“Risk adjustment is central to creating fair bundled primary care payments, because the costs and complexities of caring for patients vary enormously.”

~Dr. Arlene Ash, PhD

Risk Stratification

Risk stratification attempts to quantify the level of complexity of each patient and allocate resources accordingly. Primary Care clinicians and practices caring for more complicated patients would get paid more than those with less complicated patients.

Dr. Arlene Ash at UMass developed the Neighborhood Stress Score (NSS) to more reliably predict a patient’s social complexity by using their street address. It is essential to account for both medical and social risk.The NSS has been used successfully by MassHealth for many years. The PC4You legislation aims to replicate the model being used by MassHealth. This will maximize health equity by allocating resources where they are needed the most.

Promote Health Equity

Consider Sarah, a 50-year-old patient residing in a neighborhood with high levels of socioeconomic deprivation and limited access to healthcare resources.
- Despite having multiple chronic conditions and requiring specialized care, Sarah's current risk stratification would classify her as average-risk.
- This classification fails to capture the additional health risks she faces due to her neighborhood's stressors, such as limited access to nutritious food, higher pollution levels, and limited social support systems.
- Without incorporating metrics like the neighborhood stress score into risk stratification, Sarah may not receive the appropriate level of care that addresses her unique needs, perpetuating health disparities and inequities.
- However, by including social determinants of health, risk stratification can provide a more accurate and equitable representation of patients' health risks, ensuring they receive the necessary care and support tailored to their circumstances.

Limit Cherry Picking

Cherry picking occurs when providers are incentivized to select the healthiest patients, potentially neglecting sicker and older individuals.
PC4You discourages providers, based on financial incentives, to care for more complicated patients, from focusing solely on simple and healthy patients, ensuring that all patients receive the care they need.

Limit Gaming

Consider John, a middle-aged patient who recently visited a healthcare provider for a routine check-up.
- During the visit, John’s provider intentionally selects the highest possible complexity code to maximize the reimbursement for the encounter, even though it doesn’t accurately reflect the nature and complexity of the visit.
- By gaming the risk stratification system, the provider artificially inflates John’s risk profile, leading to higher reimbursement for the services rendered, ultimately undermining the purpose of conducting a risk assessment in the first place.