Description: A rethinking of current provider reimbursement, focusing on incentives instead of simply cutting fees. The recommended 2-pronged approach would feature integrated provider organizations as well as evidence-based decision making organized around episodes of care.

Description: Healthcare risk adjustment methodologies have become increasingly complex, largely due to the belief that complexity enhances accuracy. However, a disconnect exists between how healthcare risk is assessed and how payments are adjusted. This article explores the stark difference between measuring the accuracy of a risk assessment model at a member level, and that of a risk adjustment mechanism at the health plan level. I show that a highly simplified approach that does not use diagnosis codes can have similar accuracy on risk adjusted payments to models that do. These findings suggest that accuracy is not a barrier to developing simpler risk adjustment methodologies, which can improve payment accuracy and reduce the financial incentive for coding diagnoses.

Description: The MACRA/QPP Payer Revenue Model is designed to provide Health Plans an estimate of the expected claim cost increase/decrease due to MACRA.

Description: This paper outlines a framework for assisting a STARS manager in implementing a quantitative approach to prioritize stars measures for targeted intervention

Description: The ACA’s Medical Loss Ratio Provisions

Description: Introduction to the ACA @ 5 publication

Description: Risk adjustment is used to adjust the revenue stream to health insurers that sell ACA eligible plans and Medicare Advantage plans. This article compares and contrasts these risk adjustment programs.

Description: This is a review of literature about the development and application of medical risk adjustment models. The current Medicare model, principal inpatient diagnosis cost group [PIPDCG] and proposed enhancements are the subject of many articles. Risk adjustment is used for both provider payment and performance measurement.

Description: This dissertation by Tia Sawhney will help you understand this issue and start measuring it, or start promoting equitable public policy.

Description: CLASS Act and ACA