Medicare Advantage And Risk Adjustment Have Critical Roles In Healthcare

 A while back, Doctor Richard Gilfillan and Dr. Donald Berwick published an essay in Health Affairs Forefront criticizing the Medicare Advantage (MA) program and the Global and Professional Direct Contracting (GPDC) initiative.

Both experts stated that Centers for Medicare and Medicaid Services CMS's Hierarchical Condition Category (HCC) Risk Adjustment Solution had had several flaws since its complete introduction in 2006. They propose that CMS replace the risk-scoring methodology based on HCC in two years, that MA is "fundamentally broken," and that the GPDC program is terminated outright.

Experts' criticisms on Medicare Advantage and HCC Coding mirror a failure to recognize the critical role that Risk Adjustment plays in MA remuneration.

 

Risk Adjustment's Role to Evaluate Beneficiary's Future Medical Costs:

 

The Risk Adjustment Solution is critical for estimating a beneficiary's potential health care expenditures because it matches reimbursement with illness sensitivity and complexity. Risk Adjustment (RA) promotes registration of the chronically ill and most low - income patients; it is widely used in Medicare Advantage Plans and the Medicare Shared Savings Program (MSSP) to adequately adjust performance indicators, spending criteria, and cost statistics, making it possible for more accurate and consistent performance evaluation.

 

The statistics collected through Risk Adjustment Solution also reveal how many more individuals in vulnerable demographics are covered under MA Plans. With the benefits offered by Risk Adjustment, healthcare practitioners are pursuing the sickest and most vulnerable patients.

 

Medicare Advantage Is the Care Model of the Future:

 

The Medicare Advantage program assesses how well plans and practitioners operate throughout quality indicators by analyzing data from member satisfaction, quality of care, and plan actions.

 

The MA STARS Program includes more than 40 quality-measurement criteria. It gives a star-based rating scale to plans based on merit and performance in those parameters and a 5% reimbursement boost for many of these plans if they attain a rating of 4 stars or above. A rating of 5 STARS is regarded as outstanding. As the Stars Program became more known and understood, Medicare Advantage Plans tried to reach a four-star or superior rating; this focus on quality led to better value-based care for patients as a potential outcome.

 

The Bottom Line:

 

There is no doubt, but it is critical that such efforts not be abandoned as Medicare Advantage Plans and Risk Adjustment Solution can be changed for the better. These can provide a learning environment and pathways for healthcare organizations transitioning to value-based care. The value-based care shift may collapse if these initiatives are hampered or discontinued. We all must have an open mind concerning possible implications while correcting certain flaws.