- CMS is weighing inclusion of prescription drug data in determining a health plans risk adjustment.
- In a recent white paper, CMS said the ACA-mandated risk adjustment program has mostly met expectations to date. However, room for improvement exists.
- Using drug data to compare whether various patients pools are more or less risky is likely to have strong pharma and insurer support.
Knowing what drugs patients are taking could help insurers better assess the health status of their enrollees and the level of risk they are taking on, the white paper notes. At the same time, CMS worries that plans might be tempted to choose more pricey drugs in order to raise their risk level and get more money.
Consulting firm Avalere Health also published a study supporting the use of prescription data in risk adjustments, according to Morning Consult.
Under the Affordable Care Act, insurance companies can no longer deny people coverage based on preexisting medical conditions. To even the playing field, risk-adjustment shifts funds from plans that have healthier-than-average enrollees to those with a sicker member pool.
The program appears to be working — transferring $4.6 billion from plans with healthier enrollees to those with sicklier ones, CMS said in a blog.
CMS met with stakeholders Thursday to discuss the white paper. Among its findings: Some plans in ACA exchanges are offering plans tailored to specific patients needs, such as diabetes management.
Some modifications to the risk-adjustment methodology for the 2017 plan year have been made, CMS said. These include use of more current data, updates to medical and prescription drug trends, and including preventive services in risk calculations. The agency also made risk-adjustment data reports available to plans earlier in this month to aid in setting 2017 rates.