Risk Adjustment
It is challenging to design accurate risk adjustment mechanisms for medical and social complexity at a primary care practice level, particularly given data limitations and experience to date. A commonly accepted methodology to estimate how much primary care someone needs based on their medical condition(s) does not yet exist.
Primary care practices should understand the extent to which any capitation payments are risk adjusted based on your patient panels. For example, if a primary care model is only risk adjusting PMPM payments by age and gender, this may not sufficiently account for patients with medical and social complexity. Payers can calculate prospective payment rates in primary care models based on historical utilization with an additional payment increase to compensate for capitated procedure codes not historically reimbursed by a given payer. Learn more about risk adjustment in Section I Step 7 Understand types of financial risk in VBP models.
Social Risk Adjustment
OHA will convene a subcommittee of parties interested in developing a social risk adjustment pilot model. The subcommittee, in partnership with content experts, will identify and review social risk adjustment research, including methodologies in use nationally and in Oregon