Risk Adjustment: The use of severity-of-illness measures, such as age, to estimate the risk (measurable or predictable chance of loss, injury or death) to which a patient is subject before receiving some health care intervention. This adjustment allows comparison of performance and quality across organizations, practitioners, and communities. (from JCAHO, Lexikon, 1994)Insurance Selection Bias: Adverse or favorable selection bias exhibited by insurers or enrollees resulting in disproportionate enrollment of certain groups of people.Capitation Fee: A method of payment for health services in which an individual or institutional provider is paid a fixed, per capita amount without regard to the actual number or nature of services provided to each patient.Competitive Medical Plans: Alternative health care delivery mechanisms, such as PREFERRED PROVIDER ORGANIZATIONS or other health insurance services or prepaid plans (other than HEALTH MAINTENANCE ORGANIZATIONS), that meet Medicare qualifications for a risk-sharing contract. (From Facts on File Dictionary of Health Care Management, 1988)Rate Setting and Review: A method of examining and setting levels of payments.Integrative Medicine: The discipline concerned with using the combination of conventional ALLOPATHIC MEDICINE and ALTERNATIVE MEDICINE to address the biological, psychological, social, and spiritual aspects of health and illness.Diagnosis-Related Groups: A system for classifying patient care by relating common characteristics such as diagnosis, treatment, and age to an expected consumption of hospital resources and length of stay. Its purpose is to provide a framework for specifying case mix and to reduce hospital costs and reimbursements and it forms the cornerstone of the prospective payment system.Hospital Mortality: A vital statistic measuring or recording the rate of death from any cause in hospitalized populations.Admitting Department, Hospital: Hospital department responsible for the flow of patients and the processing of admissions, discharges, transfers, and also most procedures to be carried out in the event of a patient's death.Centers for Medicare and Medicaid Services (U.S.): A component of the Department of Health and Human Services to oversee and direct the Medicare and Medicaid programs and related Federal medical care quality control staffs. Name was changed effective June 14, 2001.United StatesQuality Indicators, Health Care: Norms, criteria, standards, and other direct qualitative and quantitative measures used in determining the quality of health care.Outcome Assessment (Health Care): Research aimed at assessing the quality and effectiveness of health care as measured by the attainment of a specified end result or outcome. Measures include parameters such as improved health, lowered morbidity or mortality, and improvement of abnormal states (such as elevated blood pressure).Cost Allocation: The assignment, to each of several particular cost-centers, of an equitable proportion of the costs of activities that serve all of them. Cost-center usually refers to institutional departments or services.Managed Competition: A strategy for purchasing health care in a manner which will obtain maximum value for the price for the purchasers of the health care and the recipients. The concept was developed primarily by Alain Enthoven of Stanford University and promulgated by the Jackson Hole Group. The strategy depends on sponsors for groups of the population to be insured. The sponsor, in some cases a health alliance, acts as an intermediary between the group and competing provider groups (accountable health plans). The competition is price-based among annual premiums for a defined, standardized benefit package. (From Slee and Slee, Health Care Reform Terms, 1993)Health Expenditures: The amounts spent by individuals, groups, nations, or private or public organizations for total health care and/or its various components. These amounts may or may not be equivalent to the actual costs (HEALTH CARE COSTS) and may or may not be shared among the patient, insurers, and/or employers.Hospitals, Veterans: Hospitals providing medical care to veterans of wars.Social Adjustment: Adaptation of the person to the social environment. Adjustment may take place by adapting the self to the environment or by changing the environment. (From Campbell, Psychiatric Dictionary, 1996)Benchmarking: Method of measuring performance against established standards of best practice.Models, Statistical: Statistical formulations or analyses which, when applied to data and found to fit the data, are then used to verify the assumptions and parameters used in the analysis. Examples of statistical models are the linear model, binomial model, polynomial model, two-parameter model, etc.Medicare: Federal program, created by Public Law 89-97, Title XVIII-Health Insurance for the Aged, a 1965 amendment to the Social Security Act, that provides health insurance benefits to persons over the age of 65 and others eligible for Social Security benefits. It consists of two separate but coordinated programs: hospital insurance (MEDICARE PART A) and supplementary medical insurance (MEDICARE PART B). (Hospital Administration Terminology, AHA, 2d ed and A Discursive Dictionary of Health Care, US House of Representatives, 1976)Risk Factors: An aspect of personal behavior or lifestyle, environmental exposure, or inborn or inherited characteristic, which, on the basis of epidemiologic evidence, is known to be associated with a health-related condition considered important to prevent.International Classification of Diseases: A system of categories to which morbid entries are assigned according to established criteria. Included is the entire range of conditions in a manageable number of categories, grouped to facilitate mortality reporting. It is produced by the World Health Organization (From ICD-10, p1). The Clinical Modifications, produced by the UNITED STATES DEPT. OF HEALTH AND HUMAN SERVICES, are larger extensions used for morbidity and general epidemiological purposes, primarily in the U.S.National Health Insurance, United StatesHospitals: Institutions with an organized medical staff which provide medical care to patients.Insurance Claim Review: Review of claims by insurance companies to determine liability and amount of payment for various services. The review may also include determination of eligibility of the claimant or beneficiary or of the provider of the benefit; determination that the benefit is covered or not payable under another policy; or determination that the service was necessary and of reasonable cost and quality.Logistic Models: Statistical models which describe the relationship between a qualitative dependent variable (that is, one which can take only certain discrete values, such as the presence or absence of a disease) and an independent variable. A common application is in epidemiology for estimating an individual's risk (probability of a disease) as a function of a given risk factor.Risk Assessment: The qualitative or quantitative estimation of the likelihood of adverse effects that may result from exposure to specified health hazards or from the absence of beneficial influences. (Last, Dictionary of Epidemiology, 1988)Health Services Research: The integration of epidemiologic, sociological, economic, and other analytic sciences in the study of health services. Health services research is usually concerned with relationships between need, demand, supply, use, and outcome of health services. The aim of the research is evaluation, particularly in terms of structure, process, output, and outcome. (From Last, Dictionary of Epidemiology, 2d ed)ChileWashingtonFee-for-Service Plans: Method of charging whereby a physician or other practitioner bills for each encounter or service rendered. In addition to physicians, other health care professionals are reimbursed via this mechanism. Fee-for-service plans contrast with salary, per capita, and prepayment systems, where the payment does not change with the number of services actually used or if none are used. (From Discursive Dictionary of Health Care, 1976)Regression Analysis: Procedures for finding the mathematical function which best describes the relationship between a dependent variable and one or more independent variables. In linear regression (see LINEAR MODELS) the relationship is constrained to be a straight line and LEAST-SQUARES ANALYSIS is used to determine the best fit. In logistic regression (see LOGISTIC MODELS) the dependent variable is qualitative rather than continuously variable and LIKELIHOOD FUNCTIONS are used to find the best relationship. In multiple regression, the dependent variable is considered to depend on more than a single independent variable.Quality of Health Care: The levels of excellence which characterize the health service or health care provided based on accepted standards of quality.MichiganRetrospective Studies: Studies used to test etiologic hypotheses in which inferences about an exposure to putative causal factors are derived from data relating to characteristics of persons under study or to events or experiences in their past. The essential feature is that some of the persons under study have the disease or outcome of interest and their characteristics are compared with those of unaffected persons.Health Benefit Plans, Employee: Health insurance plans for employees, and generally including their dependents, usually on a cost-sharing basis with the employer paying a percentage of the premium.Insurance, Health: Insurance providing coverage of medical, surgical, or hospital care in general or for which there is no specific heading.Cohort Studies: Studies in which subsets of a defined population are identified. These groups may or may not be exposed to factors hypothesized to influence the probability of the occurrence of a particular disease or other outcome. Cohorts are defined populations which, as a whole, are followed in an attempt to determine distinguishing subgroup characteristics.Databases, Factual: Extensive collections, reputedly complete, of facts and data garnered from material of a specialized subject area and made available for analysis and application. The collection can be automated by various contemporary methods for retrieval. The concept should be differentiated from DATABASES, BIBLIOGRAPHIC which is restricted to collections of bibliographic references.Odds Ratio: The ratio of two odds. The exposure-odds ratio for case control data is the ratio of the odds in favor of exposure among cases to the odds in favor of exposure among noncases. The disease-odds ratio for a cohort or cross section is the ratio of the odds in favor of disease among the exposed to the odds in favor of disease among the unexposed. The prevalence-odds ratio refers to an odds ratio derived cross-sectionally from studies of prevalent cases.Cesarean Section: Extraction of the FETUS by means of abdominal HYSTEROTOMY.Cardiac Surgical Procedures: Surgery performed on the heart.Prospective Studies: Observation of a population for a sufficient number of persons over a sufficient number of years to generate incidence or mortality rates subsequent to the selection of the study group.Severity of Illness Index: Levels within a diagnostic group which are established by various measurement criteria applied to the seriousness of a patient's disorder.Multivariate Analysis: A set of techniques used when variation in several variables has to be studied simultaneously. In statistics, multivariate analysis is interpreted as any analytic method that allows simultaneous study of two or more dependent variables.Adjustment Disorders: Maladaptive reactions to identifiable psychosocial stressors occurring within a short time after onset of the stressor. They are manifested by either impairment in social or occupational functioning or by symptoms (depression, anxiety, etc.) that are in excess of a normal and expected reaction to the stressor.National Health Programs: Components of a national health care system which administer specific services, e.g., national health insurance.Comorbidity: The presence of co-existing or additional diseases with reference to an initial diagnosis or with reference to the index condition that is the subject of study. Comorbidity may affect the ability of affected individuals to function and also their survival; it may be used as a prognostic indicator for length of hospital stay, cost factors, and outcome or survival.Treatment Outcome: Evaluation undertaken to assess the results or consequences of management and procedures used in combating disease in order to determine the efficacy, effectiveness, safety, and practicability of these interventions in individual cases or series.CaliforniaAge Factors: Age as a constituent element or influence contributing to the production of a result. It may be applicable to the cause or the effect of a circumstance. It is used with human or animal concepts but should be differentiated from AGING, a physiological process, and TIME FACTORS which refers only to the passage of time.Length of Stay: The period of confinement of a patient to a hospital or other health facility.Quality Assurance, Health Care: Activities and programs intended to assure or improve the quality of care in either a defined medical setting or a program. The concept includes the assessment or evaluation of the quality of care; identification of problems or shortcomings in the delivery of care; designing activities to overcome these deficiencies; and follow-up monitoring to ensure effectiveness of corrective steps.Infant, Newborn: An infant during the first month after birth.Infant Mortality: Postnatal deaths from BIRTH to 365 days after birth in a given population. Postneonatal mortality represents deaths between 28 days and 365 days after birth (as defined by National Center for Health Statistics). Neonatal mortality represents deaths from birth to 27 days after birth.Health Status Indicators: The measurement of the health status for a given population using a variety of indices, including morbidity, mortality, and available health resources.Registries: The systems and processes involved in the establishment, support, management, and operation of registers, e.g., disease registers.Heart Defects, Congenital: Developmental abnormalities involving structures of the heart. These defects are present at birth but may be discovered later in life.Predictive Value of Tests: In screening and diagnostic tests, the probability that a person with a positive test is a true positive (i.e., has the disease), is referred to as the predictive value of a positive test; whereas, the predictive value of a negative test is the probability that the person with a negative test does not have the disease. Predictive value is related to the sensitivity and specificity of the test.Models, Theoretical: Theoretical representations that simulate the behavior or activity of systems, processes, or phenomena. They include the use of mathematical equations, computers, and other electronic equipment.Coronary Artery Bypass: Surgical therapy of ischemic coronary artery disease achieved by grafting a section of saphenous vein, internal mammary artery, or other substitute between the aorta and the obstructed coronary artery distal to the obstructive lesion.Reproducibility of Results: The statistical reproducibility of measurements (often in a clinical context), including the testing of instrumentation or techniques to obtain reproducible results. The concept includes reproducibility of physiological measurements, which may be used to develop rules to assess probability or prognosis, or response to a stimulus; reproducibility of occurrence of a condition; and reproducibility of experimental results.Time Factors: Elements of limited time intervals, contributing to particular results or situations.Hospitalization: The confinement of a patient in a hospital.Delivery of Health Care: The concept concerned with all aspects of providing and distributing health services to a patient population.

Risk-adjusted capitation based on the Diagnostic Cost Group Model: an empirical evaluation with health survey information. (1/409)

OBJECTIVE: To evaluate the predictive accuracy of the Diagnostic Cost Group (DCG) model using health survey information. DATA SOURCES/STUDY SETTING: Longitudinal data collected for a sample of members of a Dutch sickness fund. In the Netherlands the sickness funds provide compulsory health insurance coverage for the 60 percent of the population in the lowest income brackets. STUDY DESIGN: A demographic model and DCG capitation models are estimated by means of ordinary least squares, with an individual's annual healthcare expenditures in 1994 as the dependent variable. For subgroups based on health survey information, costs predicted by the models are compared with actual costs. Using stepwise regression procedures a subset of relevant survey variables that could improve the predictive accuracy of the three-year DCG model was identified. Capitation models were extended with these variables. DATA COLLECTION/EXTRACTION METHODS: For the empirical analysis, panel data of sickness fund members were used that contained demographic information, annual healthcare expenditures, and diagnostic information from hospitalizations for each member. In 1993, a mailed health survey was conducted among a random sample of 15,000 persons in the panel data set, with a 70 percent response rate. PRINCIPAL FINDINGS: The predictive accuracy of the demographic model improves when it is extended with diagnostic information from prior hospitalizations (DCGs). A subset of survey variables further improves the predictive accuracy of the DCG capitation models. The predictable profits and losses based on survey information for the DCG models are smaller than for the demographic model. Most persons with predictable losses based on health survey information were not hospitalized in the preceding year. CONCLUSIONS: The use of diagnostic information from prior hospitalizations is a promising option for improving the demographic capitation payment formula. This study suggests that diagnostic information from outpatient utilization is complementary to DCGs in predicting future costs.  (+info)

Dissociable deficits in the decision-making cognition of chronic amphetamine abusers, opiate abusers, patients with focal damage to prefrontal cortex, and tryptophan-depleted normal volunteers: evidence for monoaminergic mechanisms. (2/409)

We used a novel computerized decision-making task to compare the decision-making behavior of chronic amphetamine abusers, chronic opiate abusers, and patients with focal lesions of orbital prefrontal cortex (PFC) or dorsolateral/medial PFC. We also assessed the effects of reducing central 5-hydroxytryptamine (5-HT) activity using a tryptophan-depleting amino acid drink in normal volunteers. Chronic amphetamine abusers showed suboptimal decisions (correlated with years of abuse), and deliberated for significantly longer before making their choices. The opiate abusers exhibited only the second of these behavioral changes. Importantly, both sub-optimal choices and increased deliberation times were evident in the patients with damage to orbitofrontal PFC but not other sectors of PFC. Qualitatively, the performance of the subjects with lowered plasma tryptophan was similar to that associated with amphetamine abuse, consistent with recent reports of depleted 5-HT in the orbital regions of PFC of methamphetamine abusers. Overall, these data suggest that chronic amphetamine abusers show similar decision-making deficits to those seen after focal damage to orbitofrontal PFC. These deficits may reflect altered neuromodulation of the orbitofrontal PFC and interconnected limbic-striatal systems by both the ascending 5-HT and mesocortical dopamine (DA) projections.  (+info)

Evaluating and improving the delivery of heart care: the University of Michigan experience. (3/409)

With increasing pressure to curb escalating costs in medical care, there is particular emphasis on the delivery of cardiovascular services, which account for a substantial portion of the current healthcare dollar spent in the United States. A variety of tools were used to improve performance at the University of Michigan Health System, one of the oldest university-affiliated hospitals in the United States. The tools included initiatives to understand outcomes after coronary bypass operations and coronary angioplasty through use of proper risk-adjusted models. Critical pathways and guidelines were implemented to streamline care and improve quality in interventional cardiology, management of myocardial infarction, and preoperative assessment of patients undergoing vascular operations. Strategies to curb unnecessary costs included competitive bidding of vendors for expensive cardiac commodities, pharmacy cost reductions, and changes in nursing staff. Methods were instituted to improve guest services and partnerships with the community in disease prevention and health promotion.  (+info)

Health-based payment and computerized patient record systems. (4/409)

Health care information technology is changing rapidly and dramatically. A small but growing number of clinicians, especially those in staff and group model HMOs and hospital-affiliated practices, are automating their patient medical records in response to pressure to improve quality and reduce costs. Computerized patient record systems in HMOs track risks, diagnoses, patterns of care, and outcomes across large populations. These systems provide access to large amounts of clinical information; as a result, they are very useful for risk-adjusted or health-based payment. The next stage of evolution in health-based payment is to switch from fee-for-service (claims) to HMO technology in calculating risk coefficients. This will occur when HMOs accumulate data sets containing records on provider-defined disease episodes, with every service linked to its appropriate disease episode for millions of patients. Computerized patient record systems support clinically meaningful risk-assessment models and protect patients and medical groups from the effects of adverse selection. They also offer significant potential for improving quality of care.  (+info)

Risk-adjusted outcome models for public mental health outpatient programs. (5/409)

OBJECTIVE: To develop and test risk-adjustment outcome models in publicly funded mental health outpatient settings. We developed prospective risk models that used demographic and diagnostic variables; client-reported functioning, satisfaction, and quality of life; and case manager clinical ratings to predict subsequent client functional status, health-related quality of life, and satisfaction with services. DATA SOURCES/STUDY SETTING: Data collected from 289 adult clients at five- and ten-month intervals, from six community mental health agencies in Washington state located primarily in suburban and rural areas. Data sources included client self-report, case manager ratings, and management information system data. STUDY DESIGN: Model specifications were tested using prospective linear regression analyses. Models were validated in a separate sample and comparative agency performance examined. PRINCIPAL FINDINGS: Presence of severe diagnoses, substance abuse, client age, and baseline functional status and quality of life were predictive of mental health outcomes. Unadjusted versus risk-adjusted scores resulted in differently ranked agency performance. CONCLUSIONS: Risk-adjusted functional status and patient satisfaction outcome models can be developed for public mental health outpatient programs. Research is needed to improve the predictive accuracy of the outcome models developed in this study, and to develop techniques for use in applied settings. The finding that risk adjustment changes comparative agency performance has important consequences for quality monitoring and improvement. Issues in public mental health risk adjustment are discussed, including static versus dynamic risk models, utilization versus outcome models, choice and timing of measures, and access and quality improvement incentives.  (+info)

Anthem Blue Cross and Blue Shield's coronary services network: a managed care organization's approach to improving the quality of cardiac care for its members. (6/409)

OBJECTIVE: To describe a managed care organization's efforts to improve value for its members by forming a coronary services network (CSN). DESIGN: To identify high-quality facilities for its CSN, Anthem Blue Cross and Blue Shield reviewed claims data and clinical data from hospitals that met its general quality standards. An external firm measured and risk-adjusted applicant hospitals' mortality rates. Hospitals that demonstrated superior performance were eligible to join the CSN. In 1996, 2 years after the CSN was formed, clinical outcomes of participants and new applicants were analyzed again by the same external firm. PATIENTS AND METHODS: Data on more than 10,000 consecutive (all-payer) inpatients discharged after coronary bypass surgery in 1993 were collected from 16 applicant hospitals using a uniform format and data definitions. This analysis was expanded to 23 participating and applicant hospitals that discharged more than 13,000 patients who underwent either bypass surgery or coronary revascularization in 1995. We compared risk-adjusted routine length of stay (a measure of efficiency), mortality rates, and adverse outcome rates between CSN and non-CSN facilities. RESULTS: From 1993 to 1995, overall length of stay in the network decreased by 20%, from 12.3 to 9.8 days (P < or = 0.01) and severity-adjusted mortality rates decreased by 7.3%, from 2.9% to 2.7%. Initially, facilities outside the network had comparable efficiency but much higher mortality. However, they improved so much in both measures that their severity-adjusted mortality rate for bypass surgery in 1995 was no more than 10% higher than that of CSN hospitals. CONCLUSION: The creation of a statewide CSN that emphasized and improved the level of performance among providers ultimately benefited the carrier's managed care members. The desirability of participation was evidenced by an increase in the number of applicant hospitals over the 2 years. This may have stimulated quality improvement among competing providers in the region and among CSN facilities themselves.  (+info)

Comparing AMI mortality among hospitals in patients 65 years of age and older: evaluating methods of risk adjustment. (7/409)

BACKGROUND: Interest in the reporting of risk-adjusted outcomes for patients with acute myocardial infarction is growing. A useful risk-adjustment model must balance parsimony and ease of data collection with predictive ability. METHODS AND RESULTS: From our analysis of 82 359 patients >/=65 years of age admitted with acute myocardial infarction to 2401 hospitals, we derived a parsimonious model that predicts 30-day mortality. The model was validated on a similar group of 78 699 patients from 2386 hospitals. Of the 73 candidate predictor variables examined, 7 variables describing patient characteristics on arrival were selected for inclusion in the final model: age, cardiac arrest, anterior or lateral location of myocardial infarction, systolic blood pressure, white blood cell count, serum creatinine, and congestive heart failure. The area under the receiver-operating characteristic curve for the final model was 0.77 in the derivation cohort and 0.77 in the validation cohort. The rankings of hospitals by performance (in deciles) with this model were most similar to a comprehensive 27-variable model based on medical chart review and least similar to models based on administrative billing codes. CONCLUSIONS: A simple 7-variable risk model performs as well as more complex models in comparing hospital outcomes for acute myocardial infarction. Although there is a continuing need to improve methods of risk adjustment, our results provide a basis for hospitals to develop a simple approach to compare outcomes.  (+info)

Case mix adjustment in nursing systems research: the case of resident outcomes in nursing homes. (8/409)

Case mix indicates, for a resident population, the degree of risk for developing favorable or unfavorable outcomes. In a study of 164 nursing homes, we explored two methods for combining resident assessment data into a case mix index (CMI). We compared a facility-level, composite CMI to a prevalence-based CMI comprised of 22 separate resident characteristics for their adequacy in explaining resident outcomes. The prevalence-based CMI consistently explained more variance in outcomes than the facility level, composite CMI. This study indicates a reasonable method for using administrative databases containing resident assessment data to adjust for the influence of case mix on nursing home resident outcomes.  (+info)

  • Risk-adjusted expenditure and utilization outcomes for calendar year 2014 were reported in 102 adult and 56 pediatric primary-care comparative practice profiles. (biomedcentral.com)
  • It applied risk adjustment to populations attributed to patient-centered medical homes (283,153 adult patients and 78,162 pediatric patients) in the state of Vermont that are part of the Blueprint for Health program. (biomedcentral.com)
  • Results indicate that more comprehensive risk-adjustment models are effective for comparing cost, utilization, and quality measures across multi-payer populations. (biomedcentral.com)
  • The importance and influence of health status based risk adjustment methodologies are likely to increase as healthcare programs that currently use risk adjustment expand the populations they cover and other programs adopt the use of risk adjustment. (actuarialstandardsboard.org)
  • Diagnosis based methods for adjusting risk are becoming increasingly common within the US managed healthcare industry. (bmj.com)
  • This ASOP is intended to provide guidance regarding the appropriate use of health status based risk adjustment models and methods. (actuarialstandardsboard.org)
  • This standard requires actuaries to explicitly consider important characteristics of the risk adjustment models and their use, rather than allowing actuaries to assume important issues are already addressed within any given risk adjustment software model. (actuarialstandardsboard.org)
  • A high level definition of the RADV audit is Risk Adjustment data Validation, that requires us (Medicare Advantage Insurance Company) to validate a patients diagnosis that we submitted to CMS. (aapc.com)
  • Better still, the filing says that HHS "will now proceed with carrying out the risk adjustment program for the 2017 benefit year, including collecting charges and making payments. (theincidentaleconomist.com)
  • For 2020, CMS proposes phasing in the new model with a blend of 50% of the risk adjustment model first used for payment in 2017 and 50% of the new model proposed. (mondaq.com)
  • In this session we will dive into the differences of the systems, give a case study of how one health plan was able to reconcile and manage the evolution through 2017, and provide you with an approach that may impact the way your teams collaborate to address this change in the risk adjustment reporting process. (medicareriskrevenue.com)
  • Currently, risk adjustment is used to move dollars from low-risk payers to relatively high-risk payers based on the health condition/diagnosis of the patient. (analysts.com)
  • Just like that, primary care physician offices were limiting or stopping entirely all but COVID-19-related care, and health payers were telling clinicians not to conduct risk adjustment assessments in patient/member homes, to prevent the spread of the virus to other patients/members and to the clinicians themselves. (managedhealthcareexecutive.com)
  • However, given the disparities between the different populations served by Medicare, Medicaid, and commercial payers, risk-adjustment methods for addressing these differences in a single measure have been a challenge. (biomedcentral.com)
  • Important HCC risk adjustment documentation and coding topics are discussed from both the payers' and the providers' perspectives. (ahima.org)
  • HCCs stratify patient risk, allowing payers to predict the costs on which capitated payments are based, she explains. (kareo.com)
  • As Federal policy trims margin on financial payments to control cost, the Physician group and Hospital landscape continues to evolve making shared risk among payers a vital part of Network contracting. (medicareriskrevenue.com)
  • Risk assessment is key for risk adjustment and it depends mostly on the traditional parameters such as demographic data (age, sex, etc.) and insurance claims data (ICD codes, treatment codes, etc. (analysts.com)
  • Dynamic Healthcare Systems, a provider of enterprise technology solutions for government-regulated health plans, today rolled out its Risk Adjustment Management Program (RAMP), designed to assist health plans participating in Medicare, Medicaid and Exchange lines of business. (prweb.com)
  • Dynamic's RAMP, combined with technical expertise from its resident Subject Matter Experts (SMEs), provides a comprehensive program that supports a health plan's Risk Adjustment department. (prweb.com)
  • Dynamic deeply understands the challenges that government-regulated healthcare plans face," said Kathy Feeny, President and Chief Executive Officer of Dynamic Healthcare Systems, Inc. "Dynamic's RAMP provides health plans with much needed capacity and extended capabilities, as well as access to highly knowledgeable SMEs and detailed analytics to make their Risk Adjustment strategies more effective and efficient," Feeny added. (prweb.com)
  • Performance status of health care facilities changes with risk adjustment of HbA1c. (diabetesjournals.org)
  • This article, the first in a two-part series, focuses on risk adjustment and its affect on health plans and providers. (harvardpilgrim.org)
  • The program measures and compares the relative health status among health plans' membership by calculating average risk scores. (harvardpilgrim.org)
  • The aim is to balance risk among health plans, eliminating any incentive to select or avoid members based on health status. (harvardpilgrim.org)
  • Risk adjustment creates an opportunity for health plans and providers to review coding practices and identify and correct common coding gaps. (harvardpilgrim.org)
  • The Affordable Care Act (ACA) diversified risk adjustment to the individual and small group health insurance markets starting in 2014. (analysts.com)
  • The challenge with the prospective risk is it predicts based on the current year data and does not take the developing health conditions of the client into consideration. (analysts.com)
  • A Technical Advisory Group (TAG) meeting then was conducted with experts in home health care and risk-adjustment as well as policymakers and provider representatives. (hhs.gov)
  • In fact, the concept of "social determinants of health" (SDOH)-the idea that individual's social circumstances can affect their health-is being used in some states to augment existing health care risk-adjustment tools, which are often used in setting payment rates or calculating performance on quality measures. (shadac.org)
  • Risk adjustment ensures that health insurance plans have adequate funding to provide care to people who are likely to have high healthcare costs while at the same time preventing overcompensation for healthy patients. (icd10monitor.com)
  • Risk adjustment has been fundamental in reducing "cherry picking" among health plans by providing incentives to enroll high-cost individuals while at the same time ensuring that the necessary resources are available to provide efficient and effective treatment. (icd10monitor.com)
  • Today, healthcare risk adjustment is used across all major public programs offering health coverage in the U.S., including Medicare (Part C & D), state Medicaid-managed care programs, and commercial insurance for all plans in the individual and small group markets, operating both inside and outside health insurance exchanges. (icd10monitor.com)
  • In the 2013 In the November 2013 Software Release, CMS acted on their stated intention to gather information on enrollee health assessments or "health risk assessments" or HRAs. (scanhealthplan.com)
  • We hope this helps answer some questions about the Health Risk Assessment Flags. (scanhealthplan.com)
  • It has been posted on SCAN Health Plan : Full En. (scanhealthplan.com)
  • Inherited mental health risks, such as an increased risk of anxiety and depression . (medindia.net)
  • Risk Adjustment Analyst - Medicare Health Insurance. (simplyhired.com)
  • I) In applying the adjustment under clause (i) for health status to payment amounts, the Secretary shall ensure that such adjustment reflects changes in treatment and coding practices in the fee-for-service sector and reflects differences in coding patterns between Medicare Advantage plans and providers under part 1 A and B to the extent that the Secretary has identified such differences. (house.gov)
  • 1 Here, we explore a few of the more useful types of analytics your commercial health plan can leverage to monitor the performance of your ACA block and help you better keep (risk) score. (milliman.com)
  • The inherent volatility in year-over-year risk transfers, especially for smaller health plans, makes this practice unreliable. (milliman.com)
  • Risk adjustment in health insurance is at first glance, and second, among the driest and most arcane of subjects. (thehealthcareblog.com)
  • The market for individual health insurance has had major challenges both before and after the Affordable Care Act's (ACA's) risk adjustment program came along. (thehealthcareblog.com)
  • Director, Risk Adjustment - Managed Care Revenue - Growing Health Org! (monster.com)
  • A data analytics and performance management solution that combines 3M Health Information Systems' decades of coding and risk-adjustment experience with the data processing power of Verily, an Alphabet company. (3m.com)
  • Dawn Peterson, CPC is the director of risk adjustment revenue management for Health Alliance Medical Plans. (medicareriskrevenue.com)
  • Electronic health record problem lists: accurate enough for risk adjustment? (cdc.gov)
  • Health Affairs has released a new policy brief (www.healthaffairs.org) explaining how risk adjustment works and why it is needed. (aafp.org)
  • Luke's Health Partners (SLHP) has an exciting opportunity for a Manager of Risk Adjustment to join our team in Boise, Idaho! (simplyhired.com)
  • The use of risk adjustment has significant effects on health insurance companies, healthcare providers, consumers, employers and others. (actuarialstandardsboard.org)
  • Some nations that encourage private insurance for health care still seek to prevent insurers from engaging in risk minimizing actions to load the premiums of people with certain high-risk profiles, typically the elderly, the sick, and to some extent, women. (wikipedia.org)
  • In all countries that apply risk-adjusted premium subsidies in their health insurance market, the sponsor organizes it in the form of risk equalization among health insurers: the risk-adjusted premium subsidies for the insured are channelled to the insurers. (wikipedia.org)
  • See Health care in the Netherlands) Dutch insurers are not allowed to risk-rate their premiums. (wikipedia.org)
  • To achieve its aims, state and federal regulators must construct an effective system of risk adjustment or risk equalization that protects health insurers that attract a disproportionate share of patients with poor health risks and punishes those that cherry pick lower risk groups. (wikipedia.org)
  • Risk Adjustment in Competitive Health Plan Markets. (wikipedia.org)
  • Access to coverage for high-risks in a competitive individual health insurance market: via premium rate restrictions or risk-adjusted premium subsidies? (wikipedia.org)
  • Risk adjustment management within the Patient Protection and Affordable Care Act (ACA) framework not only focuses on developing and maintaining revenue-generating activities (e.g., coding accuracy and completeness initiatives, prospective member outreach, and data validation and auditing), but also dedicates sufficient time to measuring and reporting results. (milliman.com)
  • This brief explains three provisions of the Affordable Care Act (ACA) - risk adjustment, reinsurance, and risk corridors - that were intended to promote insurer competition on the basis of quality and value and promote insurance market stability, particularly in the early years of reform as the ACA marketplaces, also known as exchanges, were established. (kff.org)
  • In his view, the agency failed to explain why risk adjustment had to be budget neutral and why it therefore had to use a statewide average premium, instead of the insurer's own premiums, to calculate risk adjustment transfers. (theincidentaleconomist.com)
  • Risk equalization is a way of equalizing the risk profiles of insurance members to avoid loading premiums on the insured to some predetermined extent. (wikipedia.org)
  • Insurers would start to compete over how well they could discourage unhealthy people from signing up, and the whole point of risk adjustment is to stop that behavior. (theincidentaleconomist.com)
  • First of all, this paper makes a full sample study of the risk adjustment behavior of fund manager based on the fund's first-half performance by using the combination table analysis method and regression analysis method, and further studies the relationship between market state and fund manager's risk adjustment behavior. (scirp.org)
  • In the next section we review the economic tournament literature, especially focusing on the impact of performance ranking on risk adjusting behavior, and then motivate our testable hypotheses. (scirp.org)
  • A great deal of literature suggests that fund managers' risk-choice behavior is influenced by past performance rankings, but the findings are not consistent. (scirp.org)
  • Adjustment disorders affect how you feel and think about yourself and the world and may also affect your actions or behavior. (mayoclinic.org)
  • If you have concerns about your child's adjustment or behavior, talk with your child's pediatrician. (mayoclinic.org)
  • Lerman C, Kash K, Stefanek M: Younger women at increased risk for breast cancer: perceived risk, psychological well-being, and surveillance behavior. (cancer.gov)
  • The potential benefits of adjusting for a small number of possibly prognostic covariates in trials with moderate or large sample sizes far outweigh the risks of doing so, and so should also be considered. (biomedcentral.com)
  • For patients in whom the potential benefit of ORLAAM (levomethadyl acetate) treatment is felt to outweigh the risks of potentially serious arrhythmias, an ECG should be performed prior to treatment, 12-14 days after initiating treatment, and periodically thereafter, to rule out any alterations in the QT interval. (rxlist.com)
  • It is increasingly used in observational studies, and has already been used to compare c-section rates between hospitals that are homogenous regarding their " a priori " risk of cesarean delivery. (biomedcentral.com)
  • Below is a complete list of all variables included in the risk adjustment for acute care hospitals for each measure, starting with 2015 data. (medicare.gov)
  • They end in 2016, so their benefits and harms have essentially been delivered, unless Congress is willing to reverse course and fully fund the risk corridors before time runs out. (thehealthcareblog.com)
  • Upon completion, we hope to have instilled a deeper appreciation for tracking and managing risk and to have provided the foundations for introducing these initiatives within your organization. (milliman.com)
  • Tara Russo is the Vice President of Medicare Risk Adjustment, HEDIS Quality Initiatives, and Navigate Directorate for Island Doctors, a provider organization (MSO) headquartered in St. Augustine, Florida. (medicareriskrevenue.com)
  • Associations between levels of risks in the various domains and indicators of psychological (e.g., self-esteem, negative emotionality) and behavioral (e.g., substance use) adjustment differed for male and female respondents. (unl.edu)
  • In psychiatry , adjustment disorder (AD) is a classification of mental disorder that is a psychological response from an identifiable stressor or group of stressors that causes significant emotional or behavioral symptoms that does not meet criteria for more specific disorders. (thefullwiki.org)
  • Medicaid plans have been using risk adjustment modeling since 1996. (icd10monitor.com)
  • Each HCC is assigned a "weight" that impacts the patient risk score and determines payment. (slideshare.net)
  • Unfortunately, risk adjustment under the ACA has been an example of a well-meaning regulation that has had destructive impacts directly contrary to its intent. (thehealthcareblog.com)
  • This session will address the latest industry policies and the impacts that they are having on risk adjustment processes. (medicareriskrevenue.com)
  • In this paper we give an overview of the benefits and risks of covariate adjustment in RCTs, using examples from a previously published trial. (biomedcentral.com)
  • Payment to providers is based on the individual's risk adjustment score. (slideshare.net)
  • Coding gaps or incomplete coding can skew the risk score. (harvardpilgrim.org)
  • An electronic Simplified Acute Physiology Score-based risk adjustment score for critical illness in an integrated healthcare system. (nih.gov)
  • We sought to create an automated ICU risk adjustment score, based on the Simplified Acute Physiology Score 3, using only data available within the electronic medical record (Kaiser Permanente HealthConnect). (nih.gov)
  • The customized eSimplified Acute Physiology Score 3 shows good potential for providing automated risk adjustment in the intensive care unit. (nih.gov)
  • Acquiring an initial view of the risk score in June of the current benefit year strikes a good balance of allowing experience to mature without waiting too long, when a potential adjustment to internal processes or projections becomes difficult (or even impossible). (milliman.com)
  • The entity then converts the data into a risk score for each person in the plan, using that score to determine whether the enrollee is healthier or sicker than average and how much payment to the plan should be adjusted for that patient. (aafp.org)
  • During one of our reviews, it was identified that by improving the practitioner's documentation slightly, would have increased the HCC risk adjusted score. (revintsolutions.com)
  • The ACA had three measures to stabilize the exchanges and improve competition-reinsurance, risk corridors and risk adjustment. (thehealthcareblog.com)
  • Risk adjustment takes a close look at how ICD-9-CM documentation and coding contributes to the complexity level of the encounter, medical decision-making, and time spent with the patient. (aapc.com)
  • If stage 4, 5, or 6 (end-stage renal disease), physicians may receive an additional HCC and risk-adjusted reimbursement to reflect the anticipated resources necessary to care for a sicker patient, says Wymore. (kareo.com)
  • If your symptoms don't begin to improve after several weeks of treatments, chiropractic adjustment might not be the best option for you. (mayoclinic.org)
  • Preterm birth is associated with asthma-like symptoms in childhood and possibly in adolescence, but the longer-term risk of asthma is unknown and increasingly relevant as larger numbers of these individuals enter adulthood. (aappublications.org)
  • Signs and symptoms depend on the type of adjustment disorder and can vary from person to person. (mayoclinic.org)
  • Symptoms of an adjustment disorder start within three months of a stressful event and last no longer than 6 months after the end of the stressful event. (mayoclinic.org)
  • Symptoms of adjustment disorder get better because the stress has eased. (mayoclinic.org)
  • OBJECTIVE: To develop a risk adjustment method for HbA1c, based solely on administrative data and to determine the extent to which risk-adjusted HbA1c changes the identification of high- or low-performing medical facilities. (diabetesjournals.org)
  • Prospective risk predicts the financial benefits from high to low-cost plans through these groups. (analysts.com)
  • As prospective risk adjustment is mostly for the benefit of plans to accommodate high-risk members, predictions using the incomplete data will create gaps in the exchange of financials between insurance plans. (analysts.com)
  • Developmental risks and psychosocial adjustment among low-income Brazi" by Marcela Raffaelli, Silvia H. Koller et al. (unl.edu)
  • Exposure to developmental risks in three domains (community, economic, and family), and relations between risks and psychosocial well-being, were examined among 918 impoverished Brazilian youth aged 14-19 ( M = 15.8 years, 51.9% female) recruited in low-income neighborhoods in one city in Southern Brazil. (unl.edu)
  • This summary focuses primarily on the less severe end of this continuum: the normal adjustment issues, psychosocial distress,[ 5 ] the adjustment disorders, and cancer-related anxiety. (cancer.gov)
  • This is the first study with sufficient statistical power to evaluate the risk of asthma beyond adolescence in individuals who were born extremely preterm. (aappublications.org)
  • To our knowledge, this is the largest study to date of the association between preterm birth and the subsequent risk of asthma and the first study with sufficient statistical power to estimate this risk in young adults who were born extremely preterm. (aappublications.org)