True Story: What Happens with Poor Risk Adjustment?
It won't happen to me. That is how I've felt for many years. Yesterday I spent 3 hours working on a spreadsheet of patient outcomes that was the result of a utilization company poorly categorizing the quality of care I provide. As of yesterday, I felt the sting of poor risk adjustment.
The background for this story starts over 10 years ago. Blue Cross Blue Shield of Michigan began using Landmark to determine the quality of care provided. Currently another company is responsible for determining the quality of services. "Quality" is only determined by number of visits. Quality needs to be redifined to include more parameters than just number of visits.
As of Monday, I had a problem. The utilization company deemed my services a Category B rating. What this means is that I will have to play "mother may I?" with utilization oversight. I will need to have my office manager spend extra time asking for additional visits... potentially altering the frequency in which I deliver services. For my older adult population, this may actually reduce my effectiveness for the bulk of my population due to their pre-frail or frail state. For now, this mis-categorization will only affect patients who have a Blue Cross Blue Shield of Michigan Medicare Advantage policy. As a specialist in geriatrics, I have a problem with my rating.
As I was going through the spreadsheet of patient names, it hit me that often times there was a huge discrepancy between the utilization company's risk adjusted visit number versus FOTO's prediction. This led me to dig into my FOTO portal. When I reviewed the same 12 month period, I felt very confused as to why I look reasonable and in the green for orthopedic conditions, yet not so great via the utilization company's data. (Now I do have what appears a poor performance for neurological conditions. This may not be the case because more often than not, for patients coming in with unsteadiness of gait and abnormality of gait - and no real diagnosis, my real focus is to improve their confidence in their balance to reduce their risk of falling.)
I can see from the data in FOTO's portal that 83% of the time I am meeting or exceeding the predicted outcome for patients who have an orthopedic condition. I believe that is quite favorable. Overall, the data also indicates I am in the top 10% internationally when treating orthopedic conditions. I can see that I have problems in being effective treating individuals I have identified as having a neurological type of impairment.
So, why would the utilization company rate me as a Category B, when it is easily seen that for the majority of the patients I treat that I rock?
I believe it comes down to risk adjustment. This company is not transparent online, so I can only assume that their process may only involve gender and body part. The risk adjustment only involves number of visits. I would hope age would also be considered, but I have no idea. In my email response to the company, I asked about the risk adjustment process and how much variance is explained by their process. I indicated I was very confused because my actual outcomes indicate I am a top performer and it seems odd that there would be such a discrepancy in interpretation of my outcomes.
There is a reason to question the risk adjustment process. Recent soon to be published research indicates that without risk adjustment, 70% of the time providers will be miscategorized in the quality of the care provided. It appears that I am now experiencing miscategorization due to a poor risk adjustment process. I'm so hoping that as I go through the process for reconsideration that I may persuade the powers that be to consider my FOTO data and FOTO's strong risk adjustment process in evaluating clinical performance.