Risk stratification is a critical component of improving care outcomes for Medicaid Beneficiaries with Complex Care Needs and High Costs (BCNs). Conducting risk stratification enables health policy makers and clinicians to identify and predict which beneficiaries are at high risk - or likely to be at high risk - and prioritize the management of their care in support of improving health outcomes and better managing the cost of care.
Why do we need risk stratification in healthcare?
In this era of value-based care, risk stratification becomes a necessity: to sort patients into high, moderate and low health risk tiers and delivering appropriate care to address their health needs.
What is the action action step in patient stratification?
Action step: Segment the population into target groups based on the number of conditions per patient. Providers and members of the care team can adjust stratification based on personal knowledge of each patient's utilization patterns, social risks, and other factors. Design care models and target interventions for each risk group.
How do top-performing population health organizations practice risk stratification?
Top-performing, population health-focused organizations practice risk stratification. The goal of risk stratification is to segment patients into distinct groups of similar complexity and care needs. For example, out of every 1,000 patients in a panel, there will likely be close to 200 patients (20%) who could benefit from more intensive support.
What is risk adjustment and why is it important?
The goal of risk adjustment is to enable more accurate comparisons across TINs that treat beneficiaries of varying clinical complexity, by removing differences in health and other risk factors that impact measured outcomes but are not under the TIN’s control.
Why risk stratification is important?
Practices can systematically use patient risk levels to make care management decisions, such as providing greater access and resources to patients in higher risk levels. Risk stratification helps practices to better focus on their sickest patients, reduce costs, and improve care.
Why is risk management so important in healthcare?
Healthcare risk management helps protect healthcare organizations from many risks that are specific to the healthcare industry. For example, they prevent problems with patient records, administrative systems, and more.
Why is risk adjustment important in healthcare quality metrics?
Risk adjustment attempts to solve that problem and increase the likelihood that selecting a clinician or facility based on a performance results in improved outcomes for the population.
What is the main reason risk adjustment methods are important when measuring outcomes?
Risk adjustment models are used to determine the expected rate of an outcome of interest for a provider or a population. This expected rate is compared in some way to the actual (observed) rate to make inferences about care quality.
What is the purpose of risk management?
The purpose of risk management is to identify potential problems before they occur, or, in the case of opportunities, to try to leverage them to cause them to occur. Risk-handling activities may be invoked throughout the life of the project.
Why is risk assessment important in nursing?
Risk assessment provides useful information when devising care plans. It also has an impact on psychotherapeutic issues such as engagement with the person and concordance with treatment.
What is the purpose of Medicare risk adjustment?
Risk adjustment is a statistical method that seeks to predict a person's likely use and costs of health care services. It's used in Medicare Advantage to adjust the capitated payments the federal government makes to cover expected medical costs of enrollees.
How does risk adjustment benefit patients?
In its simplest terms, risk adjustment ensures that the health conditions, health status, and demographics of the beneficiaries in a Medicare Advantage or an Affordable Care Act plan are accurately documented—and that the health plans managing those beneficiaries are adequately compensated for that management.
What is risk adjustment in the context of quality measurement and why is it important when designing quality metrics in healthcare?
Ideally, risk-adjustment assures that measured differences in the quality of care are not biased by differences in the underlying patient populations treated by different providers or in different regions. An overview of potential patient (risk-) factors that may influence outcomes of care is presented in Table 3.7.
How does risk adjustment affect providers?
Risk adjustment levels the playing field so that payers are appropriately compensated for taking on high risk patients. This increases access to healthcare for all individuals. Providers are also appropriately compensated for accurate reporting of their patients' conditions and treatment plans.
What is risk adjustment in healthcare?
As defined by the Centers for Medicare and Medicaid Services (CMS), risk adjustment predicts the future health care expenditures of individuals based on diagnoses and demographics. Risk adjustment modifies payments to all insurers based on an expectation of what the patient's care will cost.
What is Medicare risk Adjustment HCC coding?
HCC coding relies on ICD-10-CM coding to assign risk scores to patients. Each HCC is mapped to an ICD-10-CM code. Along with demographic factors such as age and gender, insurance companies use HCC coding to assign patients a risk adjustment factor (RAF) score.
What is risk stratification?
Risk stratification, to put simply, is the process of dividing patients into “buckets” based on their vital health signs, their lifestyles, and medical history. Risk stratification is a framework applied for complete population health management, combining several individual risk scores, demographic and socioeconomic characteristics and medical records to create a comprehensive patient profile.
Why is data analytics important in healthcare?
Data analytics is the current buzzword in healthcare, and rightly so. Access to actionable data combined with right analysis helps not only in predicting outcomes, but also improves the ability of care teams to align available resources to what a patient needs. Although data is just a start and not an endpoint, it can be used in several ways to make the process of risk stratification less cumbersome.
What states have risk stratification?
States seeking to develop risk stratification approaches for individuals dually eligible for Medicare and Medicaid can look to the experiences of California, Ohio, and Virginia. In these three states, a combination of prior managed care program experience and stakeholder input shaped the definition of risk groups and the process of risk stratification. Providing health plans with individual enrollee data before enrollment, including service utilization and prior approvals, is critical to timely risk stratification and subsequent assessment, care management, and continuity of care. Employing a larger number of indicators in the determination of risk level may be more beneficial to identification of individuals at highest risk. Including both clinical (e.g., prior utilization of services and gaps in care) and non-clinical factors (e.g., housing status and support system stability) may also be useful to the accurate determination of risk status.
What are the three levels of Medicare in Illinois?
Illinois’ contract with Medicare-Medicaid Plans for its capitated financial alignment demonstration requires plans to stratify enrollees into three levels: low- or no-risk; moderate-risk; and high-risk.2 Under the three-way contract, no less than 20 percent of enrollees can be assigned to the moderate- and high-risk categories, combined; while no less than five percent of enrollees can be assigned to the high-risk level. Thus far, Illinois is the only demonstration state that prescribes the percentage of enrollees that health plans must have in specific risk categories.
What is higher risk?
Higher-Risk: An individual at increased risk of an adverse health outcome or worsening health status if initial contact does not occur within 45 calendar days of coverage, including, but not limited to, those who:
What is MMP readiness review?
As part of the MMP readiness review process, Virginia created a series of enrollee vignettes depicting individuals with a range of health care and social services needs. MMPs were asked to describe their processes for completing HRAs and providing care management for these enrollees while demonstrating a person-centered approach. The state and external experts, including Community Service Boards, which serve as the single point of entry for individuals with serious mental illness and intellectual/developmental disabilities, were invited to MMPs’ vignette presentations to ensure that approaches to care management addressed population-specific needs and would work in daily practice.