Risk Adjustment Utilization Tables: New Format, New Resource

Okay, this is detailed information. Far more than the usual blog. But it’s important. It’s an opportunity to learn how and why Risk Adjustment Tables impact and improve quality measurement. And a resource for those who use them.

This summer, NCQA reformatted its Risk Adjustment Utilization (RAU) Tables and developed a supplemental user manual to provide technical documentation for the tables. These newly formatted tables and the associated user manual for HEDIS Measurement Year 2020 will be released on November 2.  We’re making them available at no cost in the NCQA Store.  After you order, you can access the tables in the My Downloads section of your My NCQA account page.

Risk Adjustment Utilization Tables: Background

Health outcomes can be influenced by underlying patient-related risk factors. As a result, certain patients may be more or less likely to experience a specific outcome, regardless of the care provided. This presents a barrier to making fair, “apples to apples”, comparisons between entities such as health plans, where differences in the distribution of members’ health status (i.e. case mix) may unfairly skew performance results. Risk adjustment exists to account for this. Specifically, risk adjustment is designed to answer the question, “How would the performance of various units compare if hypothetically they had the same mix of patients?”[1] (NQF, 2014, p. 13)

There are multiple methods for risk adjustment. NCQA uses statistical models to predict measure-specific outcomes, accounting for patient age, gender, and comorbidities. These models are the source of the risk weights found in NCQA’s Risk Adjusted Utilization (RAU) tables. The RAU Tables are used by health plans to calculate an expected event rate, which is then compared to the observed event rate using an observed-to-expected ratio. The observed-to-expected ratio reflects risk-adjusted performance, and shows whether a plan performed better, or worse, than expected, accounting for their unique case mix.

NCQA publishes two types of RAU tables: the Shared Table, which provides the logic for mapping diagnosis codes into clinical categories and applies across risk-adjusted measures, and the Measure Specific Tables, which provide the measure-specific risk weights used to calculate expected values as described in the measure specification.  There are five Measure Specific Tables, one for each risk-adjusted measure (please note, for HEDIS MY 2020 and 2021, there will be an additional table “RAU Table – PCR Medicaid” that provides the diagnosis code to clinical category mapping to be used for the risk adjustment calculations of the Plan All-Cause Readmissions (PCR) Medicaid product line ONLY).

Risk Adjustment Utilization Tables: The Updates

In response to feedback from health plans, vendors and other stakeholders, NCQA initiated the reformatting of the RAU tables to simplify the coding and calculation of risk adjustment, while also providing clear technical documentation for table use. This was accomplished by:

  • Simplifying the Measure Specific Tables by removing the use of special formatting (highlighting, merged cells) and consolidating all risk weights for a product line into a single worksheet.
  • Updating the Shared Table to simplify the formatting of “Table HCC-Comb” and rename the “Table CC-Comorbid” tab to “Table CC-Mapping”, streamlining the assignment of condition-based risk-adjustment variables.
  • Developing clear written technical guidance on the RAU tables, in the form of a new Risk Adjustment Utilization Tables User Manual.
  • Revising the HEDIS Volume 2 measure specifications to remove detailed references to RAU Table format and structure.

We realize these tables can be quite complex and believe these changes will provide a better user experience. To assist in preparation for this change, you will find a sample Measure Specific Table example and a document containing an overview of updates and excerpts from the Risk Adjustment Utilization Tables User Manual in the downloadable Vendor Package. Please note the Measure Specific Table example uses the Acute Hospital Utilization measure for purposes of demonstration but does not reflect final variables or weights. These are merely placeholders to help visualize the table updates.

[1]https://www.qualityforum.org/Publications/2014/08/Risk_Adjustment_for_Socioeconomic_Status_or_Other_Sociodemographic_Factors.aspx