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| The Impact of Changes in Centers for Medicare & Medicaid Services Payment Programs on Risk Scores
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Abdelomonaem Abunnur, Thomas Shaw, Ph.D, MBA
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Abstract:
This paper discusses the various payment methods that the U.S. Centers for Medicare & Medicaid Services (CMS) has introduced to reimburse health providers. Quality and costs control are the main goals of the alternative payment program. Fee for Services (FFS) was the traditional method; however, it has many criticisms due to focusing only on the volume of services. Alternative programs aim to promote integrated health care based on provider agreements to share risk. CMS used risk-adjustment methods to determine risk scores that enhance the accuracy and fairness of these payments. In 2021, under the Biden-Harris administration, CMS launched an alternative model. The new model is called the Accountable Care Organization Realizing Equity, Access, and Community Health (ACO REACH) Model. The introduction of this model responds to criticism about the fairness of the previous model, the Global and Professional Direct Contracting (GPDC). The new model aims to include more underserved populations in the healthcare system who may involve high risks that increase risk scores above CMS benchmarks.
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