CMS tests payment models to identify underserved communities

Don Calcagno, director of population health for the Downers Grove, Illinois-based health system, said Advocate Health sees a similar problem in the Midwest. “Some disadvantaged populations are not accurately reflected in the top ADI sectors, leading to an unequal distribution of benefits,” he said.

Chicago-based Oak Street Health estimates CMS’s proposed use of ADI in a Medicare Advantage payment model would shift resources away from beneficiaries who are Black and eligible for both Medicare and Medicaid.

The CVS Health division told federal regulators in March that it would reduce its risk-adjusted payments by $240 in risk-adjusted payments to each dual-eligible member each year under this method. Black dual-eligible beneficiaries would be severely impacted, with an annual reduction of $480 in risk-adjusted payments.

Khan said the additional funding helps Oak Street Health financial providers like behavioral health clinicians and social workers. “ADI takes weight away from dense, structurally marginalized urban areas and cities, especially where low-income black, Latino, and Asian patients congregate, and we I see the difference.

If integrated into a Medicare Advantage Star Rating program, the bonus provision would save Medicare $5.13 billion over 10 years, CMS said.

development method

In their letter to CMS, the provider organizations largely expressed support for the regulator’s decision to leverage data to target resources to communities deemed vulnerable. social aspects but has promoted the development of this method.

CMS pairs data from ADIs with dual-eligibility status to determine if a patient is considered underserved under both ACO REACH and Medicare’s Shared Savings Program, helping to capture key factors. factors that ADI did not consider, a CMS spokesperson wrote. Alexander said dual eligibility is an imperfect metric because Medicaid programs vary from state to state.

Aisha Pittman, senior vice president of government affairs at the National Association of Responsible Care Organizations, said going forward, social risk management should also assess barriers at the national level. community level and individual patient needs to address health disparities. The ADI should also include regional adjustments to account for differences in income and cost of living, she said.

To improve accuracy, the CMS should supplement ADI with metrics like lifespan, Alexander said. CMS can ultimately personalize the risk adjustment process by combining clinical notes and social assessment, but care should be taken to avoid alienating secure network providers with limited data and reporting infrastructure, she said.

CMS should also consider allowing the use of similar tools, such as the Centers for Disease Control and Prevention. social vulnerability index, Khan said. Each tool has limitations, he says, and ongoing discussions are needed to determine the most appropriate approaches to identifying high-need patients.


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