Since 2012, CMS has been transitioning health plans from the Risk Adjustment Processing System (RAPS) to the Encounter Data System (EDS). In its Final Call Letter of April 6, CMS announced that for the first time, it will use data from both RAPS and EDS submission in the calculation of risk scores for Medicare Advantage plans. Beginning with 2015 dates of service, CMS will weigh data from RAPS submissions and FFS at 90% and data from EDS submissions and FFS at 10%.
The more we study the risks associated with dual eligible members, the more interesting things get. For example, our recent study finds that a dual eligible member is at higher risk for hospital readmission compared to a non-dual eligible member with the same characteristics—and this added risk is not accounted for in the current Star Ratings.
Our study results, published in “An Investigation of Medicare Advantage Dual Eligible Member-Level Performance on CMS Five-Star Quality Measures,” demonstrate that dual eligible members have significantly worse outcomes on a majority of Medicare Advantage (“MA”) Star Rating measures evaluated. Researchers found that socio-demographic characteristics—such as living in a high poverty area—and community resource factors—such as a shortage of mental health professionals—were a main contributor to the disparity between dual eligible and non-dual eligible members, explaining 30% or more of the observed differences in outcomes.
The 9th Annual RISE Summit in Nashville, TN, which occurred March 25-27, brought together over 200 of the healthcare industry’s leading organizations. The conference focused on how improvement in risk adjustment accuracy and quality performance delivers measurable results in the healthcare landscape.
As the healthcare industry shifts from a consumption and value based model to one driven by quality, value and efficiency, consumers now have more choices than ever. As a result, health plans are increasingly focused on becoming more consumer-centric, implementing innovative member engagement strategies as a competitive differentiator not only to promote well-being, but to attract new members and retain existing members.
Engaging members is essential from a quality, value and efficiency standpoint. Further, studies show that engagement programs and incentives can greatly improve participation in health promotion programs, while building brand loyalty – a key factor in member retention.
Inovalon’s cloud-based data analytics and data-driven intervention platforms play an integral role in the evolution of the healthcare industry. No other company offers the combination of large proprietary datasets, advanced data integration technologies, sophisticated predictive analytics and deep subject matter expertise. As the industry shifts to value and quality outcome models, the ability to efficiently and rapidly integrate and analyze large sets of data has become increasingly critical for healthcare organizations to be successful. In virtually every stage of the healthcare system– Big Data analytics can provide the clarity needed to achieve meaningful insight and improvement in clinical and quality outcomes, utilization and financial performance across the healthcare landscape.