Predicting Costs of Care Using a Pharmacy-Based Measure Risk Adjustment in a Veteran Population

BACKGROUND: Although most widely used risk adjustment systems use diagnosis data to classify patients, there is growing interest in risk adjustment based on computerized pharmacy data. The Veterans Health Administration (VHA) is an ideal environment in which to test the efficacy of a pharmacy-based approach. OBJECTIVE: To examine the ability of RxRisk-V to predict concurrent and prospective costs of care in VHA and compare the performance of RxRisk-V to a simple age/gender model, the original RxRisk, and two leading diagnosis-based risk adjustment approaches: Adjusted Clinical Groups and Diagnostic Cost Groups/Hierarchical Condition Categories. METHODS: The study population consisted of 161,202 users of VHA services in Washington, Oregon, Idaho, and Alaska during fiscal years (FY) 1996 to 1998. We examined both concurrent and predictive model fit for two sequential 12-month periods (FY 98 and FY 99) with the patient-year as the unit of analysis, using split-half validation. RESULTS: Our results show that the Diagnostic Cost Group /Hierarchical Condition Categories model performs best (R2 = 0.45) among concurrent cost models, followed by ADG (0.31), RxRisk-V (0.20), and age/sex model (0.01). However, prospective cost models other than age/sex showed comparable R2: Diagnostic Cost Group /Hierarchical Condition Categories R2 = 0.15, followed by ADG (0.12), RxRisk-V (0.12), and age/sex (0.01). CONCLUSIONS: RxRisk-V is a clinically relevant, open source risk adjustment system that is easily tailored to fit specific questions, populations, or needs. Although it does not perform better than diagnosis-based measures available on the market, it may provide a reasonable alternative to proprietary systems where accurate computerized pharmacy data are available

Environmental health · Family medicine · Health care · Population · Chronic Disease Management Strategies · Demography · Electronic Health Records Systems · Medicine · Pharmaceutical Practices and Patient Outcomes · Pharmacy

• Predictive Modeling of Total Healthcare Costs Using Pharmacy Claims Data

  Christopher A Powers, Christina Meyer et al.•Medical Care•2005

  Incluir item

• Line Authority for Nurse Staffing and Costs for Acute Inpatient Care

  Open Access•Chuan-Fen Liu, Chuan‐Fen Liu et al.•INQUIRY The Journal of Health…•2009

  Incluir item

• Construction and Characteristics of the RxRisk-V

  Kevin L Sloan, Anne E Sales et al.•Medical Care•2003

  Incluir item

• The Effect of Complementary and Alternative Medicine Claims on Risk Adjustment

  Bonnie K Lind, Chad Abrams et al.•Medical Care•2006

  Incluir item

• Predicting Healthcare Utilization Using a Pharmacy-based Metric With the WHO’s Anatomic Therapeutic Chemical Algorithm

  Raymond N Kuo, Yaa-Hui Dong et al.•Medical Care•2011

  Incluir item

• Medicare Managed Care Enrollment by Disability-Eligible and Age-Eligible Veterans

  Matthew L Maciejewski, Sarah Birken et al.•Medical Care•2009

  Incluir item

• Evaluating the Impact of Prescription Fill Rates on Risk Stratification Model Performance

  Hsien-Yen Chang, Hsien‐Yen Chang et al.•Medical Care•2017

  Incluir item

• Longitudinal Patterns of Spending Enhance the Ability to Predict Costly Patients

  Julie C Lauffenburger, Jessica M Franklin et al.•Medical Care•2017

  Incluir item

• Case-Mix for Performance Management

  Jian Gao, Eileen Moran et al.•Medical Care•2018

  Incluir item

• Use of the Decision Support System for VA Cost-Effectiveness Research

  Paul G Barnett, John H Rodgers•Medical Care•1999

  Incluir item

• Construction and Characteristics of the RxRisk-V

  Kevin L Sloan, Anne E Sales et al.•Medical Care•2003

  Incluir item

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

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

  Incluir item

• Evaluating Diagnosis-Based Case-Mix Measures

  Amy K Rosen, Susan Loveland et al.•Medical Care•2001

  Incluir item

• Risk Adjustment Using Automated Ambulatory Pharmacy Data

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

  Incluir item

• A Chronic Disease Score with Empirically Derived Weights

  Daniel O Clark, MICHAEL VON KORFF et al.•Medical Care•1995

  Incluir item