Tuesday, July 10, 2018

On Risk Adjustment

The only permanent "R" of Obamacare's 3R's, Risk Adjustment, was implemented in 2014 with the impression that it would keep insurers from cherry picking the healthy risk versus the unhealthy risk. Using an actuarial formula insurers would predict health care costs based on a variety of factors.

In a nutshell, the program would take money from insurers who had lower risk members and provide funding to insurers who disproportionately attracted higher risk members. There were two goals: minimize adverse selection and stabilize premiums.

So what happened?

A handful of mainly small insurers got clobbered. The most heavily hit were Obamacare's newly created CO-OP's. Many of these start ups underfunded premiums to be competitive. They took in a large portion of good risk and had priced for it. But when Risk Adjustment (RA) was factored in they had to pay huge amounts of their premiums to other insurers who had higher risk scores.

Three CO-OPs - Minuteman, Evergreen, and New Mexico Health Connections, challenged parts of the formula laid out in HHS annual payment and parameter regulations. These lawsuits were filed in the summer of 2016 against the Obama Administration's HHS and CMS. One of the main points of contention was HHS's use of statewide average premiums instead of each plan's premiums when creating its risk adjustment formula. HHS adopted this based on the assumption that the program must be budget neutral.

Evergreen went in to receivership right after it was ordered to pay $24.2 million dollars into the RA fund in August of 2016. If they wouldn't have had to pay the RA funds they would have seen a profit of $2 million for the year. Minuteman saw their lawsuit upheld in early 2018 so no changes were required to the original HHS/CMS guidelines.

New Mexico however, received a somewhat positive outcome. In their case the judge ruled in favor of NMHC on payments being based on plans and not the state's average premium. All other claims in the suit were dismissed and lawsuit was completed at the end of February of 2018.

Which leads us to now. Without clarity the Trump Administration has temporarily suspended all payments and collections of RA until the lawsuit is resolved. Once it is resolved payments and collections will resume. Further, because the Trump Administration issued relevant guidance in the 2018 Notice of Benefit and Payment Parameters this shouldn't happen again in the future.

Trump is not "sabotaging" Obamacare. In fact this is something that could have been avoided and fixed by the prior administration. I'm not sure why they didn't fix it and I haven't seen anyone suggest or explain why Andy Slavitt and Sylvia Burwell lacked a game plan back then.

They could have issued interim rules to circumvent the problem. They could have adjusted the 2017 Notice of Benefit and Payment Parameters that were rushed through in late 2016 to mitigate the problem too.

But they didn't. So now - for at least the next news cycle - we will be stuck hearing about a small but substantial piece of the insurance payment system gone awry. Albeit those complaining are the ones who implemented it but didn't fix it.

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