Setting health care capitations through diagnosis-based risk adjustment: A suitable model for the English NHS?

Health Policy

Volumn 101, Issue 2, 2011, Pages 133-139

  Asthana, Sheena ^a   Gibson, Alex ^a  

^a UNIVERSITY OF PLYMOUTH   (United Kingdom)

Author keywords

Equity; Institutional context; NHS; Resource allocation; Risk adjustment

Indexed keywords

ARTICLE; COST BENEFIT ANALYSIS; HEALTH CARE CAPITATION; HEALTH CARE FINANCING; HEALTH CARE ORGANIZATION; HEALTH CARE POLICY; HEALTH CARE SYSTEM; HEALTH CARE UTILIZATION; HUMAN; MEDICAL FEE; PRIMARY MEDICAL CARE; RISK ASSESSMENT; TAX; UNITED STATES;

CAPITATION FEE; HEALTH SERVICES; HOSPITALS, PUBLIC; HUMANS; MODELS, ORGANIZATIONAL; RESOURCE ALLOCATION; RISK ADJUSTMENT; STATE MEDICINE;

EID: 79958008996     PISSN: 01688510     EISSN: 18726054     Source Type: Journal    
DOI: 10.1016/j.healthpol.2010.10.014     Document Type: Article

References (42)

1. Mays N. Geographical resource allocation in the English National Health Service, 1974-1994: the tension between normative and empirical approaches. International Journal of Epidemiology 1995, 24:S96-S102.
2. Asthana S., Gibson A., Moon G., Dicker J., Brigham P. The pursuit of equity in NHS resource allocation: should morbidity replace utilisation as the basis for setting health care capitations?. Social Science and Medicine 2004, 58:539-551.
3. Stone M., Galbraith J. How not to fund hospital and community health services in England. Journal of the Royal Statistical Society A 2006, 169:143-164.
4. Asthana S., Gibson A. Health care equity, health equity and resource allocation: towards a normative approach to achieving the core principles of the NHS. Radical Statistics 2008, 96:6-26.
5. Department of Health Equity and excellence: liberating the NHS (White Paper) 2010, The Stationery Office (Cm 7881), London.
6. Smith J., Wood J., Elias J. Beyond practice-based commissioning: the local clinical partnership 2009, The Nuffield Trust, London.
7. Department of Health Liberating the NHS: commissioning for patients. A consultation on proposals 2010, Department of Health, London.
8. Ham C. The coalition government's plans for the NHS in England. BMJ 2010, 341:3790.
9. The Nuffield Trust. The Coalition Government's NHS reforms: an assessment of the White Paper. London: The Nuffield Trust; 2010. http://www.nuffieldtrust.org.uk/members/download.aspx%3Ff=/ecomm/files/The_Coalition_Governments_NHS_Reforms.pdf.
10. Asthana S. Liberating the NHS? A Commentary on the Lansley White Paper, " Equity and Excellence" Social Science and Medicine (2010), doi:10.1016/j.socscimed.2010.10.020.
11. Winkelman R., Mehmud S. A comparative analysis of the claims based tools for health risk assessment 2007, Society of Actuaries, Schaumburg, IL.
12. Fowles J.B., Weiner J.P., Knutson D., Fowler E., Tucker A.M., Ireland M. Taking health status into account when setting capitation rates: a comparison of risk-adjustment methods. Journal of the American Medical Association 1996, 276:1316-1321.
13. Dixon-Woods M., Kirk D., Agarwal S., Annandale E., Arthur T., Harvey J., et al. Vulnerable groups and access to health care: a critical interpretive review 2005, NCCSDO, London.
14. Sutton M., Gravelle H., Morris S., Leyland A., Windmeijer F., Dibben C., et al. Allocation of resources to English areas; Individual and small area determinants of morbidity and use of healthcare resources. Report to the Department of Health 2002, Information and Statistics Division, Edinburgh.
15. Stone M. Supplementary evidence (Def07A). NHS deficits: first report of session 2006-07 2007, vol. II. The Stationery Office Limited, London, Ev 168-70.
16. Asthana S., Gibson A., Moon G., Dicker J., Brigham P. The demographic and social class basis of inequalities in morbidity: a comparison. Journal of Epidemiology and Community Health 2004, 58:303-307.
17. Seshamani M., Gray A.M. A longitudinal study of the effects of age and time to death on hospital costs. Journal of Health Economics 2004, 23:217-235.
18. Asthana S., Gibson A. Deprivation, demography and the distribution of general practice: challenging the conventional wisdom of inverse care. British Journal of General Practice 2008, 58:718-727.
19. Morris S, Carr-Hill R, Dixon P, Law M, Rice N, Sutton M, et al. Combining Age Related and Additional Needs (CARAN) Report: 2007 review of the needs formulae for hospital services and prescribing activity in England. Resource Allocation Research Papers 30. London: Department of Health; 2007. [accessed 07.06.10]. http://www.dh.gov.uk/en/Managingyourorganisation/Financeandplanning/Allocations/DH_4108515.
20. Asthana S., Gibson A. Funding implications for rural PCTs of the new NHS resource allocation methodology. All Party Parliamentary Group on Rural Services, the implications of national funding formulae for rural health and education provision, report, written and oral evidence 2010, House of Commons, London.
21. Hansard Written questions, 12 January: column 177W 2009, The Stationery Office, London.
22. PBRA Team Developing a person based resource allocation formula for allocations to general practices in England 2010, The Nuffield Trust, London.
23. Smith P.C. Resource allocation and purchasing in the health sector: the English experience. Bulletin of the World Health Organization 2008, 86:884-888.
24. Smith P.C. Formula funding of public services 2006, Routledge, London.
25. Smith P.C., Witter S.N. Risk pooling in health care financing: the implications for health system performance. Health, Nutrition and Population (HNP) discussion paper 2004, The World Bank, Washington.
26. Schokkaert E., Van de Voorde C. Risk selection and the specification of the conventional risk adjustment formula. Journal of Health Economics 2004, 23:1237-1259.
27. Pieter J.A., Stama P.J.A., van Vliet R.C.J.A., van de Ven W.P.M.M. A limited-sample benchmark approach to assess and improve the performance of risk equalization models. Journal of Health Economics 2010, 29:426-437.
28. Reid R., MacWilliam L., Roos N., Bogdanovic B., Black C. Measuring morbidity in populations: performance of the John Hopkins Adjusted Clinical Group (ACG) Case Mix Adjustment System in Manitoba 1999, Manitoba Centre for Health Policy and Evaluation, Department of Community Health Sciences, Faculty of Medicine, University of Manitoba, Manitoba.
29. Sheldon T.A., Carr-Hill R.A. Resource allocation by regression in the NHS: a statistical critique of the RAWP review. Journal of the Royal Statistical Society A 1992, 155:403-420.
30. Van de Ven W.P.M.M., Beck K., Van de Voorde C., Wasem J., Zmora I. Risk adjustment and risk selection in Europe: 6 years later. Health Policy 2007, 83:162-179.
31. Schokkaert E., Beck K., Shmueli A., van de Ven W., Van de Voorde C., Wasem J. Acceptable costs and risk adjustment: policy choices and ethical trade-offs 2006, Open access publications from Katholieke Universiteit Leuven urn:hdl:123456789/119264, Katholieke Universiteit Leuven.
32. Martin S, Rice N, Smith P. Risk and the GP budget holder. University of York: Centre for Health Economics; 1997. Discussion Paper 153. Available at http://www.york.ac.uk/inst/che/pdf/DP153.pdf.
33. Jones R. The actuarial basis for financial risk in practice-based commissioning and implications to managing budgets. Primary Health Care Research and Development 2009, 10:245-253.
34. Majeed A., Bindman A.B., Weiner J.P. Use of risk adjustment in setting budgets and measuring performance in primary care. II. Advantages, disadvantages, and practicalities. British Medical Journal 2001, 323:607-610.
35. Simborg D. DRG creep: a new hospital acquired disease?. New England Journal of Medicine 1981, 304:1602-1604.
36. Carter G.M., Newhouse J.P., Relles D.A. How much change in the case mix index is DRG creep?. Journal of Health Economics 1990, 9:411-428.
37. Silverman E., Skinner J. Medicare upcoding and hospital ownership. Journal of Health Economics 2004, 23:369-389.
38. Steinbusch P.J.M., Oostenbrink J.B., Zuurbier J.J., Schaepkens F.J.M. The risk of upcoding in casemix systems: a comparative study. Health Policy 2007, 81:289-299.
39. Serdén L., Lindqvist R., Rosén M. Have DRG-based prospective payment systems influenced the number of secondary diagnoses in health care administrative data?. Health Policy 2003, 65:101-107.
40. Department of Health Practice Based Commissioning: budget guidance for 2009/10: methodological changes and toolkit guide 2010, Department of Health, London, [Gateway Reference 11270].
41. Asthana S, Gibson A, Bailey T, Hewson P, Dibben C. Developing a person based resource allocation formula for setting practice-level mental health budgets: 2009/10 and 2010/11. Report to the Department of Health (Policy Research Programme). University of Plymouth; 2009.
42. Vallejo-Torres L., Morris S., Carr-Hill R., Dixon P., Law M., Rice N., et al. Can regional resource shares be based only on prevalence data? An empirical investigation of the proportionality assumption. Social Science & Medicine 2009, 69:1634-1642.