CH 12 (Risk Adjustment) Flashcards
State the rationale for risk adjustment. [1.25]
The underlying risk profile of a population✓ affects the frequency of healthcare utilization✓, as well as the associated cost.✓
Risk adjustment is necessary to compare healthcare costs and outcomes on a like-for-like basis.✓✓
Suggest possible risk-adjustment factors.
[4]
Demographic factors✓
* Age✓
* Gender✓
* Race and ethnicity✓
Acute Clinical Stability✓
Principal Diagnosis✓
Co-morbidities✓, often these are chronic conditions✓.
Functional status✓, e.g observable basic ADLs and instrumental ADLs✓
SEC status✓
* Educational Attainment
* Employment and Occupation
* Diet and Nutrition
* Housing ✓✓
Lifestyle factors✓
* Tobacco Use
* Alcohol Use
* Use of illicit drugs
* Sexual Practices
* Obesity ✓✓✓
Health Insurance Coverage✓
Urban/Rural Split✓
Supply side factors✓
* Number of hospital beds
* Number of clinics
* Specialist facilities ✓✓
Health-related behaviours and activities✓
Outline the applications of risk adjustment. [3]
- Budgeting✓, e.g. funding may be distributed by DRG✓
- Measuring efficiency✓, useful for price negotiations, network selection or insurance plans and managing facilities.✓✓✓✓
- Risk management✓, if budgets are exceeded it is important to understand whether it is due to supply or demand factors.✓✓
- Measuring healthcare outcomes✓, e.g. readmission rates or patient satisfaction scores✓✓
- Provider profiling✓, sharing info between doctors on a risk-adjusted basis increases awareness of the econ impact of clinical decisions.✓✓
Provide two examples of instrumental ADLs. [0.5]
- Shopping
- Cooking
- Using transportation
Give an example of two independent chronic conditions that might exist simultaneously. [0.5]
A person suffering from a heart condition who also has diabetes.✓✓
Describe how socio-economic status can affect healthcare outcomes. [1.25]
Poor living standards and nutrition contribute to morbidity risk.
At the same time, doctors may keep patients of a lower socio-economic status in hospital longer than a typical patient if they believe that their home environment is not conducive to recuperation.
Numerous studies have established that it is important to adjust for socio-economic status when comparing healthcare outcomes.
Define the term “risk adjustment. [ ]
Risk adjustment refers to adjusting for underlying factors, which are drivers of utilisation, or which impact the underlying morbidity, when evaluating utilisation levels and/or cost. Under alternative reimbursement arrangements, a risk-adjustment mechanism should be used to ensure that providers are remunerated appropriately for the health risk of their patients.
Define the term “risk adjustment. [ ]
Risk adjustment refers to adjusting for underlying factors, which are drivers of utilisation, or which impact the underlying morbidity, when evaluating utilisation levels and/or cost. Under alternative reimbursement arrangements, a risk-adjustment mechanism should be used to ensure that providers are remunerated appropriately for the health risk of their patients.
RA methods
Simple empirical risk adjustment or statistical modelling may be applied to risk-adjusted data, or
data may be risk adjusted using off-the-shelf software.
DRG
DRGs are common clinical classification systems used to risk-adjust hospital costs. [ ]
One of the main uses
Measuring efficency
Comparing facility efficiency
Comparing facility efficiency is useful for: l Price negotiations for purchasers and suppliers of healthcare l Network selection for insurance plans l Managing facilities efficiently.
l
Comparing facility efficiency
Comparing facility efficiency is useful for: l Price negotiations for purchasers and suppliers of healthcare l Network selection for insurance plans l Managing facilities efficiently.
l
HC Outcomes
, cardiac catheterisation mortality rate, pneumonia re-admission rate, or patient satisfaction scores
