Alliance of Community Health Plans President and CEO Ceci Connolly sees momentum around risk adjustment reform picking up.
“We see this administration taking very seriously the concerns over wide gaps in risk adjustment payments — gaps that are far outside the norm,” Ms. Connolly told Becker’s. “Policymakers are seeing this problem and seem ready and willing to address it. The challenge for all of us now is to work with them as quickly as possible to identify a much simpler, more streamlined approach to risk adjustment.”
Ms. Connolly emphasized the importance of demographic data — such as age, geography and social factors — to better understand lived experience. She also acknowledged there is a long way to go in identifying a “very reasonable, manageable set” of high-impact, high-cost diagnoses, but she suggested COPD, cancer and the proliferation of multiple chronic conditions as some possibilities that could help cut “gaming” out of the system.
“The purpose of risk adjustment is to ensure that a health plan has sufficient dollars to take care of its population,” she said. “It is not to generate profit margins.”
As Medicare Advantage exits pick up steam among larger insurers, some smaller plans are feeling the pressure. Community plans could be taking on more risk with the sicker, older population, Ms. Connolly said. With these challenges, Ms. Connolly does not think risk adjustment is necessarily a cure-all.
“It’s not so much that fixing risk adjustment solves all of those problems, but risk adjustment begins to level the competitive playing field and make it a fair fight.”
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