AUGUST 30, 2012
Risk Adjustment in Health Insurance
When coverage is broadened in 2014, new arrangements will be needed to make sure that the market works appropriately.
|What's the issue?|
Insurance market reforms under the Affordable Care Act are designed to increase the number of Americans with insuranceand to shed the current system in which health plans have an incentive to enroll healthier people while avoiding the sick. One of the arrangements that will make the new system workable is risk adjustmenta process by which health insurance plans will be compensated based on the underlying health status of the people they enroll, and therefore protected against losing money by covering people with high-cost conditions.
But implementing risk adjustment could prove challenging. The statistical methods used in risk adjustment are technically complex. There are questions about the ability of the states, which have to carry out the risk adjustment, to collect accurate data and implement methodologies that result in fair payments to plans. This policy brief explains what risk adjustment is and how it works, and it examines policy issues involved in implementation.
|What's the background?|
Much of the practical knowledge that exists about implementing risk adjustment comes from experience with the Medicare program. For example, about one in four Medicare beneficiaries purchase a Medicare Advantage plan, which is a private health insurance plan that offers Medicare benefits. Payments to such private plans have always been adjusted to reflect differences in the health risks of their enrollees, initially by adjusting payments by demographic characteristics, including age, sex, and Medicaid eligibility.
Since 2000, risk-adjusted payments to Medicare Advantage plans have used data on patient diagnoses obtained from hospital admissions. Medicares risk-adjustment techniques have also been refined by incorporating diagnostic information from beneficiaries use of outpatient care and prescription drugs. Risk adjustment is also being used by many state Medicaid programs and by the Massachusetts health insurance Connector, a type of insurance exchange that distributes both publicly subsidized and private health coverage.
RISK ASSESSMENT AND RISK SCORE: In risk adjustment, a third party, such as the federal government or a state, collects and organizes data from insurance claims and clinical diagnoses for all enrollees in every participating health plan or provider organization in a particular market. Using whats known as a risk-assessment tool or methodology, this entity then converts the data into a risk score for each person. Individual risk scores are then aggregated into an overall score for each insurance plan.
Heres how the system works: If the average risk score for the overall population is defined as 1.0, a healthy young man might receive a score of 0.4 based on historical claims data, while a young woman with asthma might be scored at 1.5, and an older person with diabetes might be scored at 2.3. A plan having an aggregate score of 1.2 for its enrollees would receive a 20 percent add-on to its average per person payments, while a plan with an aggregate score of 0.8 would experience a 20 percent reduction in payments.
In practice, individual risk scores, built from data on patient demographics, disability, institutional status, and diagnoses, are used to help determine monthly payments made to plans for each person enrolled in Medicare Advantage, Medicare Part D prescription drug benefits, and many state Medicaid managed care programs.
|What's in the law?|
The private health insurance market prior to passage of the Affordable Care Act was organized very differently than it will be once the law is fully implemented in 2014. Overall, insurers operating in the individual or small-group insurance markets had an incentive to enroll healthy, younger people and a corresponding disincentive to enroll older, less healthy people. These factors contributed to rising levels of uninsurance. They may also have resulted in higher premiums in the private insurance market, as health care providers raised their charges to private payers to help cover the costs of uncompensated care.
Traditionally, private health insurers operating in the individual and small-group markets have based their premiums on health history, or what is known as experience rating. A person with diabetes or a heart condition would be charged a higher premium than one whose health records showed only trouble-free annual checkups. Likewise, a small company with above-average care needs and costs paid more to cover its employees than it would pay if its employees were healthier.
In addition, insurers selling individual health insurance policies also have been able to deny coverage to people because of past or current health conditions. The Department of Health and Human Services (HHS) estimated that without the Affordable Care Act, up to 129 million nonelderly Americans with preexisting conditions would be at risk of losing their insurance coverage when they needed it most or might not be able to purchase affordable individual insurance coverage.
But as noted above, insurance reforms contained in the Affordable Care Act made major changes to the insurance market and insurance regulation. As of September 23, 2010, health plans were barred from excluding children from insurance coverage because of preexisting health conditions. As of January 1, 2014, plans will also be barred from using preexisting condition restrictions to prevent adults from receiving coverage. Plans will be barred as well from charging premiums based on health history.
After 2014, however, health plans will still be able to vary premium levels for individuals and small businesses based on certain factors, including age, family size, geographic region, and tobacco use. The law will allow no more than a 3:1 difference in price across age groups, meaning that older people can be charged three times as much as younger people, and no more than a 1.5:1 difference in price for individuals who use tobacco, meaning they can be charged up to 50 percent more than nonusers.
HEALTH INSURANCE EXCHANGES: In conjunction with these new insurance rules, the Affordable Care Act requires the creation of health insurance exchanges in each state, with open enrollment in the health coverage they provide scheduled to begin in October 2013. Through the exchanges, individuals and companies with no more than 100 employees will be able to shop for health insurance policies, known as qualified health plans, that will offer a package of essential health benefits and meet other standards. States have the option of establishing and operating exchanges on their own or having the federal government run one for them. (See the Health Policy Brief published on February 9, 2012, for more information on exchanges, and the Health Policy Brief published on April 25, 2012, for more information on essential health benefits.)
Because the exchanges will feature standardized benefit options and restrict insurers ability to base premiums on their enrollees health status, plans that enroll a sicker-than-average enrollee population will be in danger of losing money, while plans that enroll relatively healthier enrollees will probably be overpaid. Ultimately, if too many plans lose money, some could go out of business, and the overall system could be seriously destabilized.
To prevent this from happening, the law requires the use of risk adjustment to reallocate premium income among plans to account for differences in their enrollees aggregate health conditions, and therefore the likely cost of paying for their care. Risk-adjustment methods similar to those used in Medicare Advantage or the Medicare Part D prescription drug benefit may be used, or states can propose an alternative methodology subject to approval by HHS.
If a state does not establish a system of risk adjustment, HHS will establish and operate one for that state. On March 23, 2012, HHS published a final rule on risk adjustment along with two related programsa transitional reinsurance program and so-called risk corridors, both of which are discussed below. HHS plans to publish its proposed risk-adjustment methodology in the fall of 2012.
Risk adjustment will be required of all qualified health insurance plans sold to individuals and small groups both within and outside of the exchanges. Grandfathered health insurance plansthose in existence at the time the Affordable Care Act was signed into laware exempt from risk adjustment as well as many other provisions of the health care reform law. However, it is widely expected that many of these plans will disappear over time.
MITIGATING RISK: The Affordable Care Act creates two additional mechanisms to carry out risk adjustment and help mitigate financial risk for insurers during 20142016the first three startup years of the risk-adjustment program (Exhibit 1). The first, a transitional reinsurance program, will be run by each state or, if a state elects not to have one, by HHS. The second, risk corridors, will be run by HHS.
|What are the issues?|
The reform laws individual insurance requirement will bring many previously uninsured people into the exchanges. Plans will have little or no data with which to predict future service needs of these enrollees and estimate their premiums, but they will need to do so nonetheless. Some people will have pent-up needs that will lead to high service use in the short run but then taper off; others may have chronic illnesses that result in high costs over a long period.
Risk adjustment involves technically complex and data-intensive methods that will challenge insurers ability to predict costs and the ability of federal and state agencies charged with implementing the new arrangements. Here are some of the issues that health insurers, states, and the federal government will be facing.
Upcoding can undermine risk adjustment if it distorts the actual health-risk profile of a plan, for example, by suggesting that the people that the plan has enrolled are actually sicker than they really are. Thus, those running risk-adjustment systems will have to audit plans to enforce coding integritythat is, consistent use of diagnosis and procedure codes to negate any effect of upcoding.
As noted, HHS plans to publish its proposed risk-adjustment methodology in the fall of 2012. More broadly, federal and state regulators as well as members of Congress will be likely to watch closely as exchanges go live and insurance reforms kick in during 2013 and 2014, and risk adjustment is fully implemented in 2014 and beyond.
There has been agreement among many policy makers since the early 1990s that structured insurance market competition is an important path to cost containment and improved health system performance. At the same time, the scale of insurance reforms and the exchanges created by the Affordable Care Act are largely new and untried. Moreover, the success of these innovations hinges on methodologies that are challenging to understand even by experts, let alone the lay public. The outcome of this massive experiment will not be known until it is tested in practice.
Yet the ultimate success of health reform depends critically on this esoteric science of risk adjustment. Appropriate payment is the key to creating an environment where health plans will compete on the basis of quality and efficiency, rather than avoidance of high-cost patients. This is the kind of competition that many believe will be necessary to curb unsustainable growth in the cost of care, and risk adjustment is central to it.
American Academy of Actuaries, Risk Assessment and Risk Adjustment, May 2010.
Brown, Jason, Mark Duggan, Ilyana Kuziemko, and William Woolston, Will Risk-Adjustment Decrease Health Care Costs? New Evidence from the Medicare Advantage Program, National Bureau of Economic Research, August 21, 2011.
Department of Health and Human Services, Bulletin on the Risk Adjustment Program: Proposed Operations by the Department of Health and Human Services, May 1, 2012.
Hall, Mark, Risk Adjustment under the Affordable Care Act: A Guide for Federal and State Regulators, Commonwealth Fund, Issue Brief No. 1501, Vol. 7, May 2011.
HealthCare.gov, Standards Related to Reinsurance, Risk Corridors, and Risk Adjustment Final Rule, March 16, 2012.
Park, Edwin, Ensuring Effective Risk Adjustment an Essential Step for the Success of the Health Insurance Exchanges and Market Reforms under the Affordable Care Act, Center on Budget and Policy Priorities, May 18, 2011.
Pope, Gregory, John Kautter, Melvin J. Ingber, Sara Freeman, Rishi Sekar, and Cordon Newhart, Evaluation of the CMS-HCC Risk Adjustment Model, RTI International, March 2011.
Weiner, Jonathan P., Erin Trish, Chad Abrams, and Klaus Lemke, Adjusting for Risk Selection in State Health Insurance Exchanges Will Be Critically Important and Feasible, but Not Easy, Health Affairs 31, no. 2 (2012): 30615.
Winkelman, Ross, Julie Pepper, Patrick Holland, Syed Mehmud, and James Woolman, Analysis of HHS Final Rules on Reinsurance, Risk Corridors, and Risk Adjustment, State Health Reform Assistance Network, April 2012.
|About Health Policy Briefs||
Editorial review by
Jonathan P. Weiner
Health Policy Briefs are produced under a partnership of Health Affairs and the Robert Wood Johnson Foundation.
Sign up for free policy briefs at:
- From The Editor-In-Chief
- DataGraphic: Aging And Health
- Home-Based Care Program Results
- Specialty Drug Costs And Medicare
- Contraceptive Choices Under ACA
- Costs And Benefits Of Anticancer Drugs
- DataWatch: Mass. Health Reform At Ten
- Rapid Physician Practice Consolidation
- Medicare Joint Replacement Bundles
- Better Patient Care Saves Medicare Money
- Quality Of Care In Sub-Saharan Africa
- Narrative Matters: Uninsured In Texas
- View Table of Contents »
- Fail To Scale: Why Great Ideas In Health Care Don’t Thrive Everywhere 29 Sep 2016
- By The Numbers: Our Progress In Digitizing Health Care 29 Sep 2016
- A Unified Medicare Payment System For Post-Acute Care Is Feasible 28 Sep 2016
- CMS Bolsters Outreach To Young Adults As Open Enrollment Nears 27 Sep 2016
- People Post: Staff And Board Changes In Health Philanthropy 27 Sep 2016
Now Playing Briefing for Reporters on Control, Monitoring, and Prevention of the Zika VirusBriefing August 11, 2016
- Uninsured In Texas, Then And Now September 07, 2016
- Beating A Cancer Death Sentence July 06, 2016
- The Future Of The Individual And Small Group Markets May 18, 2016
- The Triple Aim: Care, Health, And Cost
- The History Of Vaccines And Immunization: Familiar Patterns, New Challenges
- The Role Of Nurse Practitioners In Reinventing Primary Care
- Few Hospital Palliative Care Programs Meet National Staffing Recommendations
- Training And Supervision Did Not Meaningfully Improve Quality Of Care For Pregnant Women Or Sick Children In Sub-Saharan Africa
- The Triple Aim: Care, Health, And Cost
- Medicare's New Bundled Payment For Joint Replacement May Penalize Hospitals That Treat Medically Complex Patients
- Home-Based Care Program Reduces Disability And Promotes Aging In Place
- Physician Consolidation: Rapid Movement From Small To Large Group Practices, 2013-15
- The History Of Vaccines And Immunization: Familiar Patterns, New Challenges
- The Triple Aim: Care, Health, And Cost
- Evaluating Strategies For Reducing Health Disparities By Addressing The Social Determinants Of Health
- Active Life Expectancy In The Older US Population, 1982-2011: Differences Between Blacks And Whites Persisted
- Accounting For Patients' Socioeconomic Status Does Not Change Hospital Readmission Rates
- Medicare Advantage Plans Pay Hospitals Less Than Traditional Medicare Pays