. For each potential configuration of episodes used, a separate set of relative weights should be computed. Despite differences in configuration, relative weights reflect a stable clinical model, enabling a consistent clinical language.

Structure

For profiling comparisons or establishing payment levels, users of an episode methodology must calculate both actual and expected resource use by episode. In setting up a Solventum PFE analysis, users have broad flexibility in defining the time windows for episode identification and the Solventum CRG assignment, determining which services are included and excluded and defining the readmission logic.

Solventum PFE software performs two basic functions:

1. Episode classification: Based on the patient’s claims history, each patient is assigned to event-based and/or cohort-based episodes. Event-based episodes start when a significant health care event occurs; a patient may be in only one event-based episode at a time. Cohort episodes are assigned to patients who share a common disease, condition or characteristic within a given time period. A patient may be in more than one cohort episode at the same time. Neither episode type attempts to isolate the services associated with any specific condition, but instead capture the patient’s entire resource needs during the episode. The patient’s baseline health status can be considered using the patient’s Clinical Risk Group (CRG) or Aggregated CRG.
2. Episode accumulator: Based on the time window selected and the service categories included, actual expenditures are accumulated for each episode.

The actual expenditures that output from the accumulator can be used to compare against expected expenditures derived from relative weights.

The Solventum PFE clinical logic is maintained by a team of clinicians, data analysts, clinical analysts, programmers and economists. The logic is proprietary to Solventum but is available for licensees to view in the online Solventum PFE definitions manual. The methodology is updated annually to reflect changes in the standard diagnosis and procedure code sets and is regularly enhanced to improve the clinical logic.

Examples of Solventum PFEs

Event-based episodes:

• Inpatient Surgical Event (n = 51)
  1001710 Permanent Cardiac Pacemaker Implant without AMI, Heart Failure or Shock

• Inpatient Medical Event (n = 49)
  2001340 Pulmonary Embolism

• Outpatient Procedure Event (n = 135)
  3000360 Level II Foot Procedures

• Outpatient Medical Event (n = 11)
  4004980 Kidney Infections

Cohort episodes:

• Chronic Cohort (n = 96)
  6000020 Parkinson’s Disease

• Acute Cohort (n = 25)
  5000420 Cerebrovascular Infarction

• Pregnancy Cohort (n = 6)
  8005401 High Risk Pregnancy w Delivery

• Population Cohort (n = 1)
  7000000 Population

¹Vertrees J, Averill R, Eisenhandler, J, Quain, A, Switalski J. Bundling Post-Acute Care Services into MS-DRG Payments. Medicare Medicaid Res Rev. 2013;3(3):E1-E19

²Medicare Payment Advisory Commission. Approaches to bundling payment for post-acute care. Chapter 3 in Report to the Congress: Medicare and the Health Care System. Washington, DC: MedPAC, June 2013.