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Abstract

Risk adjustment of managed care organization (MCO) payments is essential to avoid creating financial incentives for MCOs adopting enrollee selection strategies. However, all risk-adjustment methods have an inherent structural flaw that rewards preventable deterioration in enrollee health status and improved coding of disease burden. We propose a payment adjustment to offset this flaw. We use a database of 1,237,528 continuously enrolled beneficiaries to quantify the payment impact of change in enrollee health status over time for enrollees with two common chronic illnesses, hypertension and diabetes. The payment impact caused by the change in enrollee health status across MCOs ranged from +3.67% to −7.27% for enrollees with diabetes and from +5.25% to −7.69% for enrollees with hypertension. The MCO payment impact for diabetes and hypertension ranged from +0.19% to −0.31%. This difference can be used as the basis for creating payment incentives for MCOs to reduce the long-term costs of chronically ill enrollees.

Keywords

managed care organizations payment systems risk adjustment health reform Medicaid capitation cost variation

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References

American Academy of Actuaries Medicaid Work Group. (2005). Actuarial certification of rates for Medicaid managed care programs. Retrieved from http://www.actuary.org/pdf/practnotes/health_medicaid_05.pdf

America’s Health Insurance Plans. (2007). Innovations in chronic care. Retrieved from http://www.ahip.org/Innovations-in-Chronic-Care-Report/

Beaulieu

Cutler

Horrigan

Isham

(2003). The business case for diabetes disease management at two managed care organizations: a case study of health partners and independent health association. Retrieved from http://www.commonwealthfund.org/usr_doc/beaulieu_bcs_diabetesdiseasemanagement_610.pdf

Blue Cross Blue Shield Association. (2007). Medicare advantage: Improving care through prevention, coordination and management. Retrieved from http://c0540862.cdn.cloudfiles.rackspacecloud.com/Medicare_Advantage_Plan_Profile_FINAL.pdf

Centers for Medicare & Medicaid Services. (2010). Medicaid managed care penetration rates and expansion enrollment by state; penetration rates as of December 31, 2009. Retrieved from https://www.cms.gov/MedicaidDataSourcesGenInfo/downloads/09December31f.pdf

Government Accountability Office. (2012). Medicare advantage: CMS should improve the accuracy of risk score adjustments for diagnostic coding practices. Retrieved from http://www.gao.gov/assets/590/587637.pdf

Hughes

J. S.

Averill

R. F.

Eisenhandler

Goldfield

N. I.

Muldoon

Neff

J. M.

Gay

J. C.

(2004). Clinical risk groups (CRGs): A classification system for risk-adjusted capitation-based payment and health care management. Medical Care, 42(1), 81-90.

Kaiser Commission on Medicaid and the Uninsured. (2012). Medicaid managed care: Key data, trends, and issues. Retrieved from http://www.kff.org/medicaid/upload/8046-02.pdf

The Lewin Group. (2009). Medicaid managed care cost savings—A synthesis of 24 studies. Retrieved from http://www.ahip.org/content/default.aspx?docid=27090

10.

McCue

M. J.

Bailit

M. H.

(2011). Assessing the financial health of Medicaid managed care plans and the quality of patient care they provide. Issue brief (Commonwealth Fund), 11, 1-16. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/21675383

11.

McDonald

Hertz

R. P.

Unger

A. N.

Lustik

M. B.

(2009). Prevalence, awareness, and management of hypertension, dyslipidemia, and diabetes among United States adults aged 65 and older. Journals of Gerontology. Series A, Biological Sciences and Medical Sciences, 64, 256-263.

12.

Medicare Payment Advisory Commission. (2011). Medicare advantage program: Payment basics. Retrieved from http://www.medpac.gov/documents/MedPAC_Payment_Basics_11_MA.pdf

13.

New York State Department of Health. (2009). New York State Section 1115 Demonstration Project No. 11-W-00114/2; The partnership plan. Retrieved from http://www.nyhealth.gov/health_care/managed_care/appextension/waiver_extension/docs/application_for_extension.pdf

14.

Stafford

R. S.

Davis

R. B.

Iezzoni

L. I.

(2004). Modelling the ability of risk adjusters to reduce adverse selection in managed care. Applied Health Economics and Health Policy, 3(2), 107-114.

15.

State of Texas. (2011). Senate Bill 7; Legislative Session 82 (1). Retrieved from http://www.legis.state.tx.us/tlodocs/821/billtext/pdf/SB00007I.pdf#navpanes=0

Adjusting Medicaid Managed Care Payments for Changes in Health Status

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