Risk Adjusters

Evaluating Alternative Risk Adjusters for Medicare

In this study the authors use 3 years of the Medicare Current Beneficiary Survey (MCBS) to evaluate alternative demographic, survey, and claims-based risk adjusters for Medicare capitation payment. The survey health-status models have three to four times the predictive power of the demographic models. The risk-adjustment model derived from claims diagnoses has 75-percent greater predictive powe...

Rate adjusters for Medicare under capitation

This article addresses three issues related to capitation. First, the average adjusted per capita cost (AAPCC) fluctuates with the mix of risks in the fee-for-service system. More sensitive adjusters in the AAPCC are needed. Second, the AAPCC, as now estimated, exhibits large geographic variance; so-called shrinkage estimators may help. Third, the AAPCC requires new adjusters to yield more homo...

Setting health plan premiums to ensure efficient quality in health care: minimum variance optimal risk adjustment

Risk adjustment refers to the practice of paying health plans a premium per person (or per family) based on a formula using risk adjusters, such as age or gender, and weights on those adjusters. One role of risk adjustment is to make sure plans have an incentive to accept all potential enrollees. Another role, at least as important in our view, is to lead health plans to choose the efficient le...

Medicaid risk adjustment model with diagnosis and pharmacy-based adjusters: Does it work?

Using chronic disease risk factors to adjust Medicare capitation payments

This study evaluates the use of risk factors for chronic disease as health status adjusters for Medicare's capitation formula, the average adjusted per capita costs (AAPCC). Risk factor data for the surviving members of the Framingham Study cohort who were examined in 1982-83 were merged with 100 percent Medicare payment data for 1984 and 1985, matching on Social Security number and sex. Seven ...