Optimizing Your Risk Adjustment Program: Top KPIs to Measure Success

Optimizing Your Risk Adjustment Program: Top KPIs to Measure Success

“Not everything that can be counted counts, and not everything that counts can be counted” – Albert Einstein.

We could not agree with this more, especially when it comes to managing your membership and the risk score of that population. The definition of risk adjustment and its stated purpose is as simple as a process or program that is used to appropriately compensate health plans for the costs associated with members with chronic health conditions. Ensuring that your member population is reflecting the right risk scores—and that appropriate care is being provided—is a much more complicated feat and often requires a clear plan with measurable indicators.

So, when it comes to managing your risk adjustment program, how do you know what needs to be measured, and how do you know if you are measuring it correctly?

Knowing your member population is always the first, and most important, step. Dissecting and breaking your member population into manageable groups or cohorts is critical. For example, a simple way of breaking the members into cohorts can be by the duration of the member’s enrollment and the amount of history you as a health plan have with the member. For a given dates of service period, you may have new members coming in during open enrollment from other plans, or you may have new members to Medicare and have rolling membership from year to year. Creating these cohorts can be meaningful to understand the risk score and therefore the type of intervention and care program that needs to be designed. For instance, your cohorts may look like this:

  • New-to-Medicare Members: These members have the demographic risk scores to begin with but may need some active prospective intervention to capture their accurate risk scores for the first year in order to create a baseline
  • New to your plan but not new to Medicare: These are members with whom you have a limited history. It might be beneficial to collect charts for such members to understand their history and use that as a baseline for any future programs
  • Continuing members: These are the members for whom you have the most data and can design the most accurate program. Begin with members who have at-risk HCCs, or HCCs that were previously established but for which there is no known encounter in the DOS period. Then move to acute or suspected HCCs, where the member has a condition but no diagnoses codes with a valid encounter in the dates of service period

Once you know your member population cohorts and have understood their patterns of encounters, you need to design your RA program and intervention based on each cohort. Ultimately, your goal as a plan is to ensure that you have accurate risk scores for your members. Since it is not practical to do that for each member, you need to start measuring some key indicators within these cohorts that will help you design a strong program.

As these cohorts are created, the next step is to design an overall program that tailors to each one. Using tools and dashboards that help you monitor member, cohort, and population level risk scores from encounters to all the way to CMS submission will be helpful.

Monthly risk scores tracking with payment reconciliation for each CMS deadline are the key measurement criteria for the success of a risk adjustment program. It is also essential to focus on member and provider abrasion as you operationalize the interventions to capture the accurate risk scores. Understanding your member population’s behavior and creating an outreach program that aligns with their behavioral patterns is essential to retain the members. Reporting that focuses on provider education and coding patterns are also key in ensuring a behavior change when it comes to capturing the right diagnoses for your members.

A great risk adjustment program will need to have a strong analytical and reporting engine that can help measure some of these key metrics, if not all:

  • Dynamically calculate risk scores and gap closure rates at the member, cohort, and population level
  • Understand the yield per HCC by each intervention to help direct intervention initiatives based on the risk score performance
  • Track the cost of the outreach programs to the projected reimbursement from CMS
  • Perform reconciliation and true ups with CMS reports to project expected reimbursements
  • Member satisfaction scores and provider education reporting

Finally, one of the key factors to determining the success of a risk adjustment program is understanding your strengths as an organization and making sure you have the right partners or vendors to bolster your efforts. Learn more about how the right partner can elevate your risk adjustment program here.