This three-year-long study proposes to answer two questions: (1) How is health-based risk adjustment implemented? and (2) What is the impact of health-based risk adjustment on managed care organizations (MCOs)?
Methods
Our target population is geographical markets where health-based risk adjustment is currently being used. We have identified purchasers of health care in these markets, including employer groups (three states), Medicaid (eight states), and Medicare (two states). We have also identified the health plans that offer health-based, risk-adjusted products to these purchasers.
Two panels of experts in health-based risk adjustment, as well as study consultants, help guide the data collection content and methods for this project. The
(NAP) comprises some of the nation's leading health-based risk adjustment experts, including the developers of three health-based risk adjustment models: Adjusted Clinical Groups (ACGs), Chronic Illness and Disability Payment System (CDPS), and Diagnostic Cost Groups (DCGs). Our consultants, too, are expert in the various health-based risk adjustment models currently available to health plans.
We are collecting data for the study from four sources described below.
Purchaser Profiles
For each healthcare purchaser, we collect data to describe the initial implementation process, the population covered, the risk assessment method used, changes that have occurred since health-based risk adjustment was implemented, and perceptions about the impact of health-based risk adjustment on the product.
These purchaser descriptions provide the basis for analysis of technical and policy issues that affect all the markets.
Survey of Managed Care Organizations
A survey of product managers of managed care organizations documents the experiences of health plans in 12 markets that have been paid under health-based risk adjustment. Results of the survey will also provide purchasers with an evaluation of their health-based risk adjustment initiative.
The survey queries both factual items and product managers´ perceptions, including an assessment of the implementation process, the potential burden imposed by required changes in data systems, the impact of the product´s financial viability, and the perception of factors that may influence a disproportionate selection of persons with significant health care needs to a particular health plans.
Financial History
Key informants are helping direct us to public and private documents of each product´s financial history, including the base rates, reference populations for the base rates, numbers of enrollees for each plan, risk scores, and per-member-per-month revenue for the year before health-based risk adjustment was implemented and for each subsequent year.
Survey of Actuaries
To understand the experience and attitudes of professionals most closely affiliated with predicting a health plan´s financial future, we will survey members of the Society of Actuaries who have experience in health care benefits. We will ask if they use health-based risk adjustment for procedures such as setting premium rates and setting provider capitation, and ask them to evaluate the fairness of payment to health plans with and without health-based risk adjustment. We will also ask their opinions about the future of health-based risk adjustment.
