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Identify potentially preventable emergency department visits using powerful clinical grouping logic
The 3M™ Potentially Preventable Emergency Room Visits (PPV) are inefficient and expensive either because the care could have been provided in a less expensive setting that was not available, or because inadequate care of a chronic or sub-acute problem in the outpatient setting resulted in an acute deterioration, or a combination of both.
3M PPVs can identify patterns of potentially avoidable emergency department visits, and may suggest areas where primary care services should be improved.
Every year, millions of patients visit the emergency department for conditions that either could have been prevented with better management in the community or would be more appropriately treated elsewhere. Reducing potentially preventable ED visits simultaneously saves money and improves patient outcomes.
Accurate and fair PPV identification requires careful, clinically defined risk adjustment. The widely accepted 3M™ Clinical Risk Groups (CRG) methodology measures baseline population health status in comparing actual versus expected PPV rates.
3M PPVs are one of the five 3M™ Potentially Preventable Event methodologies that generate specific results for clinicians and health care managers to use in improving care and reducing cost.
Nursing facilities, intermediate care facilities and residential treatment centers that care for patients around the clock can be held to higher standards. The 3M PPV methodology includes additional logic for potentially preventable ED visits when patients are under the care of a residential nursing care facility.
All about 3M PPVs
The 3M PPV methodology identifies emergency room visits that may result from a lack of adequate access to care or ambulatory care coordination. Similar to 3M PPAs, 3M PPVs are ambulatory sensitive conditions which adequate patient monitoring and follow-up should be able to reduce or eliminate.
3M PPVs are emergency department visits for conditions that could otherwise be treated by a care provider in a nonemergency setting. 3M PPVs may also result from a lack of adequate care or ambulatory care coordination, such as access to urgent care facilities, availability of primary care physicians, etc. 3M PPVs include visits that could have been reduced or eliminated if adequate patient monitoring and treatment (e.g., medication management) had been available. High 3M PPV rates may therefore represent a failure of the ambulatory care provided to the patient.
3M PPVs can be used by 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 3M PPVs to measure the performance of contracted integrated health delivery systems or residential nursing care facilities. In turn, integrated health delivery systems and residential nursing care facilities themselves can use the 3M PPV methodology to improve their own performance by improving outcomes from year to year.
Here are a few examples of the value the 3M PPV methodology can bring to customers.
While 3M 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. 3M Health Information Systems 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, 3M Health Information Systems does not offer software that replicates a specific organization’s PPA analysis.
3M PPVs are integrated with the other 3M patient classification methodologies.
3M PPA are available in the following 3M products:
Available to Licensees on the 3M Customer Support Website
3M experts are available to advise health plans, government agencies and other interested parties on how to obtain maximum value from the use of 3M PPVs. For example, 3M consultants can help you measure the incidence of potentially preventable emergency department visits, compare the results with appropriate benchmarks and design improvement programs. 3M consultants can also help payers and other organizations measure 3M PPVs across health plans and other patient populations, design pay-for-outcomes incentive methods and facilitate learning collaboratives for provider groups.
The 3M PPV methodology can identify PPVs 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 3M PPV rates across different populations requires the 3M™ Clinical Risk Grouping (CRG) Software to perform risk adjustment by individual health status. Thus, 3M 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: 3M CRG and 3M PPV methodologies do not need to be built into the claim processing systems.
Inappropriate use of the emergency department has long been identified as a major problem in the healthcare system. The twin challenges have been exactly how to define “inappropriate” and who should be held responsible. Many payers have penalized the hospital or the patient for individual visits deemed inappropriate, but this approach can clearly be unfair. In 2012, 3M met these challenges by releasing the 3M™ Potentially Preventable Emergency Department Visit (PPV) methodology as one of the three 3M™ Population-focused Preventables. Learn more. (The others are 3M™ Potentially Preventable Admissions and 3M™ Potentially Preventable Services.)
As with the other 3M Potentially Preventable Event methodologies, three core concepts are essential. First, we recognize that not all ED visits are potentially preventable. Second, what matters is not the individual visit, but rather the overall rate of potentially preventable ED visits. 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 3M PPV experience of a population is compared with the experience that would be expected for a population with the same case mix.
The 3M PPV logic is divided into two phases.
1. Identify potentially preventable events
By definition, “ED visits” include only those visits where patients were treated and released. (Nationally, 14 percent of ED patients are admitted to the same hospital; their ED services are included within the inpatient stay.) Learn more (PDF, 274.35 KB).
All ED visits are grouped using the 3M™ Enhanced Ambulatory Patient Group (EAPG) methodology. Of the 560 3M EAPGs (as of February 2019), many principal diagnoses within 196 3M EAPGs are considered potentially preventable in the general population. In a Minnesota all-payer analysis, the most common 3M PPVs were upper respiratory tract infections, abdominal pain, and musculoskeletal systems and connective tissue diagnoses such as back pain. 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 trauma, infections, and certain other diagnoses are considered potentially preventable.
2. Determine patient risk adjustment
In any rate-based comparison of outcomes, risk adjustment is essential for a fair comparison across populations. Although 3M PPVs are generally preventable, they will never be totally eliminated, even with optimal care. As a result, there will be a residual rate of 3M PPVs in even the best-performing systems. More importantly, the rate at which PPVs occur depends on the burden of illness of the population.
The 3M PPV software measures the burden of illness of each patient (and therefore of the population) using the 3M™ Clinical Risk Groups (CRGs). In 3M CRG v2.1, there are approximately 390 base 3M CRGs and 1,470 total 3M CRGs, taking into account severity levels. For example, 3M CRG 70602 describes a person with congestive heart failure, diabetes and chronic obstructive pulmonary disease, severity level 2. ED visits for this person are more likely to be preventable than for a person in severity level 5 (i.e., 3M CRG 70605).
The 3M CRGs can be rolled up into three levels of aggregation (i.e., approximately 676, 254 or 54 groups) and nine health status group levels. The aggregated 3M CRGs sacrifice some clinical precision, but with only a slight loss of explanatory power. 3M recommends that the ACRG3 level of 54 groups (as of 2019) be used for setting risk-adjusted 3M PPV norms.
Further information on the 3M PPV logic is available in the 3M™ Population-focused Preventables Methodology Overview. Detailed information is available to licensees in the online 3M PFP definitions manual.
The 3M PPV clinical logic is maintained by a team of 3M 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 3M enhancements to the clinical logic.
Learn more about 3M PPVs
Please note that documents not published by 3M do not necessarily reflect 3M recommendations and have not been approved by 3M. These documents are listed here for the information of readers interested in the various ways that 3M patient classification methodologies have been applied. Also note that listing these references does not imply endorsement of 3M methodologies by individual authors, other organizations or government agencies.
This manual describes the 3M Population-focused Preventables (PFP) Software is a clinically-based classification system that identifies preventable hospital admissions, ED visits and ancillary services.
This fact sheet describes the development and use of 3M Potentially Preventable Events.
This e-Guide can help you understand 3M solutions for population health, patient safety and cost-effective care.
This article details the use of potentially preventable events and demonstrates how they are being applied to achieve health care value.
The New York Department of Health reports risk-adjusted 3M PPV rates by county for both the all-payer and Medicaid populations, with reports dating back to 2011.
This article offers five principles for success, emphasizing clinically credible initiatives that generate actionable information for clinicians.
The Agency for Health Care Administration continually seeks to improve access to quality healthcare services for Medicaid recipients and identify opportunities for healthcare efficiencies that do not compromise quality of care. One such opportunity lies in identifying and reducing potentially preventable healthcare events (PPEs).
This report explores one set of opportunities for health care system improvement and potential savings by analyzing Emergency Department (ED) visits, hospital admissions, and hospital readmissions to uncover the volume and make-up of potentially preventable health care events.