Table Of Content

a REPORT TO CONGRESS: RISK ADJUSTMENT IN MEDICARE ADVANTAGE DECEMBER 2018 [This page intentionally left blank.] TABLE OF CONTENTS Preface..............................................................................................................................................1 1. Introduction ..................................................................................................................................3 1.1 Background on Payment in the Medicare Advantage Program .....................................3 1.2 Risk Adjustment Provisions in the 21st Century Cures Act ..........................................5 2. Primer on Risk Adjustment and the CMS-HCC Model...............................................................9 2.1 The Function of Risk Adjustment ..................................................................................9 2.2 History of Risk Adjustment Models for Medicare Managed Care ..............................10 2.3 Principles for Risk Adjustment Model Development ..................................................14 2.4 Elements and Organization of the CMS-HCC Model .................................................16 2.4.1 Diagnostic Classification System ....................................................................16 2.4.2 Hierarchies .......................................................................................................17 2.4.3 CMS-HCC Model Structure ............................................................................19 2.4.4 Clinical Vignette ..............................................................................................20 2.5 CMS-HCC Model Changes Specific to the 21st Century Cures Act...........................22 2.5.1 HCC Changes...................................................................................................23 2.5.2 Count Variable .................................................................................................25 2.6 CMS-HCC Model Segments........................................................................................26 2.6.1 Aged and Disabled Models — Community Dual versus Non-dual, and Institutional ......................................................................................................26 2.6.2 Aged Disabled Model for New Enrollees ........................................................28 2.6.3 Chronic Condition Special Needs Plans with New Enrollees .........................29 2.7 End Stage Renal Disease (ESRD) Models...................................................................30 2.7.1 ESRD Dialysis Models ....................................................................................30 2.7.2 Kidney Transplant ............................................................................................31 2.7.3 ESRD Functioning Graft Models with Post-Graft Factors ..............................31 2.7.4 ESRD Model Statistics ....................................................................................32 2.8 Adjustments to the CMS-HCC Models .......................................................................33 2.8.1 Frailty Adjustment ...........................................................................................33 3. Model Evaluation .......................................................................................................................37 3.1 Methodology ................................................................................................................37 3.1.1 Sample..............................................................................................................37 3.1.2 Defining Chronic Conditions ...........................................................................38 3.1.3 Beneficiary Cost...............................................................................................40 3.2 Aged-Disabled CMS-HCC Model Predictive Ratios ..................................................40 3.2.1 Predictive Ratios by Deciles of Predicted Risk ...............................................42 iii 3.2.2 Predictive Ratios for All HCCs........................................................................45 3.2.3 Predictive Ratios by Body Systems or Disease Groups...................................45 3.2.4 Predictive Ratios by Count of Chronic Conditions..........................................45 3.2.5 Predictive Ratios by Count of Payment Conditions ........................................46 3.3 ESRD Dialysis Model Predictive Ratios .....................................................................46 3.3.1 Predictive Ratios by Deciles of Predicted Risk ...............................................47 3.3.2 Predictive Ratios for all HCCs .........................................................................48 3.3.3 Predictive Ratios by Body systems or Disease Groups ...................................48 3.3.4 Predictive Ratios by Count of Chronic Conditions..........................................48 3.3.5 Predictive Ratios by Count of Payment Conditions ........................................48 3.4 ESRD Functioning Graft Model and Kidney Transplant Predictive Ratios ................48 3.4.1 Predictive Ratios by Deciles of Predicted Risk ...............................................49 3.4.2 Predictive Ratios for all HCCs .........................................................................50 3.4.3 Predictive Ratios by Body Systems or Disease Groups...................................51 3.4.4 Predictive Ratios by Count of Chronic Conditions..........................................51 3.4.5 Predictive Ratios by Count of Payment Conditions ........................................51 3.4.6 Predictive Ratios by Post-Graft Factor ............................................................51 3.4.7 Predictive Ratio by Kidney Transplant Factor.................................................52 4. Ongoing Research ......................................................................................................................53 4.1 ICD-10 .........................................................................................................................53 5. Tables of Predictive Ratios ........................................................................................................57 iv LIST OF TABLES 2-1 Medicare managed care historic risk adjustment model R2 statistics ............................... 12 2-2 Hypothetical example of CMS-HCC (version 23) Expenditure Predictions .................... 22 2-3 2014/2015 model sample counts ....................................................................................... 27 2-4 Chronic conditions covered by special needs plans .......................................................... 29 2-5 ESRD risk adjustment model R2 statistics ........................................................................ 33 4-1 Model calibration data years and diagnosis code classification ....................................... 54 5-1 Predictive ratios by deciles of predicted risk (sorted low to high): All aged- disabled enrollees .............................................................................................................. 57 5-2 Predictive ratios by deciles of predicted risk (sorted low to high): Aged enrollees ......... 59 5-3 Predictive ratios by deciles of predicted risk (sorted low to high): Disabled enrollees ............................................................................................................................ 61 5-4 Predictive ratios by deciles of predicted risk (sorted low to high): Aged-disabled community continuing enrollees ....................................................................................... 63 5-5 Predictive ratios by deciles of predicted risk (sorted low to high): Aged-disabled institutional continuing enrollees ...................................................................................... 65 5-6 Predictive ratios by deciles of predicted risk (sorted low to high): Aged-disabled new enrollees .................................................................................................................... 67 5-7 Predictive ratios by deciles of predicted risk (sorted low to high): Aged community continuing enrollees ....................................................................................... 69 5-8 Predictive ratios by deciles of predicted risk (sorted low to high): Disabled community continuing enrollees ....................................................................................... 71 5-9 Predictive ratios by deciles of predicted risk (sorted low to high): Full benefit dual aged enrollees.................................................................................................................... 73 5-10 Predictive ratios by deciles of predicted risk (sorted low to high): Full benefit dual disabled enrollees .............................................................................................................. 75 5-11 Predictive ratios by deciles of predicted risk (sorted low to high): Partial benefit dual aged enrollees ............................................................................................................ 77 5-12 Predictive ratios by deciles of predicted risk (sorted low to high): Partial benefit dual disabled enrollees ...................................................................................................... 79 5-13 Predictive ratios by deciles of predicted risk (sorted low to high): Non-dual aged enrollees ............................................................................................................................ 81 5-14 Predictive ratios by deciles of predicted risk (sorted low to high): Non-dual disabled enrollees .............................................................................................................. 83 5-15 Predictive ratios by deciles of predicted risk (sorted low to high): All aged- disabled enrollees with 0 chronic conditions .................................................................... 85 5-16 Predictive ratios by deciles of predicted risk (sorted low to high): All aged- disabled enrollees with 1–3 chronic conditions ................................................................ 87 5-17 Predictive ratios by deciles of predicted risk (sorted low to high): All aged- disabled enrollees with 4–6 chronic conditions ................................................................ 89 5-18 Predictive ratios by deciles of predicted risk (sorted low to high): All aged- disabled enrollees with 7–9 chronic conditions ................................................................ 91 5-19 Predictive ratios by deciles of predicted risk (sorted low to high): All aged- disabled enrollees with 10+ chronic conditions ................................................................ 93 5-20a Predictive ratio for all eligible HCCs: All aged-disabled enrollees 2017 CMS- HCC Model ....................................................................................................................... 95 v 5-20b Predictive ratio for all eligible HCCs: All aged-disabled enrollees 2019 CMS- HCC Model ..................................................................................................................... 105 5-20c Predictive ratio for all eligible HCCs: All aged-disabled enrollees 2019 Payment Condition Count (PCC) Model ....................................................................................... 115 5-21 Predictive Ratio by Body Systems/Disease Groups: All aged-disabled enrollees ......... 124 5-22 Predictive Ratio by count of chronic conditions: Aged enrollees ................................... 127 5-23 Predictive Ratio by count of chronic conditions: Disabled enrollees ............................. 128 5-24 Predictive Ratio by count of chronic conditions: Full dual eligible enrollees ................ 129 5-25 Predictive Ratio by count of chronic conditions: Partial dual eligible enrollees ............ 130 5-26 Predictive Ratio by count of chronic conditions: Non-dual eligible enrollees ............... 131 5-27 Predictive Ratio by count of chronic conditions: All aged-disabled enrollees with Diabetes........................................................................................................................... 132 5-28 Predictive Ratio by count of chronic conditions: All aged-disabled enrollees with HIV/AIDS ....................................................................................................................... 133 5-29 Predictive Ratio by count of chronic conditions: All aged-disabled enrollees with substance use disorder..................................................................................................... 134 5-30 Predictive Ratio by count of chronic conditions: All aged-disabled enrollees with mental health ................................................................................................................... 135 5-31 Predictive Ratio by count of chronic conditions: All aged-disabled enrollees with COPD .............................................................................................................................. 136 5-32 Predictive Ratio by count of chronic conditions: All aged-disabled enrollees with CHF ................................................................................................................................. 137 5-33 Predictive Ratio by count of chronic conditions: All aged-disabled enrollees with vascular disorders............................................................................................................ 138 5-34 Predictive Ratio by count of chronic conditions: All aged-disabled enrollees with cancer .............................................................................................................................. 139 5-35 Predictive Ratio by count of chronic conditions: All aged-disabled enrollees with chronic kidney disease .................................................................................................... 140 5-36 Predictive Ratio by count of payment conditions: Aged enrollees ................................. 141 5-37 Predictive Ratio by count of payment conditions: Disabled enrollees ........................... 142 5-38 Predictive Ratio by count of payment conditions: Full dual eligible enrollees .............. 143 5-39 Predictive Ratio by count of payment conditions: Partial dual eligible enrollees .......... 144 5-40 Predictive Ratio by count of payment conditions: Non-dual eligible enrollees ............. 145 5-41 Predictive ratios by deciles of predicted risk (sorted low to high): All dialysis enrollees .......................................................................................................................... 146 5-42 Predictive ratios by deciles of predicted risk (sorted low to high): Aged dialysis enrollees .......................................................................................................................... 147 5-43 Predictive ratios by deciles of predicted risk (sorted low to high): Non-aged dialysis enrollees ............................................................................................................. 148 5-44 Predictive ratios by deciles of predicted risk (sorted low to high): Dialysis continuing enrollees ........................................................................................................ 149 5-45 Predictive ratios by deciles of predicted risk (sorted low to high): Dialysis new enrollees 2019 ESRD Model .......................................................................................... 150 5-46 Predictive ratios by deciles of predicted risk (sorted low to high): Aged dialysis continuing enrollees ........................................................................................................ 151 vi 5-47 Predictive ratios by deciles of predicted risk (sorted low to high): Non-aged dialysis continuing enrollees ........................................................................................... 152 5-48 Predictive ratios by deciles of predicted risk (sorted low to high): Full benefit dual dialysis continuing enrollees ........................................................................................... 153 5-49 Predictive ratios by deciles of predicted risk (sorted low to high): Partial benefit dual dialysis continuing enrollees ................................................................................... 154 5-50 Predictive ratios by deciles of predicted risk (sorted low to high): Non-dual dialysis continuing enrollees ........................................................................................... 155 5-51 Predictive ratio for all HCCs with an indicator for which HCCs are payment and/or chronic: All dialysis continuing enrollees 2019 ESRD Model ............................ 156 5-52 Predictive ratio for all body systems/disease groups: All dialysis continuing enrollees .......................................................................................................................... 165 5-53 Predictive ratio for ESRD interacted with count of chronic conditions: All dialysis continuing enrollees ........................................................................................................ 166 5-54 Predictive ratio for ESRD interacted with count of chronic conditions: Aged dialysis continuing enrollees ........................................................................................... 166 5-55 Predictive ratio for ESRD interacted with count of chronic conditions: Non-aged dialysis continuing enrollees ........................................................................................... 167 5-56 Predictive ratio for ESRD interacted with count of chronic conditions: Any Medicaid dialysis continuing enrollees ........................................................................... 167 5-57 Predictive ratio for ESRD interacted with count of chronic conditions: Non- Medicaid dialysis continuing enrollees ........................................................................... 168 5-58 Predictive ratio for ESRD interacted with count of chronic conditions: Full Dual eligible dialysis continuing enrollees 2019 ESRD Model .............................................. 168 5-59 Predictive ratio by count of chronic conditions: Partial dual eligible dialysis continuing enrollees ........................................................................................................ 169 5-60 Predictive ratio by count of chronic conditions: Non-Dual eligible dialysis continuing enrollees ........................................................................................................ 169 5-61 Predictive ratio by count of payment conditions: Aged dialysis continuing enrollees .......................................................................................................................... 170 5-62 Predictive ratio by count of payment conditions: Non-aged dialysis continuing enrollees .......................................................................................................................... 170 5-63 Predictive ratio by count of payment conditions: Full dual eligible dialysis continuing enrollees ........................................................................................................ 171 5-64 Predictive ratio by count of payment conditions: Partial dual eligible dialysis continuing enrollees ........................................................................................................ 171 5-65 Predictive ratio by count of payment conditions: Non-dual eligible dialysis continuing enrollees 2019 ESRD Model ........................................................................ 172 5-66 Predictive ratio by deciles of predicted risk (sorted low to high): All functioning graft enrollees 2019 ESRD Model .................................................................................. 172 5-67 Predictive ratio by deciles of predicted risk (sorted low to high): Aged functioning graft enrollees.................................................................................................................. 173 5-68 Predictive ratio by deciles of predicted risk (sorted low to high): Non-aged functioning graft enrollees .............................................................................................. 174 5-69 Predictive ratio by deciles of predicted risk (sorted low to high): Functioning graft community continuing enrollees ..................................................................................... 175 vii 5-70 Predictive ratio by deciles of predicted risk (sorted low to high): Functioning graft institutional continuing enrollees .................................................................................... 176 5-71 Predictive ratio by deciles of predicted risk (sorted low to high): Functioning graft new enrollees .................................................................................................................. 177 5-72 Predictive ratio by deciles of predicted risk (sorted low to high): Aged functioning graft community continuing enrollees ............................................................................ 178 5-73 Predictive ratio by deciles of predicted risk (sorted low to high): Non-aged functioning graft community continuing enrollees ......................................................... 179 5-74 Predictive ratio by deciles of predicted risk (sorted low to high): Full benefit dual functioning graft continuing enrollees ............................................................................ 180 5-75 Predictive ratio by deciles of predicted risk (sorted low to high): Partial benefit dual functioning graft continuing enrollees .................................................................... 181 5-76 Predictive ratio by deciles of predicted risk (sorted low to high): Non-dual functioning graft continuing enrollees ............................................................................ 182 5-77 Predictive ratio for all HCCs with an indicator for which HCCs are payment and/or chronic: All functioning graft continuing enrollees 2019 ESRD Model ............. 183 5-78 Predictive ratio for all body systems/disease groups: All functioning graft continuing enrollees ........................................................................................................ 192 5-79 Predictive ratio for ESRD interacted with count of chronic conditions: All functioning graft continuing enrollees ............................................................................ 193 5-80 Predictive ratio by count of chronic conditions: Aged functioning graft continuing enrollees .......................................................................................................................... 193 5-81 Predictive ratio by count of chronic conditions: Non-aged functioning graft continuing enrollees ........................................................................................................ 194 5-82 Predictive ratio by count of chronic conditions: Any Medicaid functioning graft continuing enrollees ........................................................................................................ 194 5-83 Predictive ratio by count of chronic conditions: Non-Medicaid functioning graft continuing enrollees ........................................................................................................ 195 5-84 Predictive ratio by count of chronic conditions: Full Dual eligible functioning graft continuing enrollees ............................................................................................... 195 5-85 Predictive ratio by count of chronic conditions: Partial dual eligible functioning graft continuing enrollees ............................................................................................... 196 5-86 Predictive ratio by count of chronic conditions: Non-dual eligible functioning graft continuing enrollees ............................................................................................... 196 5-87 Predictive ratio by count of payment conditions: Aged functioning graft continuing enrollees ........................................................................................................ 197 5-88 Predictive ratio by count of payment conditions: Non-aged functioning graft continuing enrollees ........................................................................................................ 197 5-89 Predictive ratio by count of payment conditions: Full dual eligible functioning graft continuing enrollees ............................................................................................... 198 5-90 Predictive ratio by count of payment conditions: Partial dual eligible functioning graft continuing enrollees ............................................................................................... 198 5-91 Predictive ratio by count of payment conditions: Non-dual eligible functioning graft continuing enrollees ............................................................................................... 199 5-92 Predictive ratio by post-graft factor: Functioning graft community continuing enrollees .......................................................................................................................... 199 viii 5-93 Predictive ratio by post-graft factor: Functioning graft institutional continuing enrollees .......................................................................................................................... 200 5-94 Predictive ratio by post-graft factor: Functioning graft new enrollees ........................... 200 5-95 Predictive ratio by kidney transplant factor: Kidney transplant enrollees 2019 ESRD Model ................................................................................................................... 201 LIST OF FIGURES 2-1 Aggregating ICD-9/10 codes into hierarchical condition categories ................................ 17 2-2 Hierarchical condition categories for coronary artery disease .......................................... 18 2-3 Clinical vignette for CMS-HCC (version 23) classification ............................................. 21 ix PREFACE This report is provided in accordance with Section 17006(f)(2)(A)(ii) of the 21st Century Cures Act (Public Law No: 114-255, enacted December 13, 2016). The 21st Century Cures Act requires the Secretary to submit to Congress a report on the risk adjustment model and the End- Stage Renal Disease (ESRD) risk adjustment model under the Medicare Advantage program every three years, with the first report to be submitted no later than December 31, 2018. Each report is to include any revisions to either model since the previous report, as well as information on how such revisions impact the predictive ratios under either such model for groups of enrollees in Medicare Advantage plans, including very high and very low cost enrollees, and groups defined by the number of chronic conditions of enrollees. This is the first report on risk adjustment in Medicare Advantage required by the 21st Century Cures Act. It provides information on the accuracy of the Centers for Medicare & Medicaid Services (CMS) Hierarchical Condition Categories (HCC) and ESRD risk adjustment models. The standard measure of accuracy applied to the CMS-HCC model is the predictive ratio, which is a ratio of predicted cost to actual cost, for sub-groups of beneficiaries within the model sample. We include predictive ratios for both CMS-HCC models to be implemented in payment year 2019, a CMS-HCC model with additional factors that take into account the number of conditions a beneficiary has, and the ESRD models implemented for plan year 2019. Predictive ratios are provided by decile of predicted medical expenditure, individual conditions and groups of similar diseases (body systems), counts of chronic conditions, and counts of conditions included in the model. The report follows CMS’ standard metric of evaluation for the risk adjustment models, which is based on predictive ratios for beneficiaries enrolled in the traditional Fee-for-Service (FFS) program. CMS does not uniformly collect cost information for beneficiaries enrolled in the Medicare Advantage program. While some cost information is available in aggregate from plan bids, and at an enrollee level from encounter data records submitted to CMS, this information is not consistently defined between plans. For example, some plans participate in capitated or other non-FFS payment arrangements with providers for which a price per service cannot be determined at the encounter level. Thus, in our estimation the cost information available would not accurately reflect the actual cost of providing services in Medicare Advantage. Hence, the evaluation is conducted with beneficiaries in the traditional Medicare FFS program. We provide the predicted and actual cost for each population sub group considered so that interested stakeholders may consider and compare the cost expected in FFS Medicare for each defined sub- group. 1

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1.1 Background on Payment in the Medicare Advantage Program . 5-9 Predictive ratios by deciles of predicted risk (sorted low to high): Full benefit
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1.1 Background on Payment in the Medicare Advantage Program . 5-9 Predictive ratios by deciles of predicted risk (sorted low to high): Full benefit

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