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. 1996 Spring;17(3):101-28.

Diagnosis-based risk adjustment for Medicare capitation payments

R P Ellis  1 , G C Pope, L Iezzoni, J Z Ayanian, D W Bates, H Burstin, A S Ash
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Diagnosis-based risk adjustment for Medicare capitation payments

R P Ellis et al. Health Care Financ Rev. 1996 Spring.

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.

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References

    1. Anderson GF, Cantor JC, Steinberg EP, Holloway J. Capitation Pricing: Adjusting for Prior Utilization and Physician Discretion. Health Care Financing Review. 1986 Winter;8(2):27–34. - PMC - PubMed
    1. Anderson GF, Lupu D, et al. Payment Amount for Capitated Systems. Center for Hospital Finance and Management, Johns Hopkins University; Baltimore: Dec, 1989. Contract Number 17-C-98990/3-01. Prepared for the Health Care Financing Administration.
    1. Ash A, Ellis R, Iezzoni L. Clinical Refinements to the Diagnostic Cost Group Model. Baltimore, MD.: Jun, 1990. Cooperative Agreement Number 18-C-98526/1-03. Prepared for the Health Care Financing Administration.
    1. Ash A, Porell F, Gruenberg L, et al. Adjusting Medicare Capitation Payments Using Prior Hospitalization. Health Care Financing Review. 1989;10(4):17–29. - PMC - PubMed
    1. Ash A, Porell F, Gruenberg L, et al. An Analysis of Alternative AAPCC Models Using Data from the Continuous Medicare History Sample. Health Policy Research Consortium, Brandeis University and Boston University; Sep, 1986. Contract Number 99-C-98526/1. Prepared for the Health Care Financing Administration.

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