Adjusting Medicare capitation payments using prior hospitalization data.
Ash, Arlene S
Date of Pub
Beiser, Alexa; Gruenberg, Leonard; Porell, Frank W; Sawitz, Eric
The diagnostic cost group approach to a reimbursement model for health maintenance organizations is presented. Diagnostic
information about previous hospitalizations is used to create empirically determined risk groups, using only diagnoses involving
little or no discretion in the decision to hospitalize. Diagnostic cost group and other models (including Medicare's current
formula and other prior-use models) are tested for their ability to predict future costs, using R2 values and new measures
of predictive performance. The diagnostic cost group models perform relatively well with respect to a range of criteria, including
administrative feasibility, resistance to provider manipulation, and statistical accuracy.
Capitation Fee : Fees and Charges : Models, Theoretical : Costs and Cost Analysis/trends : Data Collection : Diagnosis-Related
Groups/economics : Fee Schedules : Health Maintenance Organizations/economics : Hospitalization/economics : Medicare/organization
& administration : Probability : Reimbursement Mechanisms : Support, U.S. Gov't, Non-P.H.S. : United States