RISE reviews the latest health care research.
Changes in coding intensity indicate how upcoding occurs across outpatient settings
A new study from Trilliant Health, an analytics and market research firm, reviews a steady shift toward higher-acuity procedure codes across care settings.
Researchers evaluated national all-payer claims data to examine emergency department, urgent care, and primary care physician office E/M visit volume from 2018 to 2023. They found that the share of visits coded at higher complexity levels increased across all outpatient settings, including emergency departments (CPT 99284 increased from 32.5 percent to 39.6 percent), urgent care centers (CPT 99204 rose from 34.0 percent to 40.6 percent), and physician offices (CPT 99214 grew from 38.5 percent to 45.0 percent).
Furthermore, all ICD-10-CM chapters saw an increase in high-acuity billing, with particularly large gains for eye- and ear-related diagnoses in emergency departments, circulatory and hematologic conditions in urgent care, and mental health diagnoses in primary care. Common diagnoses like rash, cough, and nausea/vomiting saw some of the largest increases in emergency department high-acuity coding, raising questions about whether billing complexity is outpacing clinical severity.
Researchers believe some of the increase may be due to actual changes in patient acuity but also systematic incentives, such as documentation templates that encourage detailed coding and revenue cycle strategies designed to optimize reimbursement.
The majority of health care leaders expect value-based care revenue gains in 2025
New research conducted by Innovaccer, a health care AI company, in collaboration with the National Association of ACOs (NAACOS), uncovers the progress, pain points, and investment signals driving value-based care strategies.
The study, based on a survey of 168 health care leaders across 142 organizations, found that
- 64 percent of health care organizations expect higher value-based care-driven revenue in 2025 compared to 2024.
- 87 percent of respondents cite financial risk as the top barrier to adoption, followed by provider readiness (80 percent), lack of interoperability (75 percent), and high technology cost (67 percent).
- 74 percent say greater financial support and incentives would significantly accelerate adoption.
- 70 percent express optimism about AI’s role in enabling predictive analytics and scaling value-based care strategies.
“At the foundation of accountable care and population health management lies the strategic use of integrated data that drives insights and action,” said Emily D. Brower, president and CEO of NAACOS, in the announcement. “This comprehensive approach enables a deeper understanding of community, population, and individual patient needs. This report highlights how technology, collaboration, and infrastructure can support providers in accountable care to drive innovation in care delivery.”
Working paper: Medicaid coverage saves more lives
A new working paper from the National Bureau of Economic Research finds that people who obtained Medicaid after the Affordable Care Act expanded access to the program were 21 percent less likely to die during a given year than those who were not enrolled in the coverage.
States that expanded Medicaid saved 27,400 lives between 2010 and 2022, according to the report. But states that chose not to expand Medicaid missed the opportunity to save 12,800 more lives.
The authors note that Medicaid expansion may be a cost-effective way to save lives. They estimate $5.4 million per life saved and $179,000 to save a year of life. “Our findings suggest that lack of health insurance explains about five to 20 percent of the mortality disparity between high- and low-income Americans,” the authors wrote. “We contribute to a growing body of evidence that health insurance improves health and demonstrate that Medicaid’s life-saving effects extend across a broader swath of the low-income population than previously understood.”
Study: MA members experience better health outcomes under fully accountable care models
Medicare Advantage members whose physicians were under fully accountable models (taking full risk for the costs and quality of their care) have dramatically better health outcomes than patients enrolled in traditional fee-for-service Medicare, even when cared for by the same physicians, according to a recent study funded by Optum and published in the American Journal of Managed Care.
Researchers, led by Kenneth Cohen, M.D., executive director, translational research, Optum Health, conducted a retrospective cross-sectional regression analysis of claims and enrollment data from 2016 to 2019, examining 20 performance measures. All patients were cared for by the same 17 physician groups and 15,488 physicians across 35 health insurers.
The research team found outcomes for Medicare Advantage patients in fully accountable models were better across 16 of 20 measures, including lower acute inpatient admissions, lower 30-day readmissions, less likely to use the emergency department for care across four measures, and lower high-risk medication use. The other four measures were statistically equivalent.
The research team believes there may be two reasons for the difference in outcomes. Physicians in fully accountable models may have adapted their practices to prioritize preventive care, refer selectively to high-performing specialists and facilities, focus on evidence-based medicine, and reduce low-value care. Furthermore, care delivery may benefit from the infrastructure supporting at-risk Medicare Advantage, such as population risk stratification, provider performance feedback, intensive case management, and integrated support services.