The Attorney General’s Office examines how a commonly-used calculation for determining health care payments fails to accurately measure health needs and causes funding to be moved away from low-income communities in Massachusetts. Confidential insurance company data and public data from the Massachusetts Department of Public Health is used to examine four topics:
  1. How population health risk scores compare with community-level indicators of health and health care access.
  2. How the Centers for Medicare & Medicaid Services (CMS) risk adjustment program shifts funds across insurers serving different populations
  3. How changes to the CMS risk adjustment formula could address the unintended consequences of these transfers.
  4. How service closures and lack of capital investment by hospitals in low-cost networks risk further limiting access to care in the same low-income communities where utilization is already lower than social determinants of health would predict.
Health Scores and Access Barriers
Health risk scores based upon a population’s history of health care utilization entrench resource disparities and health care access barriers.  Communities who face barriers that depress their use of health care – like difficulties accessing transportation, housing, childcare, or broadband – are coded as “healthier,” contributing to a cycle of underfunding for their health care services.  

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