To account for variations in illness burden throughout the affected person inhabitants of Medicare Benefit (MA) plans, danger adjustment based mostly on the affected person's illness burden is used. MedPAC particularly notes that:

Medicare makes use of beneficiaries' traits, akin to age and former well being situations, and a danger adjustment mannequin (the CMS Hierarchical Situation Classes (CMS-HCCs)) to develop a measure of their anticipated relative danger for lined Medicare bills.

In February 2023, CMS CMS printed a Discover of Proposed Rulemaking to replace their HCC Danger Adjustment Algorithm (v28). These modifications embrace (i) utilizing ICD-10 as an alternative of ICD-9 codes as the first constructing blocks, (ii) utilizing 115 HCC indicators as an alternative of 79, and (iii) limiting some coefficients to to be similar throughout severity ranges (e.g. diabetes, coronary heart failure). The brand new algorithm shall be progressively launched over the interval 2024-2026.

An vital query is whether or not suppliers underneath the standard Medicare (TM) code are completely different from Medicare Benefit (MA) plans. As a result of MA plan cost from CMS depends upon affected person severity, there’s an incentive to upcode diagnoses. An article by Carlin et al. (2024) goals to guage whether or not or not this occurs. They first clarify the mechanism by which MA plans may extra absolutely seize sufferers' secondary diagnoses:

MA plans have the power to evaluation medical data to make sure that suppliers haven’t inadvertently omitted a prognosis from the encounter knowledge. These assessments are extra vital when healthcare supplier reimbursement doesn’t encourage detailed coding of the affected person's secondary diagnoses. MA plans to make corrections so as to add or (hardly ever) take away prognosis by way of CR data. Moreover, each MA and TM suppliers can document further diagnoses via an HRA [health risk assessment] throughout a wellness go to or a house go to for this objective.

The authors use 2019 CMS claims knowledge and divide the information into three 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 taking part within the Medicare Shared Financial savings Program (MSSP). The authors word that the TM non-ACO cohort serves as an vital comparability as a result of they don’t seem to be topic to the identical coding depth incentives skilled by MA plans and TM ACOs (since ACO's shared financial savings additionally account for danger have been corrected).

The authors establish sufferers with an HRA based mostly on whether or not they had an annual wellness go to, an preliminary preventive bodily examination, or chosen dwelling care visits (in response to the Reid et al. 2020 algorithm). The authors additionally use data from encounter claims about whether or not a affected person chart evaluation occurred. Utilizing these knowledge, the writer's propensity rating matched the MA, TM ACO, and TM non-ACO cohorts. The authors then in contrast the matched and unmatched HCC scores and evaluated how the HRA and CR visits affected the HCC danger scores. They discover:

Growing well being danger from diagnoses in HRA data elevated throughout protection cohorts, per 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 data, MA danger scores elevated by 9.8% within the matched cohort.

Analysis codes associated to vascular illness, congestive coronary heart failure, and diabetes had the best contribution to the imply HCC rating in all three cohorts. It’s possible that vascular, psychological, and congestive coronary heart failure will increase on account of HRA/CR coding depth actions.

Whereas different articles declare that Medicare Benefit has upcoded diagnoses for extra favorable reimbursement, this text clearly specifies not solely the magnitude of the influence, but additionally the mechanism by which it’s most probably to happen. You’ll be able to learn the total article right here.