Medicare & Medicaid
Risk adjustment and predictive modeling are integral components of the Medicare Modernization Act and equally important in Medicaid reform at the state level. DxCG offers models specifically designed for the unique characteristics of the Medicaid and Medicare populations. The RiskSmart Enterprise product provides important analytics that reveal potentially missing diagnosis, gaps in care and identifies patients by disease and severity levels. Program managers who use RiskSmart are better informed about populations and therefore better able to budget, measure and manage reform.
MEDICARE. The Medicare program uses a simple DxCG model (which it calls the CMS-HCC model) to pay Medicare Advantage plans. The Centers for Medicare & Medicaid Services (CMS) has announced that it will use another version of the DxCG models to set payments for the "Part D" Pharmacy Benefit Plan. CMS also integrates a DxCG-based risk adjustment into its competitive bidding programs. DxCG offers RiskSmart Medicare Advantage tools to support accurate payment and case management.
MEDICAID. In recent years, several state Medicaid programs and State Children's Health Insurance Programs (SCHIP) have used DxCG models to implement health-based allocations and payment systems as well as design and evaluate disease management programs.
In addition to several government agencies (and their consultants), DxCG clients include health plans participating in the Medicare Advantage and Medicaid programs. These health plans have used DxCG to:
- Evaluate illness burden by eligibility categories to ascertain risk, disease prevalence and cost.
- Identify and stratify (prioritize) members for case management and disease management.
- Quantify savings from disease management programs that are "true savings" and not simply a "regression to the mean."
- Implement morbidity adjusted payment systems with providers, thereby providing incentive to care for the sickest members.
- Profile variations in practice patterns among physicians and managed care contracts.
- Prepare rate submissions and budget justifications