Health Risk Adjustment Flashcards
1
Q
Health Risk Adjustment
Uses of Risk Adjustment
A
- Adjust payments for MA/Part D/Medicaid
- ACA includes risk adjustment for small group/individual
- ERs use it to analyze how EE contributions should vary by choice of health plan
- Insurers use it for provider profiling/payments, rating
2
Q
Health Risk Adjustment
Why is Risk Adjustment Needed?
A
- Provide equitable payments to insurers and providers and make fair comparisons among insurers/providers
- Induce insurers/providers to compete on efficiency and quality, rather than selection of healthier risks
- To preserve choice for consumers and have consumers pay appropriate price for choice
3
Q
Health Risk Adjustment
Steps of Risk Adjustment
A
- Risk Assessment - Classification and Measurement
- Payment Adjustment
4
Q
Health Risk Adjustment
Risk Classification (Definition and Potential Characteristics)
A
Pooling individuals with similar risk characteristics
- Demographics
- Utilization
- Dx data
- Medical history
- Perceived/functional health status
- Lifestyle
5
Q
Health Risk Adjustment
Risk Measurement
A
Quantifying risk of individuals within risk class
- Need to reflect relative risk factors for all insurers combined
- Data must be on same basis
