PCMH + risk scores suggest possible gaming or worse; Advocates call on DSS to delay expansion to protect members and taxpayers

A new analysis of PCMH + members’ risk scores finds unexplained increases compared to the control/comparison group that could signal ACO gaming of the system for financial gain and/or, far worse, a decline in the health of members in the program. PCMH Plus, a controversial new payment model, allows ACO (large health systems) to share in savings they are able to generate on their members’ healthcare. According to CMS, “Risk adjustment is a method for adjusting expenditures to account for differences in expected health costs of individuals.” Members with greater health needs, and the associated higher costs, have higher risk scores. Independent advocates actively participated in designing the program to improve policies to keep members healthy and remove incentives to inappropriately deny care (underservice) or shift less lucrative members out of the program (cherry-picking). But independent advocates have since become concerned about implementation, deceptive consumer notices, and serious risks to members.

Last week, the Medicaid Study Group of independent advocates called on DSS to delay the planned release of applications for new ACOs to continue and potentially expand PCMH Plus until both members’ health and the state budget are protected. In addition to removing ACO incentives to increase members’ risk scores, the advocates renew calls for per-member-per-month Person-Centered Medical Home PCMH) to provide consistency for practices, reduce unnecessary office visits, expand primary care capacity, and lower healthcare costs. Advocates also urged DSS to monitor and prevent underservice and cherry-picking, require that all ACO sites are PCMHs to reduce cherry-picking, improve quality methodologies to reward true improvement, against the post-hoc change the comparison/control group to improve PCMH Plus optics, expand the ACO minimum number of members to avoid random cost increases, stop double paying for intensive care management, equalize upfront ACO payments so all PCMH Plus members have resources to improve their health, and provide members with clear notices that accurately explain their rights and the risks of the new program.

DSS has not responded to the new analysis or the advocates’ cautions.