NEWS

Contact:

Sharon Grace
Vice President of Public Relations
(703) 838-0033, ext. 393
sgrace@amga.org

April 5, 2016

AMGA Efforts Modify CMS’ Medicare Advantage Encounter Data Risk Scoring Plan

Alexandria, VA - AMGA advocacy efforts prompted the Centers for Medicare and Medicaid Services (CMS) to modify its proposed Advance Notice of Methodological Changes for Calendar Year 2017 Medicare Advantage (MA) Capitation Rates, Part C and Part D Payment Policies and 2017 Call Letter. CMS had proposed a more aggressive transition to Encounter Data System (EDS) risk scoring for MA plans. Based on the concerns detailed in AGMA’s March 4 comment letter on the proposal, CMS will calculate risk scores with a more reasonable blend of EDS risk scores and the Risk Adjustment Processing System (RAPS).

“AMGA remains concerned about the underlying challenges in moving toward a risk score that is based heavily on EDS,” said Donald W. Fisher, Ph.D., CAE, AMGA’s President and Chief Executive Officer. “By proceeding more cautiously, CMS has acknowledged our concerns and has provided the MA community additional time to work with the agency to resolve the difficulties in the system.”

CMS had proposed to modify how EDS is used in calculating risk scores.  Specifically, CMS proposed to transition from a 90% RAPS and Fee-For-Service (FFS) and 10% EDS to a weighting of 50% RAPS and 50% EDS.  AMGA remains concerned that moving toward a more heavily weighted EDS risk score will further exacerbate already existing problems with accurate EDS reporting.   For example, AMGA noted there are multiple rejection points as data migrates from physicians to provider organizations and on to health plans and purchasers.  CMS’ decision to implement a blend of 75% RAPS and FFS and 25% EDS/FFS weighted risk score for Payment Year 2017 will provide AMGA and other stakeholders the opportunity and time to work with CMS to refine how EDS is used in risk scores.

AMGA is disappointed that CMS lowered its estimated expected average change in revenue for plan payments to 0.85%, down from the advance notice estimate of 1.35%. The lower plan payments, along with the reduced estimated expected change in plan revenue to an average of 3.05% (down from the anticipated 3.55%) is a less-than-expected increase, and could affect the MA plans’ ability to provide quality care at an affordable price to Medicare beneficiaries.  While AMGA generally is pleased with the growth of the MA program, this increase of less than 1% does not signal the needed support for the program, which has increased in popularity and now services about 32% of all Medicare beneficiaries.

AMGA is pleased to see that CMS implemented most of its other proposed changes to the MA program, such as improving the Hierarchical Condition Category (HCC) risk-adjustment model by adding new, specific subgroups to more accurately reflect spending to care for the dual-eligible beneficiary population.  AMGA also is pleased to that CMS has taken its recommendation to finalize its plan to equalize the Star Rating system for MA plans by more accurately accounting for those plans and providers that have a comparatively larger dual-eligible and Low-Income Subsidy (LIS) population.

Read AMGA’s Full Comments on the Proposal.

About AMGA
The AMGA is a 501(c)(6) trade association representing medical groups, health systems, and other organized systems of care, including some of the nation's largest, most prestigious integrated delivery systems. AMGA is a leading voice in advocating for efficient, team-based, and accountable care. AMGA members encompass all models of organized systems of care in the healthcare industry, including: physician-owned, independent group practices, integrated delivery systems, hospital-affiliated medical groups, independent practice associations (IPAs), academic and faculty practices, accountable care organizations, and high-performing health systems. Approximately 177,000 physicians practice in AMGA member organizations, providing healthcare services for 133 million patients (approximately one in three Americans). Headquartered in Alexandria, Virginia, AMGA is the strategic partner for these organizations, providing a comprehensive package of benefits, including political advocacy, educational and networking programs, publications, benchmarking data services, and financial and operations assistance. www.amga.org