Mark Tripodi

Basic “explainer” on Risk Adjustment and a RAF conundrum. This article from The Commonwealth Fund does a good job of providing the basics of risk adjustment. It also calls out one of the major contributors to patient outcomes that isn’t captured in traditional risk models, the Social Determinants of Health (SDoH). They do a great job on this, so I won’t summarize it here. However, I think there is another factor that isn’t captured that I wanted to discuss and would appreciate some different perspectives. I’d love to get some thoughts on the following. Maybe I am simply being pedantic. The issue not mentioned in the article that I think current methodologies of risk adjustment miss is duration and management of disease. A patient with a new diagnosis of diabetes, for example, now has an elevated risk of numerous complications over their lifetime. However, that risk in year 1 after the initial diagnosis is much lower than the risk at year 10. Current risk models don’t take that escalating risk into consideration, keeping the risk adjustment fixed regardless of duration of underlying diagnosis. In addition, there are few scenarios that will impact me differently as the provider: 1) Management of this patient’s diabetes has been poor for the prior 9 years and now my group “inherits” this patient at year 10. 2) My team has helped this patient manage their diabetes very well for the past 9 years. 3) For the past 9 years, this patient’s prior group had managed their diabetes well but they have now switched into my group. As noted above, in scenario 1, that “new” diagnosis of diabetes severely underestimates this patient’s risk of needing expensive resources this upcoming year. I will be adversely impacted from something that is clinically obvious (duration of a disease increases risks) but which is not captured in the current data. To go one step farther, in frameworks 2 and 3, there is a gap between what the patient’s risk would have been without 9 years of great care and what it likely is now. However, there is no recognition of this work. That is to say, if the patient switched to a group that did a terrible job of managing diabetes, they’d receive the same risk adjustment in year 10 as my group would receive after all of our time, effort and resources had been dedicated to keeping this patient healthy. If the patient’s healthcare needs in year 10 are low because of our efforts, shouldn’t we receive more credit than a group that simply gets attribution? And, what about the prior group? How are (were?) their efforts recognized? Please share your thoughts in the comments.

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The growth of the health insurance marketplace is picking up steam, fuelled by Medicaid disenrollment. https://ow.ly/N1vW50Tafsq MMIT’s Erin Trompeter explains what these large-scale changes mean for providers, manufacturers, payers and health IT vendors. Get the insights by clicking the link in this post. #HealthInsuranceMarketplace #HealthInsurance #Medicaid

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Medicare Advantage unrest, Change Healthcare fallout and more big takeaways from insurers’ Q1 https://lnkd.in/eyg48k7e via Healthcare Dive #MedicareAdvantage #ChangeHealthcare #Cybersecurity #CMS #Medicaid

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#MedicareAdvantage keeps getting more popular among seniors: #MA plans typically offer a range of supplemental benefits (like transportation/#NEMT) that can improve quality of life and health outcomes. But they are facing challenges headed into 2025, including lower star ratings, resistance from some health networks, rising healthcare costs, and a revised CMS payment model. Read our latest blog for a summary of MA changes that will impact health plans, providers, and members in the year ahead. https://hubs.li/Q02XP0700

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New year, new model! CMS has announced updates to the 2024 Medicare Advantage risk adjustment model, including more Hierarchical Condition Categories (HCCs) than the previous system. Read our latest blog to learn more about the new updates: https://hubs.li/Q02wgNS10 #riskadjustment #medicareadvantage #medicare #hcc #cms

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With over 2 million members displaced by major healthcare players exiting underperforming Medicare Advantage markets, regional insurers face both a challenge and an opportunity. This influx of high-cost members demands innovative solutions to manage chronic conditions like diabetes and heart failure effectively. At Circadian Health, we’re helping regional insurers navigate this disruption with virtual-first specialty care, reducing costs and improving outcomes for the most complex members. This market shake-up isn’t just a challenge—it’s a chance to redefine care delivery. Discover how regional insurers can transform disruption into opportunity—read more on our blog. #MedicareAdvantage #HealthcareInnovation #VirtualCare #CircadianHealth #ValueBasedCare #HealthEquity

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The era of splashing the market with flashy supplemental benefits is in the rearview as CMS, MA plans, and downstream risk-bearing providers are collectively challenged to "do more with less."   CMS' heightened data collection requirements will slowly but surely drive an emphasis on cost-saving, impact-driving supplemental benefits rather than those that simply attract members.   This shift could serve risk-bearing providers well, as overly generous and unmanageable supplemental benefit allowances have often driven MLR headwinds in recent years.

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Have you registered yet? If you want to transform your risk adjustment strategy, don't miss out on this free webinar with speaker and national risk adjustment expert, Jack Newsom, Sc.D. https://lnkd.in/dYa28AZy #RiskAdjustment #CMS #Medicare

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That’s a wrap on the 24th Risk Adjustment Forum! It was great seeing you all there. If you’d like to discuss your organization’s risk adjustment strategy further or we didn’t get a chance to connect, let’s set up a time. #DataLink #Events #RiskAdjustmentForum #Ri

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📊 When healthcare providers and payers don’t have real-time data, out-of-network claims become a guessing game. 🤔 ClaimsBridge connects the dots with a robust data network, so you can deliver fast, accurate claims processing. ✅ Stop guessing—start solving. #OutOfNetworkClaims #HealthcareSolutions #ClaimsProcessing #DataDriven

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📌 The Battle For Medicare Advantage Star Ratings: SCAN and Elevance Victories Provide a Roadmap for Plans to Challenge CMS Methodologies 📌 ❇ In the world of Medicare Advantage, the calculation of Star Ratings is more than a measure of quality – it’s a pivotal marker that can significantly sway federal funding and market competitiveness. ✳ Against the backdrop of high financial stakes and rigorous scrutiny, recent legal victories for SCAN Health Plan and Elevance Health have charted a path in challenging Star Ratings methodology. ▶ Read more from Charles Baker, MHA, MSW about how these cases underscore the impact that Star Ratings have on the financial and operational aspects of Medicare Advantage plans. https://rb.gy/5zc924

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Planning for Medicare - Countdown to 65 Please join Medicare expert and Senior Plan Consultant at Blue Cross Blue Shield of Massachusetts, Susan Flanagan for this lively discussion about Medicare.  Topics Include: •  Medicare and Medicare Parts A and B •  Medicare enrollment timeline •  Medigap plans that supplement Medicare coverage •  Medicare Advantage plans, such as HMOs and PPOs •  Medicare Part D prescription drug plans •  Plans and programs available to early retirees, such as COBRA

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Insurance Discovery finds active primary, secondary, and tertiary patient coverage – as well as their Medicare Beneficiary Identifier (MBI) and demographic details – all in one quick inquiry. Get enhanced clarity on patient coverage, increased efficiency and accuracy in patient access, and improved back-end revenue cycle management (RCM) results, made possible by front-end success. Explore Insurance Discovery: https://ow.ly/OS9Y50RlHv7 #HealthcareSoftware #PatientAccess #InsuranceDiscovery #FrontEndRCM

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So, CMS has decided to terminate the Medicare Advantage Value-Based Insurance Design (MA VBID) model at the end of 2025 due to unsustainable costs to the Medicare Trust Funds. Introduced in 2017 to reduce healthcare costs and improve health outcomes, the model led to significant expenses, totaling $2.3 billion in 2021 and $2.2 billion in 2022, due to increased risk scores, higher rebates, and elevated Part D costs. So, how does this impact providers 🏥 💉 Providers may see modifications in supplemental benefits like transportation and reduced drug costs, which may continue under Special Supplemental Benefits for the Chronically Ill (SSBCI) but without previous flexibility. 💊 Disruptions in Part D cost-sharing could complicate patient medication adherence. 🩺 MA organizations and providers must begin adjusting workflows and care delivery strategies for 2026. 🥼 Providers serving underserved or chronically ill populations may struggle with maintaining programs that promote health equity. While CMS recognizes VBID's achievements in enhancing transparency and health outcomes, its termination emphasizes the need for more cost-effective care delivery models. Providers will need to work closely with MA plans and CMS to ensure continuity of care for patients.

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Dr. Jain...THANK YOU for this insight and support for the kind of work I do every day! Building complex geriatrics longitudinal care programs is where I cut my value based teeth! These programs - when structured with attention to detail - can create a profoundly positive impact. A fully integrated program that is carefully facilitated, orchestrated, and navigated WITH a patient quite literally changes lives. As a system we have to shift our thinking and embrace the FACT that cookie cutter medicine is NOT effective as well as the notion that precision medicine is not scalable, replicable or sustainable....because it CAN be. Been there, done that (and continue to do it) and have the results to prove it! At Synergy 3C, THESE are the models we build and have a track record of success! We would love to have a conversation with you about HOW these models can and do work! #complexpopulationhealth #complexgeriatrics #medicareadvantage

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