RISE RAPS-EDS COLLABORATION RESEARCH PROJECT EXECUTIVE SUMMARY

Avalere analyzed data from eight Medicare Advantage Organizations (MAOs) representing 1.1 million beneficiaries in more than 30 unique plans operating across the country to understand the impact of shifting the determination of plan risk scores from the Risk Adjustment Processing System (RAPS) to the new Encounter Data System (EDS). Centers for Medicare and Medicaid Services (CMS) intends to transition gradually to EDS-based payments, starting with 10 percent of the payment based on EDS in 2016, increasing to 25 percent in 2017 and 50 percent in 2018. 

CMS has said the diagnoses captured in EDS should not be different from those identified in RAPS.  However, we found that this transition will significantly reduce the identification of diagnoses used to calculate the risk scores that reflect the disease burden of the plans membership.  Average risk scores resulting from the EDS process were 26 percent lower in the 2015 payment year (based on 2014 claims data) and 16 percent lower in the 2016 payment year (based on 2015 claims data) compared to RAPS. The lower risk scores were primarily the result of 35-40 percent fewer Hierarchical Condition Category (HCC) diagnoses identified in EDS compared to RAPS.

 The risk score differences will have significant negative implications for MAOs and the 18 million beneficiaries they serve.  As an example, using an $800 bid rate, if there had been a full transition from RAPS to EDS in 2016, this would equate to an average reduction of 16.1 percent in PMPM rates, representing a decrease of $260.4 million per year for the average plan in our study.  The 90/10 phase in in 2016 would result in a 1.6% reduction in PMPM rates which would translate to $25.2 million per-plan in lower payments on average.

 

To Read the Full Executive Summary Report, please follow either this link to the report on the RISE website  www.RISEHEALTH.ORG  or the Avalere website at http://avalere.com/expertise/managed-care/insights/impact-of-medicare-advantage-data-submission-system-on-risk-scores


Categories: Risk Adjustment
Tags: RAPS, EDS, EDPS, RAF score, CMS payment, Medicare Advantage

Log on to Your Rise Account

Forgot your password?
Create an Account

Association Sponsors

Latest Posts

It’s not Obamacare anymore. It’s our national health-care system.

By Drew Altman and Larry Levitt July 29 Drew Altman is president and chief executive of the Henry J. Kaiser Family Foundation. Larry Levitt is senior vice president of the Kaiser Foundation. Republicans failed to repeal and replace the Affordable Care Act early Friday because of divisions within their own ranks, and because they tried not only to repeal and replace the ACA but also to cut and cap the Medicaid program, generating opposition from many red-state governors and their senators. But most of all, they failed because they built their various plans on the false claim — busted by the Congressional Budget Office — that they could maintain the same coverage levels as the ACA and lower premiums and deductibles, while at the same time slashing about a trillion dollars from Medicaid and ACA subsidies and softening the ACA’s consumer protection regulations. Had they succeeded, they would have won a big short-term victory with their base, which strongly supports repeal, but suffered the consequences in subsequent elections as the same voters lost coverage or were hit with higher premiums and deductibles. ...
Read More

Where to Now? True North Again

By Kevin Mowll, Executive Director of the RISE Association The failure of the Republicans to repeal, replace, or wreck ObamaCare is a wakeup call for everyone, not just Republicans. While the RISE Association steers away from purely political commentary, the lesson of this protracted political mess needs to be called out for the sake of putting our priorities straight around public policy regarding healthcare reform. In the attached Wall Street Journal article, which suggests that bipartisan solutions are the only remaining way forward, the author proffers hope that the blistering truth will be obvious to all the participants in the 7-year-long fracas around repeal and replace. The bloodied players may still brood in frustration that their political wills were not enough to win, but the author wonders if cooler heads will prevail. I, for one, am not so sanguine; yet I can only hope. https://www.wsj.com/articles/republicans-search-for-answers-can-they-find-any-across-the-aisle-1501259286 The lesson I take away from the many years of wrangling is that the ObamaCare political football games demonstrates that political wills are not the way forward. They lose sight of the True North issue at hand. Rather, the failures of both political parties in arriving at a bipartisan solution signals the fact that what is good for America is good healthcare policy, not political prowess over rivals. Governing from the fringe is not sustainable in a democracy. ...
Read More

Upcoming Conference

 

RISE West 2017 

Featuring three pre-conference workshops, and five tracks covering 20+ in-depth session topics, this event is an extraordinary value-proposition you don’t want to miss. Hear from industry thought leaders, as well as health plan and provider group experts who will share practical insights and updated lessons learned from the trenches on critical topics in risk adjustment, quality improvement, data management, coding compliance & more!

More

Upcoming Webinar

The Encounter Management Best Practices Playbook

What encounter best practices can managed care plans put into place to help them manage the pace of change in formats, rules and regulations? What do managed care plans have to stop doing if they want to ensure business continuity with their encounter operations in the face of change and bleeding revenue? What can you do to make sure your plan isn’t one of the ones that figured these things out too late? Join us to get answers to these questions and more on September 12th.

 

Connect With Us

Copyright © 2014 Resource Initiative & Society for Education. All rights reserved.