From Tom's Desk
Risk Code Revamp
CMS has released "Part 1" of its 2019 advance notice of changes to MA capitation rates and Part D payment policies.
These changes represent CMS' response to the statutory language in the 21st Century Cures Act, passed last year.
The big picture: It's a significant win for the industry.
Chronic Kidney Disease Stage 3 will be funded as a risk-based HCC. Drug overdoses and soft psychiatric diagnoses will be funded as well. CMS was also directed to include total disease burden in it's RAF calculation---and it elected to do so with a model that was favorable to overall risk score calculations.
Lots more documentation requirements, only a little additional funding for the implementations of the changes, and the potential for a whole lot of fraud.
Higher risk scores do not equal higher revenue. There is still a fixed amount of money going into the system. And higher coding is still going to result in a downward adjustment of the value of each risk score.
The biggest downside of all?
These changes may further encourage Medicare Advantage Organizations to take their eye off the cost-control ball---using old, tried-and-failed utilization barriers, rather than innovative shared-risk designs.
Why is this the biggest downside? Because when the growth in capitation dollars eventually slows, and it will, cost control is all you will have left---and those doing it best will be the ones who'll excel.