Assessing the Performance of Alternative Risk Adjustors. (Report for September 30, 1999-September 29, 2003.);Final rept

摘要

This project had two major goals: (1) to examine empirically several commercially available risk adjustment methods$ and (2) to conduct case studies of Medicare and six health care marketplaces nationwide to explore how decisions are made about whether or not to adopt risk adjustment. Many factors affect how persons find health care, ranging from specific health concerns to financial considerations to geographic location to preferences and expectations for health outcomes and services. Therefore, the mix of persons treated by different clinical interventions, providers, or health plans varies. Higher-risk patients typically generate larger costs and experience more complications, even with efficient, high-quality providers or health plans. Risk adjustment aims to account for differences in intrinsic health risks that patients bring to their health care encounters. We studied 5 risk adjusters, three based only on coded diagnoses Adjusted Clinical Groups (ACGs), Chronic illness and Disability Payment System (CDPS), and Diagnostic Cost Group/Hieratchical Condition Categories (DCGlHCC) and two that use prescription drug codes (Medicaid Rx and RxGroups). We used 1994-1995 Medicaid data from 4 states (California, Georgia, New Jersey, and Wisconsin) and data from three private insurers in Massachusetts. We interviewed more than 30 persons about Medicare decisions about risk adjustment and 128 persons within Baltimore, Denver, Cleveland, Greenville, SC, Phoenix, and Seattle about local experiences with risk adjustment.