At Accordion Health, we help Medicare Advantage (MA) plans improve their Star Ratings. We identify the right measures to focus and provide data-driven platforms that engage members and providers to improve those measures. The MA Star Rating System is arguably one of the most sophisticated and complex quality rating systems; 44 different measures are collected from multiple … Continue reading Can You Predict My Star Rating?
Risk adjustment has become arguably one of the most important yet complex operational program for modern payers. Every year, payers invest millions of dollars on the risk adjustment program, and still some payers lose million dollars from it [1,2]. Due to this unpredictable nature, risk adjustment sometimes has been referred to as “legalized gambling” . … Continue reading Difficulty Of Identifying Diabetic Patients As Diabetic
Modern Healthcare and Society of Actuaries recently published a survey study about the current state of predictive analytics in the U.S. healthcare (click here for the original article). They surveyed 388 healthcare executives, and identified various types of applications and challenges for using predictive analytics. The study revealed that payers and providers have different sets of interests and … Continue reading Predictive Analytics in U.S. Healthcare
The U.S. Department of Health and Human Services (HHS) recently published a summary report on Affordable Care Act's transitional reinsurance (RI) payments and permanent risk adjustment (RA) transfers for the 2015 benefit year . The report revealed the amounts of RI and RA transfers between health plans and the program. Centers for Medicare and Medicaid Services (CMS) commented that … Continue reading Trends in ACA Risk Adjustment: The Rich Get Richer?
Medication adherence measures are some of the most important measures in Medicare Advantage's Star Ratings system. Not only are they heavily weighted measures, but they are also lead measures for other clinical outcome measures. Improving Diabetes Medication Adherence Leads to a Better Blood Sugar Control score. In Star Ratings, Diabetes Medication Adherence (DMA) represents the percent of diabetic members who adhere … Continue reading Two Birds with One Stone: Outcome of Medication Adherence
In this article, we estimate the dollar impact of improving one star rating measure in the MA Star Rating system. Based on the CMS advance notice , if an MA plan scores 4 stars and above, the plan can receive 5% Quality Bonus Payments (QBP). Below 3.5 stars, plans receive 0% QBP. Thus, we will … Continue reading Value of One Star Rating Measure
In healthcare, we see risk has two dimensions: medical risk and financial risk. Traditional actuarial models treat these two as the same, and in doing so, many important characteristics leading to actionable insights are overlooked. This affects how to successfully manage patients under value-based reimbursement models. Risk Quadrants in Value-based Care We can visualize the … Continue reading How to understand risk for value-based care
The Centers for Medicare and Medicaid Services recently announced a new form of bundled payment for lower extremity joint replacement, the Comprehensive Care for Joint Replacement (CJR) model. Under CJR, hospitals are accountable for the quality and cost of the episode of care, where the episode starts with the admission to the participant hospital for … Continue reading What happens after Knee Replacement?
Each year, the Centers for Medicare and Medicaid Services (CMS) collect various quality and performance measures on Medicare Advantage (MA) plans. CMS analyzes this massive collection of information and assigns from 1 star to 5 stars to each plan, where 5 stars represent excellent performance. There are huge financial incentives for receiving 5 stars. On … Continue reading Have Star Ratings improved medication adherence?
It’s no longer uncommon to hear the words “big data” and “healthcare” together in a sentence. It almost seems to be the trendy new thing, and some skeptics think it is only a passing fad. In fact, Gartner places machine learning (the algorithms that make big data useful) past the “peak of inflated expectations” and … Continue reading How to Realize Big Health Impact from Big Health Data