Risky Business

Helen Gelly recently blogged about the HCC methodology that CMS uses to create risk adjustments and why it is a really big deal for wound care practitioners. Last year “Minuteman Health,” a Massachusetts based insurance company, filed a lawsuit in federal court against CMS over a policy in the Affordable Care Act (aka “Obamacare”) which they called a “reverse Robin Hood program.” The court has just ruled against them. The way this works under the ACA is that Health and Human Services (HHS) takes money away from insurance companies caring for patients who are not as sick and gives it to the insurance companies caring for sicker patients, based on the HHS patient risk stratification scores.

In 2016, Minuteman Health estimated they would have to pay $16.7 million through the risk adjustment program, based on ACA rules it called “arbitrary, capricious and unlawful.” HHS says the program is “working as it was designed.” Minuteman Health says that HHS and CMS went “beyond the bounds of their statutory directive, injecting unauthorized factors into the Risk-Adjustment methodology.” The judge said that the implementation of Obamacare and its regulations “can hardly be called an unqualified success,” and that it, “appears to have triggered a host of unintended consequences.” But, the judge went on to say that it wasn’t the court’s job to adjudicate the merits of the law, only whether the actions of HHS were legal, which apparently they were.

I bring this up because that’s the point of risk stratification in the zero sum world of MIPS where physician payment is concerned. The point of risk stratification in MIPS is to take Medicare Part B dollars away from doctors caring for healthier patients and pay it to doctors caring for sicker patients. Quite frankly, that seems fair. However, whether it works as planned depends on whether the risk stratification method is a good one, and whether doctors capture the data needed to ensure that their patients’ level of illness is correctly reflected.

So, the best thing we can do to preserve the field of wound care and the therapeutic interventions provided to these patients is to start doing a better job of depicting how sick they are – from both a statistical and a medical complexity standpoint.  All the patients whose outcomes are not reported by wound centers because they are “too complicated” and thus considered in “palliative wound care,” well, THOSE WOULD BE THE PATIENTS ON WHOM WE MOST NEED TO REPORT DATA. Otherwise, the money doctors are currently being paid to treat them will be taken away and paid to someone else.

That’s what the US Wound Registry is doing with the Wound Healing Index (WHI), and the next generation risk models we are building, and the tools the US Wound Registry is building to optimize the HCC score in wound care patients. Because, “Robin Hood” is only a fun story for the people who GOT the money, not the ones who lost it.