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A Simple, But Highly Effective, Explanation of CMS Risk
Adjustment
Author: Donna Naugher RN, HCS-D
CQI Director
Care First, Inc.
Dnaugher@carefirst-al.com
August 4, 2009
This is the best way
that I can explain Risk Adjustment. (Risk Adjustment is used for outcome
measures by CMS).
Take a 50 year old
patient that has had a total knee replacement. The only co-morbidity is HTN.
You would expect that
person to get back to baseline with no problem...So (using a ruler with a scale
of 0 to 12 inches), we could get that patient to 12 inches by discharge and meet
our goals and have our Outcomes be the best that they can be.
Now take that same 50
year old patient that had a joint replacement and has HTN and now let’s say the
patient also has CHF, DM 2, ESRD and is on dialysis 3 x week and for fun let’s
say the patient has a BKA on the opposite leg. Now you would never expect this
second patient to get to the same baseline as the 1st example. But, by
answering all of the questions appropriately, i.e., (inpatient diagnosis,
correct diagnosis on 485, correct diagnosis on M0210, etc.), the patient is
going to be “Risk Adjusted” by CMS to show that the second patient cannot get to
the 12 inch mark but may get to 6 inch mark. If we get this second patient to 6
inches, we have then met our goals and will have good outcomes.
If you do not put in
the co-morbidities of the patient and do not answer the Oasis questions
correctly, CMS will think that you are going to get that 2nd patient to the 12
inch mark. Even though you met YOUR real goal of 6 inches, because you did not
answer the questions appropriately, you will not get the Risk Adjustment
credit. This will ultimately cause you to have poor outcomes even though you
know that your staff is doing what they should.
Risk Adjustment is
how CMS can take every agency’s patient population and make them equal, because,
realistically, we know that not everyone can reach the same goals. |