Pharmacy- and Diagnosis-Based Risk Adjustment for Children With Medicaid

BACKGROUND: Risk adjustment is useful for adjusting health care payments based on patients' health status. OBJECTIVE: This work seeks to examine how well pharmacy- and diagnosis-based risk adjusters predict child health expenditures in Medicaid populations. RESEARCH DESIGN: We used 1994-1995 Medicaid claims files for all children ages 0-18 years who were not covered by managed care in 3 states: Georgia, New Jersey, and Wisconsin. We examined separately 6 risk adjustment methods, 2 pharmacy-based and 4 diagnosis-based. We compared predictive accuracy of the methods for the whole sample and stratified by state and Medicaid enrollment category. FINDINGS: Models with risk adjustment (either diagnosis- or pharmacy-based) had better predictive accuracy than demographic models. The pharmacy and diagnosis-based models had similar predictive accuracy. Risk adjuster performance differed by Medicaid enrollment category and state. Risk-adjusted models generally underpredict expenditures in populations with worse health status (eg, those in the Supplemental Security Income program [SSI]). The pharmacy-based models performed well for children in SSI relative to children in foster care. CONCLUSIONS: Both pharmacy- and diagnosis-based risk adjustment improved the prediction of health expenditures compared models without risk adjustment. No single risk adjuster performed best in all situations, suggesting that optimal choices of risk adjusters may differ by purpose and context

Family medicine · Health care · Medicaid · MEDLINE · Health Systems, Economic Evaluations, Quality of Life · Healthcare Policy and Management · Medication Adherence and Compliance · Medicine · Pharmacy

• A Review on Methods of Risk Adjustment and their Use in Integrated Healthcare Systems

  Open Access•Christin Juhnke, Susanne Bethge et al.•International Journal of…•2016

  Añadir item

• A medication-estimated health status measure for predicting primary care visits

  Open Access•Abdullah Ahmed Dhabali, Rahmat Awang•Health Policy and Planning•2010

  Añadir item

• Improving Risk Equalization Using Multiple-year High Cost as a Health Indicator

  Richard C van Kleef, René C J A Van Vliet•Medical Care•2012

  Añadir item

• Mental Health Care Utilization and Expenditures by Children in Foster Care

  Jeffrey S Harman, George E Childs et al.•Archives of Pediatrics and…•2000

  Añadir item

• Psychotropic medication use among children in foster care

  Bonnie T Zima, Regina Bussing et al.•American Journal of Public Health•1999

  Añadir item

• Development and Application of a Population-Oriented Measure of Ambulatory Care Case-Mix

  Jonathan P Weiner, Barbara Starfield et al.•Medical Care•1991

  Añadir item

• Development and Estimation of a Pediatric Chronic Disease Score Using Automated Pharmacy Data

  Paul Fishman, Paul A Fishman et al.•Medical Care•1999

  Añadir item

• The Medicaid Rx Model

  Todd Gilmer, Richard Kronick et al.•Medical Care•2001

  Añadir item

• Risk Adjustment Using Automated Ambulatory Pharmacy Data

  Paul Fishman, Paul A Fishman et al.•Medical Care•2003

  Añadir item