Department of Quantitative Health Sciences
Medical Subject Headings
Aged; *Capitation Fee; Diagnosis-Related Groups; Disability Evaluation; Disabled Persons; Female; Health Care Costs; Health Maintenance Organizations; Humans; Male; Medicaid; Medicare; Models, Economic; Rate Setting and Review; Regression Analysis; Risk Management; United States
Biostatistics | Epidemiology | Health Services Research
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.
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Citation: Health Care Financ Rev. 1996 Spring;17(3):101-28. Re-published in: Managed Care: Advances in Financing, by Linda F. Wolf.
Ellis, Randall P.; Pope, Gregory C.; Iezzoni, Lisa I.; Ayanian, John Z.; Bates, David W.; Burstin, Helen; and Ash, Arlene S., "Diagnosis-based risk adjustment for Medicare capitation payments" (1997). Quantitative Health Sciences Publications and Presentations. 654.