ASSESSING THE PERFORMANCE OF ALTERNATIVE RISK ADJUSTERS

对风险调整的担忧阻碍了评估护理质量和为保健计划和提供者建立公平的补偿水平的努力。对于质量评估和确定付款，风险调整旨在抵消避免病人和残疾人的激励措施。尽管存在重要的方法问题，1997年的平衡预算法案要求联邦医疗保险在1/1/00之前对首字母付款进行风险调整；总统的消费者保护和质量咨询委员会呼吁改善风险调整。本项目将审查付款和业绩衡量的风险调整方法。这项研究将审查支付和业绩衡量的风险调整方法。这项研究将包括两个部分：(1)统计分析；(2)案例研究，以了解利益相关者的观点和风险调整在医疗保健市场中的作用。统计分析将审查主要的风险调整方法：非卧床护理小组(ACGs)、临床详细费用风险信息系统(CD-RISC)、诊断费用组分级条件类别(DCG-HCC)和残疾支付系统(DPS)。我们将使用三个数据集：(1)由马萨诸塞州东部的三家大型保险公司提交的风险合同的登记和遭遇记录“(即，大写字母)，用于两个大型、集成的医疗卡式交付系统，CareGroup and Partners Healthcare System(超过500,000个承保生命)；(2)对于在附属学术医疗中心接受初级保健的人，这些行政记录辅以来自电子报告系统的临床信息(例如，实验室、药房、计算机化的医疗记录)；以及(3)来自四个州的医疗补助索赔和遭遇记录。我们将对卫生系统变化研究中心目前正在密切跟踪的全国12个市场的当前使用情况和利益相关者对风险调整的看法进行案例研究。该项目的成果将是关于风险调整员的方法建议，关于评估其业绩的统计方法的指导，关于数据要求的建议，以及关于与不同利益攸关方解决风险调整并将其落实到实际应用中的进展。

Concerns about risk adjustment impede efforts to evaluate quality of care and establish fair reimbursement levels for health plans and providers. For quality assessment and setting payments, risk adjustment aims to counteract incentives to avoid sick and disabled persons. Despite important methodological questions, the 1997 Balanced Budget Act requires Medicare to risk adjust capitated payments by 1/1/00; the President's Advisory Commission on Consumer Protection and Quality has called for improving risk adjustment. This project will examine risk adjustment methodologies for both payment and performance measurement. This study will examine risk adjustment methodologies for both payment and performance measurement. This study will involve two components: (1) statistical analyses; and (2) case studies to understand the views of stakeholders and role of risk adjustment in the health care marketplace. The statistical analyses will examine the leading risk adjustment methodologies: Ambulatory Care Groups (ACGs); the Clinically Detailed Risk Information System for Cost (CD-RISC); the Diagnostic Cost Groups Hierarchical Condition Categories (DCG-HCC); and the Disability Payment System (DPS). We shall use three data sets: (1) enrollment and encounter records submitted for risk contracts" (i.e., capitated) by three large insurers in eastern Massachusetts for two large, integrated health carte delivery systems, CareGroup and Partners HealthCare System (over 500,000 covered lives); (2) for person receiving primary care at affiliated academic medical centers, these administrative records supplemented with clinical information from electronic reporting systems (e.g., laboratory, pharmacy, computerized medical records); and (3) Medicaid claims and encounter records from four states. We shall conduct case studies about current uses and stakeholders' views of risk adjustment at 12 markets nationwide that are current being intensively tracked by the Center for the Study of Health Systems Change. The project's outcome will be methodological recommendations about risk adjustors, guidance about statistical approaches for evaluating their performance, suggestions about data requirements, and advance about addressing risk adjustment with various stakeholders' and implementing it for practical applications.