Diagnosis-based risk adjustment for Medicare capitation payments.
PubMedPublished 1 January 1996Open access
Randall P. Ellis, Gregory C. Pope, Lisa I. Iezzoni, John Z. Ayanian, David W. Bates, Helen Burstin
Citations288
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TL;DR
Using 1991-92 data for a 5-percent Medicare sample, risk-adjustment models that utilize diagnostic information from both inpatient and ambulatory claims to adjust payments for aged and disabled Medicare enrollees are developed, estimate, and evaluate.
Abstract
Using 1991-92 data for a 5-percent Medicare sample, we develop, estimate, and evaluate risk-adjustment models that utilize diagnostic information from both inpatient and ambulatory claims to adjust payments for aged and disabled Medicare enrollees. Hierarchical coexisting conditions (HCC) models achieve greater explanatory power than diagnostic cost group (DCG) models by taking account of multiple coexisting medical conditions. Prospective models predict average costs of individuals with chronic conditions nearly as well as concurrent models. All models predict medical costs far more accurately than the current health maintenance organization (HMO) payment formula.
Keywords
Economics, Econometrics and FinanceHealth Professions
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