Washington Administrative Code
Title 182 - Health Care Authority
WASHINGTON APPLE HEALTH
Chapter 182-557 - Health homes
Section 182-557-0225 - Health home services-Methodology for calculating a person's risk score

Universal Citation: WA Admin Code 182-557-0225

Current through Register Vol. 24-18, September 15, 2024

The agency uses eight steps to calculate a person's risk score.

(1) Step 1. Collect paid claims and health plan encounter data. The agency obtains a set of paid fee-for-service claims and managed care encounters for a client.

(a) For clients age 17 and younger, the agency uses all paid claims and encounters within the last 24 months.

(b) For clients age 18 and older, the agency uses all paid claims and encounters within the last 15 months.
(i) The claims and encounters include the international classification of diseases (ICD) diagnosis codes and national drug codes (NDC) submitted by health care providers. These are used in steps 2 and 3 to create a set of risk categories.

(ii) The agency uses two algorithms developed by the University of San Diego:
(A) Chronic illness and disability payment system (CDPS) which assigns ICD diagnosis codes to CDPS risk categories (see Table 3 in subsection (5)(b) of this section); and

(B) Medical Rx (MRx) which assigns NDCs to MRx risk categories (see Table 2 in subsection (3)(b) of this section).

(2) Step 2. Group ICD diagnosis codes into chronic illness and disability payment system risk categories.

(a) To group ICD diagnosis codes into the CDPS risk categories (see Table 1 in (b) of this subsection), the agency uses an ICD diagnosis code to CDPS risk categories crosswalk in subsection (1)(b)(ii)(A) of this section. Each of the ICD diagnosis codes listed is assigned to one risk category. If an ICD diagnosis code is not listed in the crosswalk it does not map to a risk category that is used in the calculation of the risk score.

(b) Table 1. Titles of Chronic Illness and Disability Payment System Risk Categories

CARVH

Cardiovascular, very high

CARM

Cardiovascular, medium

CARL

Cardiovascular, low

CAREL

Cardiovascular, extra low

PSYH

Psychiatric, high

PSYM

Psychiatric, medium

PSYML

Psychiatric, medium low

PSYL

Psychiatric, low

SKCM

Skeletal, medium

SKCL

Skeletal, low

SKCVL

Skeletal, very low

CNSH

Central Nervous System, high

CNSM

Central Nervous System, medium

CNSL

Central Nervous System, low

PULVH

Pulmonary, very high

PULH

Pulmonary, high

PULM

Pulmonary, medium

PULL

Pulmonary, low

GIH

Gastro, high

GIM

Gastro, medium

GIL

Gastro, low

DIA1H

Diabetes, type 1 high

DIA1M

Diabetes, type 1 medium

DIA2M

Diabetes, type 2 medium

DIA2L

Diabetes, type 2 low

SKNH

Skin, high

SKNL

Skin, low

SKNVL

Skin, very low

RENEH

Renal, extra high

RENVH

Renal, very high

RENM

Renal, medium

RENL

Renal, low

SUBL

Substance abuse, low

SUBVL

Substance abuse, very low

CANVH

Cancer, very high

CANH

Cancer, high

CANM

Cancer, medium

CANL

Cancer, low

DDM

Developmental Disability, medium

DDL

Developmental Disability, low

GENEL

Genital, extra low

METH

Metabolic, high

METM

Metabolic, medium

METVL

Metabolic, very low

PRGCMP

Pregnancy, complete

PRGINC

Pregnancy, incomplete

EYEL

Eye, low

EYEVL

Eye, very low

CERL

Cerebrovascular, low

AIDSH

AIDS, high

INFH

Infectious, high

HIVM

HIV, medium

INFM

Infectious, medium

INFL

Infectious, low

HEMEH

Hematological, extra high

HEMVH

Hematological, very high

HEMM

Hematological, medium

HEML

Hematological, low

(3) Step 3. Group national drug codes (NDCs) into MRx risk categories.

(a) To group the NDC codes into MRx risk categories (see Table 2 in (b) of this subsection), the agency uses a NDC code to MRx risk categories crosswalk in subsection (1)(b)(ii)(B) of this section.

(b) Table 2. Titles of Medicaid Rx Risk Categories

MRx1

Alcoholism

MRx2

Alzheimer's

MRx3

Anti-coagulants

MRx4

Asthma/COPD

MRx5

Attention Deficit

MRx6

Burns

MRx7

Cardiac

MRx8

Cystic Fibrosis

MRx9

Depression/Anxiety

MRx10

Diabetes

MRx11

EENT

MRx12

ESRD/Renal

MRx13

Folate Deficiency

MRx14

CMV Retinitis

MRx15

Gastric Acid Disorder

MRx16

Glaucoma

MRx17

Gout

MRx18

Growth Hormone

MRx19

Hemophilia/von Willebrands

MRx20

Hepatitis

MRx21

Herpes

MRx22

HIV

MRx23

Hyperlipidemia

MRx24

Infections, high

MRx25

Infections, medium

MRx26

Infections, low

MRx27

Inflammatory/Autoimmune

MRx28

Insomnia

MRx29

Iron Deficiency

MRx30

Irrigating Solution

MRx31

Liver Disease

MRx32

Malignancies

MRx33

Multiple Sclerosis/Paralysis

MRx34

Nausea

MRx35

Neurogenic Bladder

MRx36

Osteoporosis/Pagets

MRx37

Pain

MRx38

Parkinsons/Tremor

MRx39

Prenatal Care

MRx40

Psychotic Illness/Bipolar

MRx41

Replacement Solution

MRx42

Seizure Disorders

MRx43

Thyroid Disorder

MRx44

Transplant

MRx45

Tuberculosis

(4) Step 4. Remove duplicate risk categories. After mapping all diagnosis and drug codes to the risk categories, the agency eliminates duplicates of each client's risk categories so that there is only one occurrence of any risk category for each client.

(5) Step 5. Select the highest CDPS risk category within a disease group.

(a) The agency organizes CPDS risk categories into risk category groups of different intensity levels. The high risk category in each group is used in the calculation of the risk score. The lower level risk categories are eliminated from further calculations.

(b) Table 3. Chronic Disease Payment System Risk Category Groups

Group Description

Risk Categories (Ordered Highest to Lowest Intensity)

AIDS/HIV and Infection

AIDSH, INFH, HIVM, INFM, INFL

Cancer

CANVH, CANH, CANM, CANL

Cardiovascular

CARVH, CARM, CARL, CAREL

Central Nervous System

CNSH, CNSM, CNSL

Diabetes

DIA1H, DIA1M, DIA2M, DIA2L

Developmental Disability Eye

DDM, DDL EYEL, EYEVL

Gastrointestinal

GIH, GIM, GIL

Hematological

HEMEH, HEMVH, HEMM, HEML

Metabolic

METH, METM, METVL

Pregnancy

PRGCMP, PRGINC

Psychiatric

PSYH, PSYM, PSYML, PSYL

Substance Abuse

SUBL, SUBVL

Pulmonary

PULVH, PULH, PULM,

Renal

RENEH, RENVH, RENM, RENL

Skeletal

SKCM, SKCL, SKCVL

Skin

SKNH, SKNL, SKNVL

(6) Step 6. Determine age/gender category.

(a) For each client, the agency selects the appropriate age/ gender category. The 11 categories are listed in Table 4 in (b) of this subsection. The categories for ages below five and above 65 are gender neutral.

(b) Table 4. Age/Gender Categories

Age

Gender

Age < 1

Age 1 to 4

Age 5 to 14

Male

Age 5 to 14

Female

Age 15 to 24

Male

Age 15 to 24

Female

Age 25 to 44

Male

Age 25 to 44

Female

Age 45 to 64

Male

Age 45 to 64

Female

Age 65+

(7) Step 7. Apply risk weights.

(a) The agency assigns each risk category and age/gender category a weight. The weight comes from either the model for clients who are age 17 and younger or from the model for clients age 18 and older.

(b) In each model there are three types of weights.
(i) Age/gender - Weights that correspond to the age/gender category of a client.

(ii) CDPS - Weights that correspond to 58 of the CDPS risk categories.

(iii) MRx - Weights that correspond to 45 of the MRx risk categories.

(c) Table 5. Risk Score Weights

Category Type

Category

Description

Weights for Children (age <18)

Weights for Adults (age 18+)

Age/Gender

Age <1

Clients of age less than 1

0.91261

0.00000

Age 1 to 4

Clients age 1 to 4

0.31764

0.00000

Age 5 to 14, Male

Male clients age 5 to 14

0.25834

0.00000

Age 5 to 14, Female

Female clients age 5 to 14

0.26338

0.00000

Age 15 to 24, Male

Male clients age 15 to 24

0.25662

-0.01629

Age 15 to 24, Female

Female clients age 15 to 24

0.29685

0.03640

Age 25 to 44, Male

Male clients age 25 to 44

0.00000

0.04374

Age 25 to 44, Female

Female clients age 25 to 44

0.00000

0.06923

Age 45 to 64, Male

Male clients age 45 to 64

0.00000

0.13321

Age 45 to 64, Female

Female clients age 45 to 64

0.00000

0.06841

Age 65+

Clients age 65 and older

0.00000

-0.05623

CDPS

CARVH

Cardiovascular, very high

0.84325

2.86702

CARM

Cardiovascular, medium

0.33428

0.73492

CARL

Cardiovascular, low

0.12835

0.24620

CAREL

Cardiovascular, extra low

0.04307

0.06225

PSYH

Psychiatric, high

0.40351

0.27085

PSYM

Psychiatric, medium

0.23892

0.00000

PSYML

Psychiatric, medium low

0.13796

0.00000

PSYL

Psychiatric, low

0.07675

0.00000

SKCM

Skeletal, medium

0.21071

0.42212

SKCL

Skeletal, low

0.08343

0.15467

SKCVL

Skeletal, very low

0.06244

0.06773

CNSH

Central Nervous System, high

0.80483

0.78090

CNSM

Central Nervous System, medium

0.31945

0.40886

CNSL

Central Nervous System, low

0.15106

0.18261

PULVH

Pulmonary, very high

1.14056

4.01723

PULH

Pulmonary, high

0.34356

0.39309

PULM

Pulmonary, medium

0.35587

0.31774

PULL

Pulmonary, low

0.11315

0.13017

GIH

Gastro, high

0.65934

1.34924

GIM

Gastro, medium

0.24699

0.24372

GIL

Gastro, low

0.09767

0.05104

DIA1H

Diabetes, type 1 high

0.27018

1.04302

DIA1M

Diabetes, type 1 medium

0.27018

0.23620

DIA2M

Diabetes, type 2 medium

0.13647

0.17581

DIA2L

Diabetes, type 2 low

0.13647

0.09635

SKNH

Skin, high

0.56322

0.37981

SKNL

Skin, low

0.23664

0.45155

SKNVL

Skin, very low

0.05697

0.02119

RENEH

Renal, extra high

1.80489

3.41999

RENVH

Renal, very high

0.59311

0.69251

RENM

Renal, medium

0.28630

0.92846

RENL

Renal, low

0.21048

0.17220

SUBL

Substance Abuse, low

0.15170

0.16104

SUBVL

Substance Abuse, very low

0.01794

0.08784

CANVH

Cancer, very high

1.19700

2.80074

CANH

Cancer, high

0.51985

0.97173

CANM

Cancer, medium

0.22164

0.38022

CANL

Cancer, low

0.10350

0.22625

DDM

Developmental Disability, medium

0.50073

0.27818

DDL

Developmental Disability, low

0.19696

0.05913

GENEL

Genital, extra low

0.00790

0.01121

METH

Metabolic, high

0.47167

0.47226

METM

Metabolic, medium

0.26297

0.11310

METVL

Metabolic, very low

0.11546

0.18678

PRGCMP

Pregnancy, complete

0.00244

0.00000

PRGINC

Pregnancy, incomplete

0.12631

0.51636

EYEL

Eye, low

0.09919

0.13271

EYEVL

Eye, very low

0.02835

0.00000

CERL

Cerebrovascular, low

0.14294

0.00000

AIDSH

AIDS, high

0.70597

0.47361

INFH

Infectious, high

0.70597

0.79689

HIVM

HIV, medium

0.26129

0.07937

INFM

Infectious, medium

0.26129

0.79689

INFL

Infectious, low

0.07784

0.05617

HEMEH

Hematological, extra high

5.37808

12.71981

HEMVH

Hematological, very high

0.72873

3.08836

HEMM

Hematological, medium

0.37824

0.63211

HEML

Hematological, low

0.18676

0.25601

MRx

MRx1

Alcoholism

0.05982

0.01924

MRx2 MRx3

Alzheimer's Anti-coagulants

0.00000

0.34428

0.08112 0.13523

MRx4

Asthma/COPD

0.08758

0.05751

MRx5 MRx6

Attention Deficit Burns

0.00000

0.16633

0.00779 0.00000

MRx7

Cardiac

0.0906

0.06425

MRx8

Cystic Fibrosis

0.50399

0.37265

MRx9

Depression/Anxiety

0.06743

0.09436

MRx10

Diabetes

0.1519

0.17046

MRx11 MRx12

EENT ESRD/Renal

0.00000

1.24598

0.00072 1.20707

MRx13

Folate Deficiency

0.17973

0.11899

MRx14

CMV Retinitis

0.37762

0.00000

MRx15

Gastric Acid Disorder

0.10082

0.15470

MRx16

Glaucoma

0.12971

MRx17

Gout

0.00000

0.00000

MRx18

Growth Hormone

0.9741

1.59521

MRx19

Hemophilia/von Willebrands

13.56192

89.14461

MRx20

Hepatitis

0.03018

0.00000

MRx21

Herpes

0.0348

0.01725

MRx22

HIV

0.65537

1.01178

MRx23

Hyperlipidemia

0.00000

0.03791

MRx24

Infections, high

1.38405

1.51663

MRx25

Infections, medium

0.07462

0.06192

MRx26

Infections, low

0.00000

0.00918

MRx27

Inflammatory/Autoimmune

0.08075

0.20046

MRx28

Insomnia

0.07093

0.06437

MRx29

Iron Deficiency

0.13306

0.15054

MRx30

Irrigating Solution

0.87573

0.16387

MRx31

Liver Disease

0.45314

0.22681

MRx32

Malignancies

0.36859

0.44200

MRx33

Multiple Sclerosis/Paralysis

0.0345

0.04353

MRx34

Nausea

0.18219

0.17120

MRx35

Neurogenic Bladder

0.15282

0.07675

MRx36 MRx37

Osteoporosis/Pagets Pain

0.00000

0.0295

0.00000 0.04151

MRx38

Parkinsons/Tremor

0.17163

0.06257

MRx39

Prenatal Care

0.00000

0.13192

MRx40

Psychotic Illness/Bipolar

0.22819

0.20274

MRx41

Replacement Solution

0.58622

1.49405

MRx42

Seizure Disorders

0.23997

0.19837

MRx43

Thyroid Disorder

0.03948

0.06326

MRx44

Transplant

0.37388

0.05810

MRx45

Tuberculosis

0.20006

0.00000

(8) Step 8. Sum risk weights to obtain the risk score.

After obtaining the weights that correspond to a client's age/ gender category and set of risk categories, the agency takes a sum of the values of all of the weights. This sum is the risk score for a client.

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