The current state of risk adjustment technology for capitation

Journal of Ambulatory Care Management

Volumn 21, Issue 4, 1998, Pages 1-28

  Ingber, Melvin J ^a  

^a CENTERS FOR MEDICARE AND MEDICAID SERVICES   (United States)

Author keywords

Capitated payment; Health maintenance organizations; Managed care; Risk adjustment

Indexed keywords

CAPITATION FEE; DATA ANALYSIS; HEALTH MAINTENANCE ORGANIZATION; MANAGED CARE; MEDICAID; MEDICARE; PROSPECTIVE PAYMENT; REVIEW; RISK ASSESSMENT; RISK FACTOR; TREATMENT OUTCOME;

EID: 0031656788     PISSN: 01489917     EISSN: None     Source Type: Journal    
DOI: 10.1097/00004479-199810000-00002     Document Type: Review

References (29)

1. Anderson, G.F., Lupu, D., Powe, N., Horn, S., Antebi, S., Whittle, J., & Steinberg, E. (1989, December). Payment amounts for capitated systems (Prepared for the Health Care Financing Administration under Cooperative agreement number No. 17-C-98990). Baltimore: The Johns Hopkins University.
2. Anderson, G.F, Steinberg, E.P., Powe, N.R., Antebi, S., Whittle, J., Horn, S., & Herbert, R. (1990). Setting payment rates for capitated systems: A comparison of various alternatives. Inquiry, 27, 225-233.
3. Ash, A., Ellis, R., Yu, W., McKay, E., Iezzoni, I., Ayanian, J., Bates, D., Burstin, H., Byrne-Logan, S., & Pope, G. (1998). Risk adjustment for the non-elderly (Prepared for the Health Care Financing Administration under Cooperative Agreement 18-C-90462). Boston: Boston University.
4. Ash, A., Porell, F., Gruenberg, L., Sawitz, E., & Beiser, A. (1989). Adjusting Medicare capitation payments using prior hospitalization. Health Care Financing Review, 10(4), 17-29.
5. Beebe, J., Lubitz, J., & Eggers, P. (1985). Using prior utilization to determine payments for Medicare enrollees in health maintenance organizations. Health Care Financing Review, 6(2), 27-38.
6. Brown, R.S., Clement, D.G., Hill, J.W., Retchin, S.M., & Bergeron, J.W. (1993). Do health maintenance organizations work for Medicare? Health Care Financing Review, 15(1), 7-24.
7. Carter, G.M., Bell, R.M. Dubois, R.W., Goldberg, G.A., Keeler, E.B., McAlearny, J.S., Post, E.P., & Rumpel, J.D. (1997, September). "A Clinically Detailed Risk Information System for Cost," Contract number 500-92-0023. Prepared for the Health Care Financing Administration. RAND.
8. Dobson, A., Coleman, K., Weiner, J.P., Starfield, B., Anderson, G., Abrams, C., & Hu, Y. (1996, August). The development and testing of risk adjusters using Medicare inpatient and ambulatory data (Prepared for the Health Care Financing Administration under Contract No. 500-92-0021). Baltimore: The Lewin Group and Johns Hopkins University.
9. Dobson, A., Coleman, K., Weiner, J.P., Starfield, B., Anderson, G., Abrams, C., & Hu, Y. (1997, October). The development of a diagnosis-based risk adjustment system for setting capitation rates for under-65 populations (Prepared for the Health Care Financing Administration under Contract No. 500-92-0021). Baltimore: The Lewin Group and Johns Hopkins University.
10. Eggers, P. (1980). Risk differential between Medicare beneficiaries enrolled and not enrolled in an HMO. Health Care Financing Review, 1(3), 91-99.
11. Eggers, P., & Prihoda, R. (1982). Pre-enrollment reimbursement patterns of Medicare beneficiaries enrolled in "at-risk" HMOs. Health Care Financing Review, 4(1), 55-74.
12. Ellis, R.P., Pope, G.C., Iezzoni, L.I., Ayanian, J.Z., Bates, D.W., Burstin, H., & Ash, S. (1996). Diagnosis-based risk adjustment for Medicare capitation payments. Health Care Financing Review, 17(3), 101-128.
13. Ellis, R.P., Pope, G.C., Iezzoni, L.I., Ayanian, J.Z., Bates, D.W., Burstin, H., Dayhoff, D.A., Rensko, A., Dawes, T., & Ash, A.S. (1996, April). Diagnostic cost group (DCG) and hierarchical coexisting conditions (HCC) models for Medicare risk adjustment (Prepared for the Health Care Financing Administration under Contract No. 500-92-0020).
14. Fowles, J.B., Weiner, J.P., Knutson, D., Fowler, E., Tucker, A.M., & Ireland, M. (1996). Taking health status into account when setting capitation rates: A comparison of risk-adjustment methods. Journal of the American Medical Association, 276(16), 1316-1321.
15. Gruenberg, L., Kaganova, E., & Hornbrook, M. (1996). Improving the AAPCC with health status measures from the MCBS. Health Care Financing Review, 17(3), 59-75.
16. Hill, J.W., & Brown, R.S. (1990, September). Biased selection in the TEFRA HMO/CMP program (Prepared for the Health Care Financing Administration under Contract No. 500-88-0006). Mathematic Policy Research, Inc.
17. Hornbrook, M., & Goodman, M. (1995). Assessing relative health plan risk with the RAND-36 health survey. Inquiry, 32(1), 56-74.
18. Johns Hopkins University, Health Services Research and Development Center. (1997, January). The development and testing of an ACG-based risk-adjustment capitation methodology for the Maryland Medicaid 115-waiver managed care program (Contract final report. Prepared for the Center for Health Program Development and Management of the University of Maryland, Baltimore County).
19. Kronick, R., Dreufus, T., Lee, L., & Zhou, Z. (1996). Diagnostic risk adjustment for Medicaid: The disability payment system. Health Care Financing Review, 17(3), 7-33.
20. Lamers, L.M., & van Vliet, R.C. (1996). Multiyear diagnostic information from prior hospitalization as a risk adjuster for capitation payment. Medical Care, 34(6), 549-561.
21. Newhouse, J.P., Manning, W.G., Keeler, E.B, & Sloss, E.M. (1989). Adjusting capitation rates using objective health measures and prior utilization. Health Care Financing Review, 10(3), 41-54.
22. Pope, G.C., Adamache, K.W., Walsh, E.G., & Khandker, R.K. (1998). Evaluating Alternative Risk Adjusters for Medicare. (Prepared for the Health Care Financing Administration under cooperative agreement number 17-C-903161). Center for Health Economics Research, Waltham, MA.
23. Pope, G.C., Ellis, R.P., Liu, C.F., Ash, A.S., Iezzoni, L.I., Ayanian, J.Z., Bates, D.W., & Burstin, H. (1998, February). Revised diagnostic cost group (DCG)/Hierarchical coexisting condition (HCC) models for Medicare risk adjustment. (Prepared for the Health Care Financing Administration under Contract No. 500-95-048.) Health Economics Research, Waltham, MA.
24. Pope, G.C., Adamache, K.W., et al. (1997, November). Evaluating alternative risk adjusters for Medicare (Interim report. Prepared for the Health Care Financing Administration, Center for Health Economics Research, under Grant 17-C-90316).
25. Riley, G., Tudor, C., Chiang, Y.P., & Ingber, M.J. (1996). Health status of Medicare enrollees in HMOs and fee-for-service in 1994. Health Care Financing Review, 17(4), 65-76.
26. Shewry, S., Hunt, S., Ramey, J., & Bertko, J. (1996). Risk adjustment: The missing piece of market competition. Health Affairs, 15(1), 171-181.
27. van Vliet, R.C., & van de Ven, W.P. (1993). Capitation payments based on prior hospitalizations. Economics and Health Economics, 2(2), 177-188.
28. Weiner, J.P., Dobson, A., Maxwell, S.L., Coleman, K., Starfield, B.H., & Anderson, G.F. (1996). Risk-adjusted capitation rates using ambulatory and inpatient diagnoses. Health Care Financing Review, 17(3), 77-100.
29. Weiner, J.P., Starfield, B.H., Steinwachs, D.M., & Mumford, L.M. (1991). Development and application of a population-oriented measure of ambulatory case mix. Medical Care, 19(5), 452-472.