In-home health risk assessments and in-home health evaluations are a key part of Medicare Advantage (MA) plans’ strategy. On one end, they help recognize member needs, and help connect those members to other health care services. On the other end, they help boost MA plan profits, quite considerably.
A recent study published in Health Affairs suggests that in-home health risk assessments increase coding intensity in MA, which leads to higher payments from the Centers for Medicare & Medicaid Services (CMS).
In-home health risk assessments help MA plans find additional diagnoses for members, which classifies them as more at-risk or complex. That, in turn, raises the dollar amount plans are paid out for that member.
“There are two unique ways in which providers and enrollees interact in the MA setting that do not occur in traditional Medicare that contribute to the problem,” Paul D. Jacobs, Senior Fellow at Agency for Healthcare Research and Quality, wrote. “The first is through in-home health risk assessment, whereby a health care professional visits MA enrollees’ residences and obtains information about their health conditions and health risks. The second mechanism is chart review, whereby MA insurers review enrollees’ medical records to identify additional diagnoses that a provider did not submit or mistaken diagnoses that should be removed.”
Health risk is estimated using the Hierarchical Condition Categories (HCC) model, which was developed by CMS. The research found that encounter-based risk scores for MA enrollees were 7.4% higher when in-home health risk assessments or chart reviews were included.
As a result of these perceived efforts to up the risk scores of these members, the author argued that taxpayers end up paying more for MA members than traditional Medicare members.
While the combined effect of chart reviews and in-home health risk assessments represented an average increase in risk scores of 0.078 in 2016, that number rose to 0.091 by 2021, according to the author. Those increases can make a multi-billion dollar difference.
“In-home health risk assessments and chart reviews contributed meaningfully to overall coding intensity differences,” the author wrote. “Understanding how payments have changed because of health risk assessments and chart reviews and for which groups the problems are most acute can help CMS focus its efforts to ameliorate potential payment distortions.”
From the MA plan perspective, evaluating a member in their home is of benefit to everyone – including the larger health care system.
The home – as home-based care providers know – is a place where health care experts can notice things impacting a member’s health that wouldn’t otherwise be clear.
For instance, Signify Health – which is owned by CVS Health (NYSE: CVS) – conducts millions of in-home visits per year.
“We basically do in-home health evaluations; we’re going into over 3 million homes in 2024,” Signify Health President Paymon Farazi told Home Health Care News earlier this year. “And the purpose of those visits is to really meet members where they are, do a full, end-to-end assessment of their current health situation, and help them think about what the next steps on their health journey should be.”
Signify sees these visits as a way to more holistically look at a senior’s health situation, connecting them to other health providers and making sure their needs are met.
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