Christopher Bradbury

Basic “explainer” on Risk Adjustment and a RAF conundrum. This article from The Commonwealth Fund does a good job of providing the basics of risk adjustment. It also calls out one of the major contributors to patient outcomes that isn’t captured in traditional risk models, the Social Determinants of Health (SDoH). They do a great job on this, so I won’t summarize it here. However, I think there is another factor that isn’t captured that I wanted to discuss and would appreciate some different perspectives. I’d love to get some thoughts on the following. Maybe I am simply being pedantic. The issue not mentioned in the article that I think current methodologies of risk adjustment miss is duration and management of disease. A patient with a new diagnosis of diabetes, for example, now has an elevated risk of numerous complications over their lifetime. However, that risk in year 1 after the initial diagnosis is much lower than the risk at year 10. Current risk models don’t take that escalating risk into consideration, keeping the risk adjustment fixed regardless of duration of underlying diagnosis. In addition, there are few scenarios that will impact me differently as the provider: 1) Management of this patient’s diabetes has been poor for the prior 9 years and now my group “inherits” this patient at year 10. 2) My team has helped this patient manage their diabetes very well for the past 9 years. 3) For the past 9 years, this patient’s prior group had managed their diabetes well but they have now switched into my group. As noted above, in scenario 1, that “new” diagnosis of diabetes severely underestimates this patient’s risk of needing expensive resources this upcoming year. I will be adversely impacted from something that is clinically obvious (duration of a disease increases risks) but which is not captured in the current data. To go one step farther, in frameworks 2 and 3, there is a gap between what the patient’s risk would have been without 9 years of great care and what it likely is now. However, there is no recognition of this work. That is to say, if the patient switched to a group that did a terrible job of managing diabetes, they’d receive the same risk adjustment in year 10 as my group would receive after all of our time, effort and resources had been dedicated to keeping this patient healthy. If the patient’s healthcare needs in year 10 are low because of our efforts, shouldn’t we receive more credit than a group that simply gets attribution? And, what about the prior group? How are (were?) their efforts recognized? Please share your thoughts in the comments.

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Medicare Advantage unrest, Change Healthcare fallout and more big takeaways from insurers’ Q1 https://lnkd.in/eyg48k7e via Healthcare Dive #MedicareAdvantage #ChangeHealthcare #Cybersecurity #CMS #Medicaid

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The era of splashing the market with flashy supplemental benefits is in the rearview as CMS, MA plans, and downstream risk-bearing providers are collectively challenged to "do more with less."   CMS' heightened data collection requirements will slowly but surely drive an emphasis on cost-saving, impact-driving supplemental benefits rather than those that simply attract members.   This shift could serve risk-bearing providers well, as overly generous and unmanageable supplemental benefit allowances have often driven MLR headwinds in recent years.

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The growth of the health insurance marketplace is picking up steam, fuelled by Medicaid disenrollment. https://ow.ly/N1vW50Tafsq MMIT’s Erin Trompeter explains what these large-scale changes mean for providers, manufacturers, payers and health IT vendors. Get the insights by clicking the link in this post. #HealthInsuranceMarketplace #HealthInsurance #Medicaid

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With over 2 million members displaced by major healthcare players exiting underperforming Medicare Advantage markets, regional insurers face both a challenge and an opportunity. This influx of high-cost members demands innovative solutions to manage chronic conditions like diabetes and heart failure effectively. At Circadian Health, we’re helping regional insurers navigate this disruption with virtual-first specialty care, reducing costs and improving outcomes for the most complex members. This market shake-up isn’t just a challenge—it’s a chance to redefine care delivery. Discover how regional insurers can transform disruption into opportunity—read more on our blog. #MedicareAdvantage #HealthcareInnovation #VirtualCare #CircadianHealth #ValueBasedCare #HealthEquity

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CMS’s 2025 Medicare Advantage star ratings are down—only 62% of enrollees are in 4-star+ plans vs. 90% in 2022. Are plans getting worse—or is CMS stricter? Joe Albanese explains the new CMS rules and their impact in this week's #ParagonPIC. READ: https://t.co/1c6vwrlEiB MA star ratings peaked in 2022 but have fallen since. #MedicareAdvantage’s average star rating fell to 3.92 for 2025, with just 7 plans earning 5 stars. Avoiding "grade inflation" for stars may be one goal, but the ratings have other well-known flaws. Plans want to get more stars and earn bonuses, but this encourages a focus on government metrics rather than accountability to enrollees. And the cost of bonuses has risen over the past decade. #MedicareAdvantage #StarRatings Technical changes to CMS calculations are likely a bigger factor in declining stars than worsening plan quality. But fixes to the star ratings and quality bonuses are needed.

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📈 #HealthcareAlert: Hospital & Prescription Drug Spend Projected to Surge by ~6% Annually Through 2032, with Medicare at the Forefront Recent projections from the CMS Office of the Actuary, National Health Statistics Group indicate a significant surge in hospital and prescription drug spend, with Medicare driving the most growth. 🤝 Reach out to learn more about how MDI Health is helping payers and risk-bearing providers reduce Rx and medical spend by $2,000 per high-risk member. #Medicare #PayerSolutions #UtilizationSpend #RxSpend #MedicalCosts 

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New CMS report: The Medicare Shared Savings Program (MSSP) continues to demonstrate its effectiveness in delivering high-quality care while generating significant cost savings. Key highlights from the report: - MSSP generated $1.8B in savings for Medicare in 2022 - 483 ACOs participated, serving 11 million Medicare beneficiaries - 99% of ACOs successfully reported quality measures - 54% of ACOs earned shared savings payments These outcomes reinforce that VBC can drive care quality while improving financial outcomes for the ACOs who participate. Check it out here: https://lnkd.in/dJDNU6-c #Valuebasedcare #healthcareinnovation #ACOs #Medicare

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That’s a wrap on the 24th Risk Adjustment Forum! It was great seeing you all there. If you’d like to discuss your organization’s risk adjustment strategy further or we didn’t get a chance to connect, let’s set up a time. #DataLink #Events #RiskAdjustmentForum #Ri

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CMS will sunset the Medicare Advantage (MA) Value-Based Insurance Design model at the end of 2025 because of cost. https://lnkd.in/gJ3wQeiQ

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So, CMS has decided to terminate the Medicare Advantage Value-Based Insurance Design (MA VBID) model at the end of 2025 due to unsustainable costs to the Medicare Trust Funds. Introduced in 2017 to reduce healthcare costs and improve health outcomes, the model led to significant expenses, totaling $2.3 billion in 2021 and $2.2 billion in 2022, due to increased risk scores, higher rebates, and elevated Part D costs. So, how does this impact providers 🏥 💉 Providers may see modifications in supplemental benefits like transportation and reduced drug costs, which may continue under Special Supplemental Benefits for the Chronically Ill (SSBCI) but without previous flexibility. 💊 Disruptions in Part D cost-sharing could complicate patient medication adherence. 🩺 MA organizations and providers must begin adjusting workflows and care delivery strategies for 2026. 🥼 Providers serving underserved or chronically ill populations may struggle with maintaining programs that promote health equity. While CMS recognizes VBID's achievements in enhancing transparency and health outcomes, its termination emphasizes the need for more cost-effective care delivery models. Providers will need to work closely with MA plans and CMS to ensure continuity of care for patients.

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According to the news published by HFMA on April 4, 2024, concerning Medicare Advantage states that CMS has finalized a slight decrease in the 2025 payment rates for Medicare Advantage (MA), potentially leading to constrained revenue and payments for stakeholders. While average revenue for MA plans is expected to rise by 3.7%, primarily due to an increase in the risk-score trend, base payments from Medicare to plans are slated to decline by 0.16%. Despite stakeholder comments seeking a more positive adjustment, CMS believes its policies will maintain stability for the MA market and beneficiaries, ensuring accurate payments and preventing wasteful spending. CMS also disagrees with the idea that this update represents a payment cut that would increase costs or reduce benefits for beneficiaries, citing the 3.32% net updates for 2024, and a significant decrease from the 8.5% increase in 2023. CMS asserts that plan availability, enrollment, and benefit offerings have remained stable or improved this year. Read More: - https://lnkd.in/giSgidsV

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