(ACO) regulations - American Society of Anesthesiologists

CMS-1345-P 249
Capitation Rates, Part C and Part D Payment Policies and 2011 Call Letter, which can be
found at http://www.cms.gov/MedicareAdvtgSpecRateStats/Downloads/Advance2011.pdf
and
http://www.cms.gov/MedicareAdvtgSpecRateStats/Downloads/Announcement2011.pdf .
As discussed previously, a key issue when using a risk adjustment model that
incorporates diagnosis data is that risk scores can be affected not just by changes in the
health status of the population but also by changes in coding intensity and by the mix of
specialists and providers furnishing services. The experience in MA clearly shows that
health plans can significantly increase the HCC score of their populations by focusing on
more complete coding. Similarly, our experience with the PGP demonstration shows that
participating sites have an incentive to code more fully or intensely because of the
potential impact on performance payments, to provide more accurate measurement and
reporting of quality measures, as well as to provide for more complete and accurate
information that can be used for population management.
If we adopt a risk adjustment methodology in the Shared Savings Program that
incorporates diagnostic data, we expect that ACOs would have a similar incentive to code
more fully for purposes of population management, quality reporting and to optimize
their risk scores for the purpose of achieving shared savings. Because they are
responsible for the delivery of care, and can control the information included in Parts A
and B claims, the ACO providers/suppliers could potentially increase the risk scores for
their FFS patients by more completely reporting diagnoses. The practical effect of
increasing risk scores would be to decrease the actual annual expenditures compared to
the benchmark, because the benchmark would be increased to reflect changes in the
ACO's risk score, while actual expenditures would not change. As a result, the ACO's