Manage your Population with Risk Stratification

Risk stratification informs ACOs on the risk scores of their population. This risk stratification helps ACOs identify members for care management interventions before they become high-use healthcare resources. Risk stratification allows ACO leaders to proactively identify patients who will benefit from intervention and care management services.

CMS uses risk adjustment models to assess the acuity of patients within a population, ensuring that payments are appropriately distributed and cost benchmarks are adjusted to reflect the health status and complexity of the population being served. The HCC risk score reflects the patient's demographics (age and gender), diagnoses, and disease interactions as documented in eligible professional claims. Healthcare providers must document relevant chronic and non-chronic conditions annually to reflect each patient’s acuity and ensure appropriate resources to manage their patient populations.

Establishing your HCC recapture goals for your patient population and strategies at the beginning of each performance year is critical for annual success. Analyzing your patient registries and documented conditions from the prior year is the first step in setting the best approach for your ACO. Additionally, objective data should be used to identify potential suspect conditions that were not previously documented. Aligning with your providers on your goals and keeping them engaged and accountable for their patients’ HCC gaps is foundational. Keep your providers informed with performance scorecards and patient lists.