
A Review on Methods of Risk Adjustment and their Use in Integrated Healthcare Systems
References
- Behrend C Buchner F Happich M Holle R Reitmeir P Wasem J Risk-adjusted capitation payments: how well do principal inpatient diagnosis-based models work in the German situation? Results from a large data set The European Journal of Health Economics 2007 8 1 31 39 10.1007/s10198-006-0004-7
- Reschke P Sehlen S Methoden der Morbiditätsadjustierung 2005 Gesundheits-und Sozialpolitik 10 9
- Bauhoff S Do Health Plans Risk-Select? An Audit Study on Germany’s Social Health Insurance IRB 2010 17130 101
- Gaskins M Busse R Morbidity-based risk adjustment in Germany 2009 Eurohealth 15 3 29
- Göpffarth D Reforming Germany’s risk structure equalization scheme—taking stock at the halfway point Journal of Public Health 2005 13 5 248 256 10.1007/s10389-005-0121-2
- Greiner W Options for a future risc structure compensation in Germany Gesundheitswesen 2006 68 7 442 8 10.1055/s-2006-926889
- Antioch K Walsh M Risk-adjusted capitation funding models for chronic disease in Australia: alternatives to casemix funding The European Journal of Health Economics 2002 3 2 83 93 10.1007/s10198-002-0096-7
- Antioch KM Walsh MK The risk-adjusted vision beyond casemix (DRG) funding in Australia The European Journal of Health Economics 2004 5 2 95 109 10.1007/s10198-003-0208-z
- Donato R Richardson J Diagnosis-based risk adjustment and Australian health system policy Aust Health Rev 2006 30 1 83 99
- Duckett S Agius P Performance of diagnosis-based risk adjustment measures in a population of sick Australians Aust N Z J Public Health 2002 26 6 500 507 10.1111/j.1467-842X.2002.tb00356.x
- Beck K Growing importance of capitation in Switzerland Health Care Manag Sci 2000 3 2 111 119 10.1023/A:1019081021645
- Holly A Gardiol L Eggli Y Yalcin T Ribeiro T Health-based Risk Adjustment in Switzerland: an exploration using medical information from prior hospitalisation 2003 Final report. Research financed by the Swiss National Fund
- Nagy B Brandtmüller Á Implementing Risk Adjusted Capitation Payments with Health Care Reforms in Hungary Journal of Economic Literature 2008 147 160 10.21845/comp/2008/2/8
- Bertko J Current and future use of risk adjustment in the USA Journal of Health Policy, Insurance and Management 2011 May 2011 1 135 138
- Brown J Duggan M Kuziemko I Woolston W How does Risk Selection Respond to Risk Adjustment? Evidence from the Medicare Advantage Program 2011 National Bureau of Economic Research 10.3386/w16977
- Brown J Duggan M Kuziemko I Woolston W Will risk-adjustment decrease health care costs? New evidence from the Medicare Advantage Program 2011b
- Ellis RP Pope GC Iezzoni L Ayanian JZ Bates DW Burstin H Ash AS Diagnosis-based risk adjustment for Medicare capitation payments Health Care Financ Rev 1997 17 3 101 28
- Feldman R Dowd B Wrobel M Risk selection and benefits in the Medicare+ Choice program Health Care Financ Rev 2003 25 1 23 36
- Gorman JK Medicare+ Choice risk adjustment: don’t leave money on the table Healthc Financ Manage 2001 55 8 45 8
- Kan H Does the Medicare Principal Inpatient Diagnostic Cost Group Model Adequately Adjust for Selection Bias? 2002 RAND Graduate School
- Pope GC Adamache KW Walsh EG Khandker RK Evaluating alternative risk adjusters for Medicare Health Care Financ Rev 1998 20 2 109 129
- Gilmer T Kronick R Fishman P Ganiats TG The Medicaid Rx model: pharmacy-based risk adjustment for public programs Med Care 2001 39 11 1188 10.1097/00005650-200111000-00006
- Kuhlthau K Ferris TG Davis RB Perrin JM Iezzoni LI Pharmacy-and diagnosis-based risk adjustment for children with Medicaid Med Care 2005 43 11 1155 10.1097/01.mlr.0000182551.87591.73
- Robst J Development of a Medicaid Behavioral Health Case-Mix Model Evaluation Review 2009 33 6 519 538 10.1177/0193841X09349420
- Welch WP Outpatient encounter data for risk adjustment: strategic issues for Medicare and Medicaid J Ambul Care Manage 2002 25 3 1 10.1097/00004479-200207000-00002
- Best WR Cowper DC The Ratio of Observed-to-Expected Mortality as a Quality of Care Indlcator in Non-Surgical VA Patients Med Care 1994 32 4 390 400 10.1097/00005650-199404000-00007
- Khuri SF Daley J Henderson W Hur K Demakis J Aust JB Chong V Fabri PJ Gibbs JO Grover F The Department of Veterans Affairs’ NSQIP: the first national, validated, outcome-based, risk-adjusted, and peer-controlled program for the measurement and enhancement of the quality of surgical care. National VA Surgical Quality Improvement Program Annals of surgery 1998 228 4 491 10.1097/00000658-199810000-00006
- Maciejewski ML Liu CF Derleth A McDonell M Anderson S Fihn SD The performance of administrative and self-reported measures for risk adjustment of Veterans Affairs expenditures Health Serv Res 2005 40 3 887 904 10.1111/j.1475-6773.2005.00390.x
- Pietz K Ashton CM McDonell M Wray NP Predicting healthcare costs in a population of veterans affairs beneficiaries using diagnosis-based risk adjustment and self-reported health status Med Care 2004 42 10 1027 35 10.1097/00005650-200410000-00012
- Rosen AK Loveland S Anderson JJ Rothendler JA Hankin CS Rakovski CC Moskowitz MA Berlowitz DR Evaluating diagnosis-based case-mix measures: how well do they apply to the VA population? Med Care 2001 39 7 692 704 10.1097/00005650-200107000-00006
- Sloan KL Sales AE Liu CF Fishman P Nichol P Suzuki NT Sharp ND Construction and characteristics of the RxRisk-V: a VA-adapted pharmacy-based case-mix instrument Med Care 2003 41 6 761 74 10.1097/01.MLR.0000064641.84967.B7
- Aguado A Guino E Mukherjee B Sicras A Serrat J Acedo M Ferro JJ Moreno V Variability in prescription drug expenditures explained by adjusted clinical groups (ACG) case-mix: a cross-sectional study of patient electronic records in primary care BMC Health Serv Res 2008 8 53 10.1186/1472-6963-8-53
- Calderon-Larranaga A Abrams C Poblador-Plou B Weiner JP Prados-Torres A Applying diagnosis and pharmacy-based risk models to predict pharmacy use in Aragon, Spain: the impact of a local calibration BMC Health Serv Res 2010 10 22 10.1186/1472-6963-10-22
- Carlsson L Borjesson U Edgren L Patient based ‘burden-of-illness’ in Swedish primary health care. Applying the Johns Hopkins ACG case-mix system in a retrospective study of electronic patient records Int J Health Plann Manage 2002 17 3 269 82 10.1002/hpm.674
- Engstrom SG Carlsson L Ostgren CJ Nilsson GH Borgquist LA The importance of comorbidity in analysing patient costs in Swedish primary care BMC Public Health 2006 6 36 10.1186/1471-2458-6-36
- Mohamed R Determination of Risk Factors for High-Cost Cases within DRG Systems of Selected European Countries 2009 Westfälischen Wilhelms-Universität Münster Universitätsklinikum Münster
- Ghali WA Rothwell DM Quan H Brant R Tu JV A Canadian comparison of data sources for coronary artery bypass surgery outcome “report cards” Am Heart J 2000 140 3 402 8 10.1067/mhj.2000.109222
- Reid RJ MacWilliam L Verhulst L Roos N Atkinson M Performance of the ACG case-mix system in two Canadian provinces Med Care 2001 39 1 86 99 10.1097/00005650-200101000-00010
- Sibley LM Moineddin R Agha MM Glazier RH Risk adjustment using administrative data-based and survey-derived methods for explaining physician utilization Med Care 2010 48 2 175 82 10.1097/MLR.0b013e3181c16102
- Lamers LM Risk-adjusted capitation payments: developing a diagnostic cost groups classification for the Dutch situation Health Policy 1998 45 1 15 32 10.1016/S0168-8510(98)00031-1
- Persaud D Narine L Cross-national comparison of capitation funding: the American, British and Dutch experience Health Serv Manage Res 1999 12 2 121 35
- Van de Ven WPMM Beck K Van de Voorde C Wasem J Zmora I Risk adjustment and risk selection in Europe: 6 years later Health Policy 2007 83 2–3 162 179 10.1016/j.healthpol.2006.12.004
- Van de Ven WPMM van Vliet RCJA Lamers LM Health-adjusted premium subsidies in the Netherlands Health Affairs 2004 23 3 45 55 10.1377/hlthaff.23.3.45
- Chang HY Lee WC Weiner JP Comparison of alternative risk adjustment measures for predictive modeling: high risk patient case finding using Taiwan’s National Health Insurance claims BMC Health Serv Res 2010 10 343 10.1186/1472-6963-10-343
- Chang HY Weiner JP An in-depth assessment of a diagnosis-based risk adjustment model based on national health insurance claims: the application of the Johns Hopkins Adjusted Clinical Group case-mix system in Taiwan BMC Med 2010 8 7 10.1186/1741-7015-8-7
- Chern JY Wan TT Begun JW A structural equation modeling approach to examining the predictive power of determinants of individuals’ health expenditures J Med Syst 2002 26 4 323 36 10.1023/A:1015868720789
- Lee WC Huang TP Explanatory ability of the ACG system regarding the utilization and expenditure of the national health insurance population in Taiwan—a 5-year analysis J Chin Med Assoc 2008 71 4 191 9 10.1016/S1726-4901(08)70103-5
- Cid Pedraza C Diagnoses-Based Risk Adjusted Capitation Payments for Improving Solidarity and Efficiency in the Chilean Health Care System: Evaluation and Comparison with a Demographic Model 2011 Fakultät für Wirtschaftswissenschaften: Universität Duisburg-Essen, Campus Essen
- Vargas V Wasem J Using selected diagnoses to improve the Chilean capitation formula 2002
- Shmueli A Messika D Zmora I Oberman B Health care costs during the last 12 months of life in Israel: estimation and implications for risk-adjustment International Journal of Health Care Finance and Economics 2010 10 3 257 273 10.1007/s10754-010-9080-4
- Yuen EJ Louis DZ Loreto PD Gonnella JS Modeling risk-adjusted capitation rates for Umbria, Italy The European Journal of Health Economics 2003 4 4 304 312 10.1007/s10198-003-0193-2
- Holly R Szczepaniak M The development of the private health insurance and medical services market in Poland in the years 2005–2010 Journal of Health Policy, Insurance and Management 2011 May 2011 1 111 121
- Salchev P Hristov N Georgieva L Possible approaches to benchmarking voluntary health insurance funds in Bulgaria Journal of Health Policy, Insurance and Management 2011 May 2011 1 101 111
- Erler A Beyer M Muth C Gerlach F Brennecke R Garbage in-Garbage out? Validität von Abrechnungsdiagnosen in hausärztlichen Praxen Garbage in-Garbage out? Validity of Coded Diagnoses from GP Claims Records Gesundheitswesen 2009 71 12 823 831 10.1055/s-0029-1214399
-
Reschke
P
Sehlen
S
Schiffhorst
G
Schräder
WF
Lauterbach
KW
Wasem
J
Klassifikationsmodelle für Versicherte im Risikostrukturausgleich Bundesministerium für Gesundheit und Soziale Sicherung, Referat Information, Publikation, Redaktion 2005 Bonn Institut für Gesundheits- und Sozialforschung (IGES) Berlin - Mühlbacher A Integrierte Versorgung: Risikoadjustierung 2006 Berlin ZiG Print 2006–05
- Kronick R Gilmer T Dreyfus T Lee L Improving health-based payment for Medicaid beneficiaries: CDPS Health Care Financ Rev 2000 21 3 29 64
- Trottmann M Weidacher A Leonhardt R Morbiditätsbezogene Ausgleichsfaktoren im Schweizer Risikoausgleich. Gutachten im Auftrag des Bundesamts für Gesundheit 2010
- Shanmugam G West M Berg G Additive and logistic EuroSCORE performance in high risk patients Interact Cardiovasc Thorac Surg 2005 4 4 299 303 10.1510/icvts.2004.104042
- Roques F Nashef S Michel P Gauducheau E De Vincentiis C Baudet E Cortina J David M Faichney A Gavrielle F Risk factors and outcome in European cardiac surgery: analysis of the EuroSCORE multinational database of 19030 patients European Journal of Cardio-Thoracic Surgery 1999 15 6 816 823 10.1016/S1010-7940(99)00106-2
- Mohr VD Bauer J Döbler K Eckert O Fischer B Woldenga C Qualität sichtbar machen. BQS-Qualitätsreport 2004 2005 Düsseldorf BQS Bundesgeschäftsstelle Qualitätssicherung gGmbH
- Schneeweiss S Sangha O Weiterentwicklung von Krankenhausbetriebsvergleichen: Wie wichtig ist Risiko-Adjustierung für den Krankenhausvergleich 2000 Berlin Springer Krankenhausbetriebsvergleiche
- Nashef S Roques F Michel P Gauducheau E Lemeshow S Salamon R European system for cardiac operative risk evaluation (EuroSCORE) European Journal of Cardio-Thoracic Surgery 1999 16 1 9 13 10.1016/S1010-7940(99)00134-7
- Mark DB Implications of cost in treatment selection for patients with coronary heart disease Ann Thorac Surg 1996 61 2 s12 s15 10.1016/0003-4975(95)01077-7
- Pope GC Ellis RP Ash AS Ayanian J Bates D Burstin H Iezzoni L Marcantonio E Wu B Diagnostic cost group hierarchical condition category models for Medicare risk adjustment 2000 December Final Report to Health Care Financing Administration
- Zhao Y Ellis RP Ash AS Calabrese D Ayanian JZ Slaughter JP Weyuker L Bowen B Measuring population health risks using inpatient diagnoses and outpatient pharmacy data Health Serv Res 2001 36 6 Pt 2 180 93
- Bundesrat Einbezug eines weiteren Morbiditätsfaktors in den Risikoausgleich. Bericht des Bundesrates in Erfüllung des Postulates 07.3769 der Kommission für soziale Sicherheit und Gesundheit des Ständerates vom 9 2007 November 2007
-
World Health Organization
The Anatomical Therapeutic Chemical Classification System with Defined Daily Doses (ATC/DDD)
Available from:
http://www.who.int/classifications/atcddd/en/ - Beck K Trottmann M Auswirkungen eines Hochrisikopools auf die Risikoselektion im Schweizer Krankenversicherungs-Wettbewerb: Eine empirische Klärung 2007 Luzern Schriften des CSS-Instituts für empirische Gesundheitsökonomie
- Clark DO Von Korff M Saunders K Baluch WM Simon GE A chronic disease score with empirically derived weights Med Care 1995 33 8 783 10.1097/00005650-199508000-00004
- Von Korff M Wagner EH Saunders K A chronic disease score from automated pharmacy data J Clin Epidemiol 1992 45 2 197 203 10.1016/0895-4356(92)90016-G
- Ash AS Ellis RP Pope GC Ayanian JZ Bates DW Burstin H Iezzoni LI MacKay E Yu W Using diagnoses to describe populations and predict costs Health Care Financing Review 2000 21 3 7 28
- Pope GC Ellis RP Ash AS Liu CF Ayanian JZ Bates DW Burstin H Iezzoni LI Ingber MJ Principal inpatient diagnostic cost group model for Medicare risk adjustment Health Care Financ Rev 2000 21 3 93 118
- Pope GC Kautter J Ellis RP Ash AS Ayanian JZ Ingber MJ Levy JM Robst J Risk adjustment of Medicare capitation payments using the CMS-HCC model 2004
- Fishman PA Goodman MJ Hornbrook MC Meenan RT Bachman DJ O’Keeffe Rosetti MC Risk adjustment using automated ambulatory pharmacy data: the RxRisk model Med Care 2003 41 1 84 99 10.1097/01.mlr.0000039830.19812.29
- Fishman PA Shay DK Development and estimation of a pediatric chronic disease score using automated pharmacy data Med Care 1999 37 9 874 83 10.1097/00005650-199909000-00004
- Lamers LM van Vliet RCJA van de Ven WPMM Risk-adjusted capitation payment systems for health insurance plans in a competitive market Expert Review of Pharmacoeconomics and Outcomes Research 2003 3 5 541 549 10.1586/14737167.3.5.541
- Lamers LM Vliet R Health-based risk adjustment Improving the pharmacy-based cost group The European Journal of Health Economics 2003 4 2 107 114 10.1007/s10198-002-0159-9
- Zhao Y Ash AS Ellis RP Ayanian JZ Pope GC Bowen B Weyuker L Predicting pharmacy costs and other medical costs using diagnoses and drug claims Med Care 2005 43 1 34
-
University of California
Medicaid Rx
Available from:
http://medicaidrx.ucsd.edu/ - Glaeske G Anpassung des Klassifikationsmodells RxGroups an die speziellen Voraussetzungen in der GKV 2005 Köln Bundesgesundheitsministerium, Editor
- Lamers LM Risk-adjusted capitation based on the Diagnostic Cost Group Model: an empirical evaluation with health survey information Health Serv Res 1999 33 6 1727 44
- Weiner JP Starfield BH Powe NR Stuart ME Steinwachs DM Ambulatory care practice variation within a Medicaid program Health Serv Res 1996 30 6 751 70
- Dubois MF Dubuc N Kröger E Girard R Hébert R Assessing comorbidity in older adults using prescription claims data Journal of Pharmaceutical Health Services Research
- Dubois RW Brook RH Rogers WH Adjusted hospital death rates: a potential screen for quality of medical care Am J Public Health 1987 77 9 1162 6 10.2105/AJPH.77.9.1162
- Kronick R Gilmer T Dreyfus T Ganiats T CDPS-Medicare: The chronic illness and disability payment system modified to predict expenditures for Medicare beneficiaries 2002 Final Report to CMS
- Kahn KL Rogers WH Rubenstein LV Sherwood MJ Reinisch EJ Keeler EB Draper D Kosecoff J Brook RH Measuring quality of care with explicit process criteria before and after implementation of the DRG-based prospective payment system JAMA: The Journal of the American Medical Association 1990 264 15 1969 10.1001/jama.1990.03450150069033
-
Eggli
Y
SQLape®
2012
Available from:
http://sqlape.com/index.htm (cited 2012 August, 8) - Meenan RT Goodman MJ Fishman PA Hornbrook MC O’Keeffe-Rosetti MC Bachman DJ Using risk-adjustment models to identify high-cost risks Med Care 2003 41 11 1301 12 10.1097/01.MLR.0000094480.13057.75
- Starfield B Weiner J Mumford L Steinwachs D Ambulatory care groups: a categorization of diagnoses for research and management Health Serv Res 1991 26 1 53
- Thomas JW Lichtenstein R Including health status in Medicare’s adjusted average per capita cost capitation formula Med Care 1986 259 275 10.1097/00005650-198603000-00008
- Orueta JF Lopez-De-Munain J Báez K Aiarzaguena J Aranguren JI Pedrero E Application of the Ambulatory Care Groups in the Primary Care of a European National Health Care System: Does It Work? Medical Care 1999 37 3 238 248 10.1097/00005650-199903000-00004
- Mühlbacher A Methoden der Risikoadjustierung: Herausforderungen und Alternativen Wirtschaftspolitische Blätter 2005 4 2005 540 548
- Ellis RP Risk adjustment in health care markets: Concepts and applications Financing Health Care 2008 177 222
- Beeuwkes Buntin M Garber AM McClellan M Newhouse JP The costs of decedents in the Medicare program: implications for payments to Medicare+ Choice plans Health Serv Res 2004 39 1 111 130 10.1111/j.1475-6773.2004.00218.x
- Rosen AK Loveland SA Anderson JJ Hankin CS Breckenridge JN Berlowitz DR Diagnostic cost groups (DCGs) and concurrent utilization among patients with substance abuse disorders Health Serv Res 2002 37 4 1079 103 10.1034/j.1600-0560.2002.67.x
- Robst J Levy JM Ingber MJ Diagnosis-based risk adjustment for medicare prescription drug plan payments Health Care Financ Rev 2007 28 4 15
- Barcley T Patterson K An Introduction to diagnosis-based Risk Adjusters. Research Report 1999 Milliman&Robertson
- Hughes JS Averill RF Eisenhandler J Goldfield NI Muldoon J Neff JM Gay JC Clinical Risk Groups (CRGs): a classification system for risk-adjusted capitation-based payment and health care management Med Care 2004 42 1 81 10.1097/01.mlr.0000102367.93252.70
- Kemka JM A new risk management paradigm for managed care Healthc Financ Manage 2000 54 6 41 3
- McClellan M McNeil BJ Newhouse JP Does More Intensive Treatment of Acute Myocardial Infarction in the Elderly Reduce Mortality? JAMA: The Journal of the American Medical Association 1994 272 11 859 10.1001/jama.1994.03520110039026
- Leiber S Greß S Heinemann S Explaining Different Paths in Social Health Insurance Countries–Health System Change and Cross-border Lesson-drawing between Germany, Austria and the Netherlands Social Policy & Administration 2015 49 1 88 108 10.1111/spol.12078
- Göpffarth D Bekanntmachung zum Gesundheitsfonds Nr. 1/2012 2011 Bonn Bundesversicherungsamt
- Bundesversicherungsamt So funktioniert der neue Risikostrukturausgleich im Gesundheitsfonds 2008 Berlin
- Konig T National health fund and morbidity-based risk structure equalization with focus on haemophilia Hamostaseologie 2010 30 Suppl 1 S70 5
- Mühlbacher A Integrierte Versorgung: Risikomanagement 2007 32 ZIG Print. 2007–03
- Amelung V Schumacher H Managed Care. Neue Wege im Gesundheitswesen 2004 Wiesbaden Gabler
- Fowles JB Weiner JP Knutson D Fowler E Tucker AM Ireland M Taking health status into account when setting capitation rates: a comparison of risk-adjustment methods JAMA 1996 276 16 1316 1321 10.1001/jama.1996.03540160038030
- Freund T Szecsenyi J Ose D Charakteristika von eingeschriebenen Versicherten eines flächendeckenden Vertrages zur hausarztzentrierten Versorgung Medizinische Klinik-Intensivmedizin und Notfallmedizin 2010 105 11 808 811 10.1007/s00063-010-1138-z
- Schone E Brown R Risk Adjustment: What is the Current State of the Art and how can it be Improved? 2013 Pinceton Robert Wood Johnson Foundation
DOI: https://doi.org/10.5334/ijic.2500 | Journal eISSN: 1568-4156
Language: English
Submitted on: Jun 28, 2016
Accepted on: Jun 28, 2016
Published on: Oct 26, 2016
Published by: Ubiquity Press
In partnership with: Paradigm Publishing Services
Publication frequency: 4 issues per year
Keywords:
© 2016 Christin Juhnke, Susanne Bethge, Axel C Mühlbacher, published by Ubiquity Press
This work is licensed under the Creative Commons Attribution 4.0 License.