For the fourth installment of our semi-regular series that recommends articles, white papers, or issue briefs of importance to RISE members, we suggest a recent Health Affairs blog post written by leaders at Avalere Health and Better Medicare Alliance. The post reviews the issues around Medicare Advantage (MA) encounter data, including its limitations to evaluate plan performance and its potential to offer new insights into MA.

A recent blog post published in Health Affairs examines the limitations and potential of MA encounter data. The piece was written by Sean Creighton, a managing director at Avalere Health, Robin Duddy-Tenbrunsel, a consultant at Avalere Health, and James Michel, director of policy and research at Better Medicare Alliance (BMA), a leading policy and advocacy organization for Medicare Advantage.

The Centers for Medicare & Medicaid Services (CMS) uses records of beneficiary "encounters" with providers to collect encounter data from health plans. Its goal is to transition away from the Risk Adjustment Processing System currently used to calculate beneficiary risk scores and eventually use the encounter data to determine the scores. But health plans note that there are operational challenges to gathering and validating encounter data, and in 2019 CMS only used 25 percent encounter data in risk score calculation, with 75 percent being calculated off Risk Adjustment Processing System (RAPS) data.

The authors of the blog post explore the challenges of encounter data, including those identified in recent reports produced by MedPAC, the Government Accountability Office, and the Office of Inspector General. Those reports noted that incompleteness and inaccuracy in the encounter data may result in underreporting of claims from important sites of care.  Other issues include inconsistent reporting, lack of information within the data about supplemental benefits, and limited ability to track specific providers.

The authors emphasize that meaningful research will require CMS to be transparent about the rules for collection of encounter data, improving the quality of the data received by the site of service, and by benchmarking the data relative to other plans and to fee-for service. They conclude that with time and attention to quality, encounter data does provide an opportunity for policy makers and researchers to evaluate the MA program for cost, quality, and effectiveness.

Editor’s note: Creighton is a RISE board member and chairs our risk adjustment policy advisory committee. He will be among the 50 speakers at RISE Nashville, March 17-19 at the Gaylord Opryland Resort. The dynamic learning event, now in its 13th year, features eight tracks and more than 40 sessions for executives and senior managers from Medicare Advantage, Commercial, and Medicaid health plans, provider groups/integrated health systems and service providers from across the United States.