Clinical Risk Groups (CRGs) - A classification system for risk-adjusted capitation-based payment and health care management
Clinical Risk Groups (CRGs) - A classification system for risk-adjusted capitation-based payment and health care management
复制标题
DOI：
10.1097/01.mlr.0000102367.93252.70
复制
发表时间：
2004-01-01
期刊：
影响因子：
3
通讯作者：
Gay, JC
中科院分区：
文献类型：
--
作者：
Hughes, JS;Averill, RF;Gay, JC
目的：开发临床风险组(CRGs)，这是一种基于索赔的风险调整分类系统，它根据历史临床和人口学特征将每个人分配到一个相互排斥的风险组，以预测未来医疗资源的使用。研究设计/数据来源：我们通过广泛的临床假设生成的高度迭代过程，然后使用基于索赔的计算机化数据库进行评估和验证，其中包含来自三个来源的住院和门诊信息：1991-1994年5%的联邦医疗保险参保人样本，同一时期的私人参保人口，以及具有2年数据的医疗补助人群。结果：我们创建了一个具有269个等级的系统，基于慢性病和慢性病组合的相互排斥的基本风险组(基本CRG)。我们根据疾病的严重程度细分基本CRG，得出总共1075组。我们评估了使用R-2计算的完整CRG模型的预测性能，在没有调整预测年死亡人员的预测付款的情况下，对于Medicare验证数据集，得到的值为11.88，在死亡调整后的值为10.88。同时分析，使用同一年的诊断信息作为支出，得出1994年的R-2为42.75。结论：CRGs的表现与其他风险调整系统相当。CRG有可能为支持护理路径和病例管理的大写支付系统和管理系统提供风险调整。
Objective: To develop Clinical Risk Groups (CRGs), a claims-based classification system for risk adjustment that assigns each individual to a single mutually exclusive risk group based on historical clinical and demographic characteristics to predict future use of healthcare resources.Study Design/Data Sources: We developed CRGs through a highly iterative process of extensive clinical hypothesis generation followed by evaluation and verification with computerized claims-based databases containing inpatient and ambulatory information from 3 sources: a 5% sample of Medicare enrollees for years 1991-1994, a privately insured population enrolled during the same time period, and a Medicaid population with 2 years of data.Results: We created a system of 269 hierarchically ranked, mutually exclusive base-risk groups (Base CRGs) based on the presence of chronic diseases and combinations of chronic diseases. We subdivided Base CRGs by levels of severity of illness to yield a total of 1075 groups. We evaluated the predictive performance of the full CRG model with R-2 calculations and obtained values of 11.88 for a Medicare validation data set without adjusting predicted payments for persons who died in the prediction year, and 10.88 with a death adjustment. A concurrent analysis, using diagnostic information from the same year as expenditures, yielded an R-2 of 42.75 for 1994.Conclusion: CRGs performance is comparable to other risk adjustment systems. CRGs have the potential to provide risk adjustment for capitated payment systems and management systems that support care pathways and case management.