10. Risk Adjustment Flashcards
Health outcomes are expected to vary between
CASH’D
- Clinical factors
- Attitudes and perceptions
- Socio-economic factors
- Health-related factors and activities
- Demographic characteristics (age, gender, race and ethnicity)
Examples of clinical factors by which health outcomes are expected to vary
- acute clinical stability
- principal diagnosis (severity)
- co-morbidities
- cognitive status
mental health
Examples of attitudes and perceptions by which health outcomes are expected to vary
- overall health status and quality of life
- religious beliefs and behaviour
- references and expectations for healthcare services
Examples of socio-economic factors by which health outcomes are expected to vary
- familial characteristics
- household composition
- education
- health literacy
- economic resources
- employment and occupation
- health insurance coverage
- cultural beliefs and behaviours
Examples of health-related factors and activities by which health outcomes are expected to vary
- tobacco use
- alcohol use
- use of illicit drugs
- sexual practices (“safe sex”)
- diet and nutrition
- obesity
Examples of demographic characteristics by which health outcomes are expected to vary
- age
- gender
- race and ethnicity
Diagnosis-related Groups (DRGs)
Common classification systems used to risk-adjust hospital costs
Many countries distribute budgets according to underlying demand of patients measured by DRGs
Purposes for which risk adjustment can be used (BL)
RA PREM
Risk management
Allocating budget (by the State to determine appropriate allocation of funds to segments of the population)
Provider profile/ Pricing and reserving (for PMI insurers who need to allow for variations in covered policyholders
Reporting on costs, outcomes, and future plans
Efficiency measurement for applications to: network selection, managing facilities, price negotiations
Measuring healthcare outcomes (quality)
