Articlegreen1989

Adjusting Medicare capitation payments using prior hospitalization data.

Arlene S. Ash · Frank W. Porell · Leonard W. Gruenberg · Eric Sawitz · Alexa Beiser

189 citations0/0 files storedPubMed Central

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Healthcare Policy and Management Healthcare Systems and Reforms Medical Coding and Health Information

Abstract

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.

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1993Do health maintenance organizations work for Medicare?2005Predicting pharmacy costs and other medical costs using diagnoses and drug claims.1992How can we prevent cream skimming in a competitive health insurance market?1995Protecting Children With Chronic Illness in a Competitive Marketplace 1997The Effect of Increased Prescription Drug Cost-Sharing on Medical Care Utilization and Expenses of Elderly Health Maintenance Organization Members 1996Diagnostic risk adjustment for Medicaid: the disability payment system.1999How well does a single question about health predict the financial health of Medicare managed care plans?1997The impact of increasing patient prescription drug cost sharing on therapeutic classes of drugs received and on the health status of elderly HMO members.

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