Accounting for Social Risk Factors in Medicare Payment (2017) / Chapter Skim
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CA: Criteria for Selecting Risk Factors Reviewed by the Committee
CA: Criteria for Selecting Risk Factors Reviewed by the Committee
Pages 445-452
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-HCC risk ad justment model for individual and small group markets under the Affordable Care Act (Kautter et al., 2014) ; and • The National Quality Forum 2014 report Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors.
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Diagnostic categories used in establishing payments should have adequate sample sizes in available data sets. Given the extreme skewness of medical expenditure data, the data cannot reliably determine the expected cost of extremely rare diagnostic categories.
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Principle 10 -- Discretionary diagnostic categories should be excluded from payment models. Diagnoses that are particularly subject to intentional or unintentional discretionary coding variation or inappropriate coding by health plans/providers, or that are not clinically or empirically credible as cost predictors, should not increase cost predictions.
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By combining both predictive power and heterogeneity into a single measure, the impact factor is more informative than purely predictive measures such as R2; it approximates the magnitude of the incremental adjustments due to adding a variable to the case-mix model (O'Malley et al., 2005)
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. NATIONAL QUALITY FORUM CRITERIA GUIDELINES FOR SELECTING RISK FACTORS FOR ADJUSTMENT TABLE CA-1 Guidelines for Selecting Risk Factors for Adjustment Clinical/ Health Status SDS Guideline Rationale Factorsa Factorsb Clinical/conceptual relationship Begin with conceptual model ü ü with the outcome of interest informed by research and experience Empirical association with the To confirm conceptual ü ü outcome of interest relationship Variation in prevalence of the If there is no variation in ü ü factor across the measured prevalence across health care entities units being measured, it will not bias performance results Not confounded with quality of Trying to isolate effects of ü ü care, risk factors should: quality of care • present at the start of Be Ensures not a result of care ü ü care and provided • an indicator or not Although these could explain ü ü characteristic of care variation in outcome, in provided (e.g., treatments, performance measurement the interventions, expertise of goal is to isolate differences in staff)
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considered less susceptible to manipulation than a clinical procedure or treatment (e.g., physical therapy) Accurate data that can be Data limitations often represent ü ü reliably and feasibly captured a practical constraint to what factors are included in risk models Contribution of unique variation Prevent overfitting and unstable ü ü in the outcome (i.e., not estimates, or coefficients that redundant or highly correlated appear to be in the wrong with another risk factor)
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2014. The HHS-HCC risk adjustment model for individual and small group markets under the Affordable Care Act.
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