Diagnosis-based risk adjustment for Medicare capitation payments.
Ellis, Randall P
Date of Pub
Ash, Arlene S; Ayanian, John Z; Bates, David W; Burstin, Helen; Iezzoni, Lisa I; Pope, Gregory C
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.
Capitation Fee : Aged : Diagnosis-Related Groups/economics : Disability Evaluation : Disabled Persons/classification : Female
: Health Care Costs : Health Maintenance Organizations/classification/economics : Human : Male : Medicaid/classification/economics
: Medicare/classification/organization & administration : Models, Economic : Rate Setting and Review/methods : Regression
Analysis : Risk Management : Support, U.S. Gov't, Non-P.H.S. : United States