In 2014, the state of Maryland partnered with the Centers for Medicare and Medicaid Services (CMS) to modernize its unique all-payer rate-setting system for hospital services to improve the overall health of Maryland residents by increasing health care quality and reducing the cost of care. In service of providing better care at lower costs, The Hilltop Institute at UMBC, in partnership with the Maryland Department of Health, has developed predictive risk stratification models to identify patients at high risk for potentially preventable health care utilization that can be used to help target care resources to the patients who need them most.
This document strives to explain the intended use, technical implementation, and model performance of the Hilltop Pre- Models as of November 2022. The Pre- Models are a suite of prediction tools spanning the Pre-AH Model™, Pre-CH Model™, Pre-DC Model™, and Pre-HE Model™. This document will be updated as the models are updated or when new models become operational, and significant changes will be noted in the documentation edit history table and in the text when necessary. This first section of the codebook provides a short introduction; the second section provides a general overview of data sources, training methodology, and scoring methodology; the third section provides specific details on the performance and operations of each model within the Hilltop Pre- Models suite; and the fourth section presents limitations.
The Hilltop Pre- Models are risk prediction models developed by The Hilltop Institute at UMBC that use a variety of risk factors derived from Medicare claims data to estimate the event risk that a given patient incurs a given outcome in the near future. As of November 2022, there are three such prediction models in production for the Maryland Primary Care Program (MDPCP) population: the Hilltop Pre-AH Model™, which generates the “Avoidable Hospitalizations (PreAH)” scores; the Hilltop Pre-DC Model™, which generates the “Severe Diabetes Complications (Pre-DC)” scores; and the Hilltop Pre-HE Model™, which generates the “Hospice Eligibility and Advanced Care Planning (Pre-HE)” scores. These risk scores are displayed in the MDPCP Prediction Tools area on Chesapeake Regional Information System for our Patients (CRISP).
The Hilltop Pre-HE Model™—which generates the rankings for the Hospice Eligibility and Advanced Care Planning (Pre-HE) scores—is designed to support proactive advanced care planning discussions by estimating a patient’s risk of eligibility for hospice. The Pre-HE Model provides risk scores and reasons for risk for all attributed beneficiaries of Maryland Primary Care Program (MDPCP) practices every month in order to identify patients that are potentially appropriate for hospice care and to provide care teams with information that can guide the sensitive and difficult conversations about end-of-life care with patients and their families.
This report describes the services The Hilltop Institute provided to the Maryland Department of Health (the Department) under the Master Agreement between Hilltop and the Department. The report covers fiscal year (FY) 2022 (July 1, 2021, through June 30, 2022). Hilltop’s interdisciplinary staff provided a wide range of services, including Medicaid program development and policy analysis; HealthChoice program support, evaluation, and financial analysis; long-term services and supports program development, policy analysis, and financial analytics; and data management and web-accessible database development.
The Hilltop Pre-AH Model™—which generates the rankings for the Avoidable Hospitalizations (Pre-AH) scores—is designed to assist providers by allowing them to easily identify patients at a high risk of incurring an avoidable inpatient hospitalization or emergency department (ED) visit. The Pre-AH Model provides risk scores and reasons for risk for all attributed beneficiaries of Maryland Primary Care Program (MDPCP) practices every month to help care teams make informed decisions about how to direct scarce care coordination resources to the individuals who will benefit from them the most.
The Assistance in Community Integration Services (ACIS) pilot program began in late 2017 with the goal of reducing unnecessary health services use among Medicaid beneficiaries by providing tenancy and housing case management services through four lead entities (LEs). This infographic provides a brief overview of Hilltop’s 2021 review of the pilot program.
This chart book explores service utilization and expenditures for dual-eligible beneficiaries (individuals who are eligible to receive both Medicare and Medicaid services)—with a focus on full-benefit dual-eligible beneficiaries—of all ages who received services in calendar years (CYs) 2015 through 2019.
The Maryland Department of Health (MDH) engaged The Hilltop Institute and Aurrera Health Group to conduct a landscape needs assessment of the state’s School-Based Health Center (SBHC) Program. The assessment will inform the Program’s strategic priorities, growth, and structure as it transitions from the Maryland State Department of Education (MSDE) to MDH. The assessment includes an analysis of the status of SBHCs in Maryland, geographic areas that may benefit from establishing SBHCs, and recommendations for program implementation and SBHC funding allocation.
Reducing hospital readmissions is a federal policy priority, and predictive models of hospital readmissions have proliferated in recent years; however, most such models tend to focus on the 30-day readmission time horizon and do not consider readmission over shorter (or longer) windows. The objective of this study, co-authored by Drs. Morgan Henderson and Fei Han and published in the Journal of General Internal Medicine, was to evaluate the performance of a predictive model of hospital readmissions over three different readmission timeframes in a commercially insured population.
This is the first annual review of the integration requirements for Medicare Advantage dual eligible special needs plans (D-SNPs), completed for the Maryland Department of Health. The goal of D-SNP integration, which became effective in calendar year (CY) 2021, is to improve coordination of care transitions for individuals who are dually eligible for Medicare and Medicaid. To meet this goal, D-SNPs are required to notify the state designees (e.g., supports planners) of Medicare hospital and skilled nursing facility (SNF) admissions when members receive long-term services and supports (LTSS) through a home and community-based services (HCBS) waiver or state plan program. This review describes key findings from the first year of implementation, focusing on aggregate trends.