To account for variations in illness burden throughout a Medicare Benefit (MA) plans affected person inhabitants, makes use of danger adjustment based mostly on affected person illness burden. Particularly, MedPAC notes that:
Medicare makes use of beneficiaries’ traits, akin to age and prior well being situations, and a risk-adjustment mannequin—the CMS hierarchical situation classes (CMS– HCCs)—to develop a measure of their anticipated relative danger for lined Medicare spending.
In February 2023, CMS CMS revealed a discover of proposed rulemaking to replace their HCC danger adjustment algorithm (v28). These modifications included (i) leveraging ICD-10 moderately than ICD-9 codes as the first constructing blocks, (ii) use of 115 HCC indicators moderately than 79, and (iii) constraining some coefficients to be an identical throughout severity ranges (e.g., diabetes, coronary heart failure). The brand new algorithm will probably be phased in throughout 2024–2026.
One key query is whether or not suppliers underneath conventional Medicare (TM) code otherwise than Medicare Benefit (MA) plans. As a result of MA plan cost from CMS is dependent upon affected person severity, there’s an incentive to up-code diagnoses. A paper by Carlin et al. (2024) goals to judge whether or not or not this happens. They first clarify the mechanism by means of which MA plans might extra absolutely seize affected person secondary diagnoses:
MA plans have a possibility to evaluation medical information to make sure that suppliers didn’t unintentionally omit a analysis from encounter information. These critiques are extra essential when the suppliers’ reimbursement doesn’t incent detailed coding of the sufferers’ secondary diagnoses. MA plans to make corrections so as to add or (hardly ever) delete a analysis by means of CR information. As well as, each MA and TM suppliers might report further diagnoses by means of a HRA [health risk assessment] throughout a wellness go to or a house go to for this goal.
The authors use 2019 CMS claims information and divide the information into 3 cohorts: MA plans, TM beneficiaries attributed to ACOs (“TM ACO”), and TM beneficiaries not attributed to an ACO (“TM non-ACO”). ACO consists of sufferers attributable to accountable care organizations (ACO), akin to these collaborating within the Medicare Shared Financial savings Program (MSSP). The authors word that the TM non-ACO cohort serves as a key comparability since they don’t seem to be topic to the identical coding depth incentives skilled by MA plans and TM ACOs (since ACO shared financial savings is also danger adjusted).
The authors establish sufferers who had a HRA based mostly on whether or not they had an annual wellness go to, preliminary preventive bodily examination, or chosen dwelling well being visits (following the Reid et al. 2020 algorithm). The authors additionally use info from encounter claims on whether or not a affected person chart evaluation came about. Utilizing these information, the authors propensity-score matched the MA, TM ACO, and TM non-ACO cohorts. The authors then examine the matched and unmatched HCC scores and evaluated how the HRA and CR visits impacted the HCC danger scores. They discover:
Incremental well being danger because of diagnoses in HRA information elevated throughout protection cohorts according to incentives to maximise danger scores:+0.9% for TM non-ACO,+1.2% for TM ACO, and+3.6% for MA. Together with HRA and CR information, the MA danger scores elevated by 9.8% within the matched cohort.
Prognosis codes associated to vascular situations, congestive coronary heart failure, and diabetes had the most important contribution to common HCC rating throughout all 3 cohorts. Vascular, pscyh, and congestive coronary heart failure had been almost certainly to extend because of HRA/CR coding depth actions.
Whereas different papers have claimed Medicare Benefit have upcoded diagnoses for extra favorable reimbursement, this paper clearly specifies not solely the magnitude of the influence, but in addition the mechanism by means of which it’s almost certainly to happen. You’ll be able to learn the total paper right here.