I'm sitting on pins and needles just waiting for the recent article on what happens when outcomes are not risk adjusted to be published ahead of print in Journal of Orthopaedic and Sports Physical Therapy. I'm told it should be any day now....
Let me tell you a real story. About 3 years ago, my 10 year term on my life insurance policy was due to expire. Being the responsible person, I started the process of renewing my life insurance. One key aspect with renewal was to provide access to medical notes from all of my providers. Easy enough. I filled out all the paper work. Well, there was one little incident in my life that had me actually go in to see a physician... which resulted in a referral to a cardiologist... which resulted in multiple cardiac tests.
About 7 years ago, my goal was to complete an Olympic distance triathlon in Traverse City, MI. For those of you not familiar with Michigan, google it... and look at the peninsula and the bays. The triathlon started in the West Bay... which was enticing to me because it was Lake Michigan. I have a special place in my heart for Lake Michigan. The bike and run portions were in the peninsula. It's so beautiful in that area. Well, as I was training for months before the event, I was having feelings of almost passing out while I was running. I finally realized the problem had to do with tachycardia. What I couldn't figure out was why. I didn't want to die during the event, so I chose to see my primary care physician.
Well, after multiple appointments and various tests, it was deemed I have an amazing heart. No one could actually answer why I have the issue - and it is an issue. I just have to monitor my rate and stay 170 bpm or less. I do my best, but it's quite unrealistic when competing, especially in the swim event. Anyways, according to the medical community, I have a clean bill of health.
Well, let's fast forward to the life insurance company. The immediate response, after they sought out all of the documentation, was I was a cardiac risk. This was based on the fact that I was young, saw a cardiologist and had a full cardiac work up because of symptoms. Because I was deemed a cardiac risk, the required payment was lots higher than what I had paid for the previous 10 years. I can't remember the cost, but I remember it was so much higher that my husband and I questioned the quote.
The risk adjustment and predictive modeling the life insurance company used viewed me as having a cardiac problem. This would mean to them that there was a higher likelihood that I would potentially die and the life insurance company would have a claim to pay. But... based on my clean bill of health, does that seem reasonable? Should I immediately be considered a death risk with a clean bill of health?
I was miscategorized during the risk adjustment process based on the appointments and the tests that had been performed. Believe it or not, once we fought the quote and demanded that all the notes be read by a human, the required premium was changed to a more acceptable rate. That rate was based my actual health versus the miscategorization that happened based on the fact that tests occurred.
Based on the recent study, ranking clinics with unadjusted outcomes resulted in a 70% error rate in decile ranking.