The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) recently issued a report titled “Medicare Advantage: Questionable Use of Health Risk Assessments Continues to Drive Up Payments to Plans by Billions.” This report interested me on several levels.
As a person rapidly approaching Medicare age – and I am sure you will hear more about this from me in the future – I found the statistics interesting.
In 2023, a total of 32 million Medicare enrollees, who compose about half of the 65.75 million Medicare beneficiaries, elected to enroll in Medicare Advantage (MA) plans. The costs to the Centers for Medicare & Medicaid Services (CMS) for Medicare Part C were $448 billion of the total trillion dollars of Medicare cost, which seems to be just short of what the proportional costs would calculate out to be.
We use my cell-phone number as my father’s contact number, as he has advanced dementia. He is not able to answer his phone reliably, and he does not have the understanding or executive functioning to respond to a phone call from someone other than a loved one inquiring about his status.
As a result, I frequently get calls from UnitedHealthcare’s House Calls program. They are not affiliated with my father’s primary care provider (PCP).
They bill this as “an opportunity to ask questions and get answers about the things that matter most to you about your health.” They offer up to an hour of one-on-one time with a healthcare practitioner, a physical exam, healthcare screenings, a medication review, and an opportunity to get advice or education, and have your questions answered. At the end of the visit, you are supposed to get a personalized checklist of items to discuss with your PCP.
I do not think this accurately sums up their goals and what they accomplish. My take is that this is a mechanism to try to inventory a client’s medical conditions so the payor can maximize risk adjustment factors. The benefit is to UnitedHealthcare’s capitation, not to my father’s health. What do they think their nurse practitioner will unmask that a competent PCP would be heretofore unaware of?
When I decline on his behalf, because there is nothing to be gained for him, and it will just be a waste of my time, they offer to see him without me. Now exactly what information are they planning to derive from that visit?!
In fact, when he was in assisted living, I visited him one day and found a House Calls mug, magnet, print-out, and a Visa gift card. They had visited him without discussing it with me, and I suspect they didn’t get much valuable (or probably any) information. He probably said a lot of, “I don’t remember. You should ask my daughter.”
The OIG report notes that diagnoses reported only on enrollees’ health risk assessments (HRAs) and HRA-linked chart reviews resulted in an estimated $7.5 billion in MA risk-adjusted payments for 2023.
The authors point out that if a diagnosis is only found in an HRA and not noted in any following service, one of two likely scenarios are in play: either the diagnosis is in error, or the patient is not receiving necessary treatment for a valid condition. If diagnoses are added without intervention, follow-up care, or care coordination to address them, why should the provider/payor be allotted more Medicare dollars, presumably for the treatment of the chronic conditions?
A total of 13 health conditions resulted in 75 percent of the risk adjustment payments from HRAs and HRA-linked chart reviews. Polyneuropathies from diabetes and rheumatoid arthritis, diabetes with complications, and secondary hyperaldosteronism (from heart failure, perhaps) were disproportionately discovered.
The top 20 MA companies had obvious target diagnoses that resulted in a substantially greater share of payments in comparison to the other 137 MA companies. Humana and UnitedHealth Group represented over $5 billion of payments. A total of 19,000 enrollees had no service records in 2022 other than a single in-home HRA.
OIG’s recommendations to CMS were that there should be actions associated with diagnoses that result from HRAs, that ongoing Risk Adjustment Data Validation (RADV) audits should be undertaken, and that the use of diagnoses reported only on in-home HRAs or chart reviews be restricted. The only recommendation that CMS agreed with was to determine whether select Hierarchical Condition Categories (HCCs) are more prone to misuse among MA plans.
I am supportive of healthcare providers being thorough and regularly assessing a patient’s medical and social needs. I don’t think it should be for show or merely for financial gain, however. Our goal should be taking excellent care of patients, documenting it well, and having it coded accurately.
If we do that, the compensation should be commensurate with the effort and resources put into caring for the patient, and the risk-adjusted quality metrics should fall where they belong.
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