Maryland Primary Care Program (MDPCP) Pre-AH Risk Score Specifications and Codebook (Version 3)

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The Hilltop Institute


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The Maryland Primary Care Program (MDPCP) is a key element of the Total Cost of Care (TCOC) All-Payer Model, an agreement between the Centers for Medicare & Medicaid Services (CMS) and the state of Maryland. The MDPCP is a voluntary program that provides funding and support for the delivery of advanced primary care throughout the state. It allows primary care providers to play an increased role in the prevention and management of chronic disease, as well as in the prevention of unnecessary hospital utilization. As an important part of supporting providers in their care management efforts, the MDPCP will provide to participating practices risk scores of their attributed beneficiaries according to each patient’s risk of incurring a potentially avoidable hospitalization or emergency department (ED) visit. Accordingly, The Hilltop Institute, in conjunction with the Maryland Department of Health, has developed the Hilltop Pre-AH (Predicting Avoidable Hospitalizations) Model™ in order to operationalize these risk scores. These patient-level risk scores are provided to participating medical practices on a monthly basis via the MDPCP portal on the Chesapeake Regional Information System for our Patients (CRISP) unified landing page. This document aims to explain the intended use, technical implementation, and model performance of the Hilltop Pre-AH Model™ as of June 2020. It will be updated as future versions of the model become operational.