Minimal-Burden Risk Adjusters for the Medicare Risk Program

摘要

Studies have shown that payments to risk plans under the Medicare program exceed211u001ethe cost that HCFA would have incurred under traditional fee-for-service (FFS) 211u001eMedicare. The overpayment occurs because the mechanism for setting the capitation 211u001erates that risk plans are paid for providing coverage of Medicare services fails 211u001eto reflect health status adequately. HCFA funded this study, among others, to 211u001edevelop more effective risk adjusters for the general Medicare population. This 211u001eproject developed a risk adjuster that is based on (1) a history of serious 211u001edisease (including cancer, heart disease or stroke) and severity of illness; (2) 211u001ethe length of time since the last hospital stay; and (3) comorbidities. The 211u001epredictive power from using history of serious illness was compared to the 211u001epredictive power of two existing risk adjusters-the diagnostic-cost group and 211u001eambulatory-care group models. Both predictive accuracy and operational features 211u001ewere compared.