Chapter 10: Risk Adjustment

Question 1

What is risk adjustment adjusting for?

Answer 1

The patient demand factors

Question 2

What are common demographic factors?

Answer 2

1. Age (old patients are expected to have worse clinical outcomes than the young)
2. Gender (women get pregnant, they get get breast cancer, men get prostate cancer)
3. Race and ethnicity

Question 3

What are some clinical RA factors

Answer 3

1. Acute physiologic stability (functioning of the body, assess a patients imminent risk of death)
2. Principal diagnosis (grouping into homogenous disease treatment groups)
3. Severity of principal diagnosis
4. Extent and severity of co=morbidities
5. Physical functional status (Activities of daily living)
6. Cognitive state
7. Mental health

Question 4

What are some health related behaviour and activities RA factors

Answer 4

1. Tobacco use
2. Alcohol use
3. Use of illicit drugs
4. Sexual practices
5. Diet and nutrition
6. Obesity and being overweight

Question 5

What are some socio-economic RA factors

Answer 5

1. Household composition
2. Education
3. Economic resources
4. Employment and occupation
5. Housing and neighbourhood characteristics (doctors may keep patients longer if they feel that their home conditions are not conducive for recuperation)
6. Health insurance coverage
7. Cultural beliefs and behaviours

Question 6

What are some uses of Risk Adjustment?

Answer 6

HERB P
* Budgeting
o State- gvt distributed money to hospitals according to their needs
o Pricing/reserving – expected healthcare costs of a new group of lives purchasing PMI
* Risk management
o Understanding bad experience and finding whether the source is demand or supply factors
* Provider profiling
* Health care outcomes measurement (Patient satisfaction score, readmission rates)
* Efficiency measurement (adjusting for patient case mix)
o Network selection
o Price negotiation
o Managing facilities efficiently