ASSESSING THE PERFORMANCE OF ALTERNATIVE RISK ADJUSTERS

对风险调整的关切妨碍了评估保健质量和为保健计划和提供者确定公平的报销水平的努力。对于质量评估和付款设定，风险调整旨在抵消避免生病和残疾人的激励。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2010年1月1日之前对资本支付进行风险调整；消费者保护和质量总统咨询委员会呼吁改善风险调整。该项目将审查支付和绩效衡量的风险调整方法。本研究将探讨支付和绩效评估的风险调整方法。本研究将包括两个组成部分：(1)统计分析；(2)案例分析，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。统计分析将检查主要的风险调整方法：门诊护理组（acg）；临床详细成本风险信息系统（CD-RISC）；诊断费用组分级条件分类（DCG-HCC）；以及残疾补助制度（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为两个大型综合医疗服务系统，CareGroup和Partners HealthCare System（覆盖超过50万人）提交的“风险合同”（即资本）登记和遭遇记录；(2)对于在附属学术医疗中心接受初级保健的人，这些行政记录补充了来自电子报告系统的临床信息（例如，实验室、药房、计算机医疗记录）；(3)来自四个州的医疗补助索赔和遭遇记录。我们将对全国12个市场的当前用途和利益相关者对风险调整的看法进行案例研究，这些市场目前正由卫生系统变革研究中心集中跟踪。该项目的成果将是关于风险调整者的方法学建议，关于评估其绩效的统计方法的指导，关于数据需求的建议，以及关于与各利益相关者解决风险调整问题并将其实施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.