Evaluating diagnosis-based risk-adjustment methods in a population with spinal cord dysfunction

Capturing patients' needs in casemix: a systematic literature review on the value of adding functioning information in reimbursement systems

BACKGROUND

Contemporary casemix systems for health services need to ensure that payment rates adequately account for actual resource consumption based on patients' needs for services. It has been argued that functioning information, as one important determinant of health service provision and resource use, should be taken into account when developing casemix systems. However, there has to date been little systematic collation of the evidence on the extent to which the addition of functioning information into existing casemix systems adds value to those systems with regard to the predictive power and resource variation explained by the groupings of these systems. Thus, the objective of this research was to examine the value of adding functioning information into casemix systems with respect to the prediction of resource use as measured by costs and length of stay.

METHODS

A systematic literature review was performed. Peer-reviewed studies, published before May 2014 were retrieved from CINAHL, EconLit, Embase, JSTOR, PubMed and Sociological Abstracts using keywords related to functioning ('Functioning', 'Functional status', 'Function*, 'ICF', 'International Classification of Functioning, Disability and Health', 'Activities of Daily Living' or 'ADL') and casemix systems ('Casemix', 'case mix', 'Diagnosis Related Groups', 'Function Related Groups', 'Resource Utilization Groups' or 'AN-SNAP'). In addition, a hand search of reference lists of included articles was conducted. Information about study aims, design, country, setting, methods, outcome variables, study results, and information regarding the authors' discussion of results, study limitations and implications was extracted.

RESULTS

Ten included studies provided evidence demonstrating that adding functioning information into casemix systems improves predictive ability and fosters homogeneity in casemix groups with regard to costs and length of stay. Collection and integration of functioning information varied across studies. Results suggest that, in particular, DRG casemix systems can be improved in predicting resource use and capturing outcomes for frail elderly or severely functioning-impaired patients.

CONCLUSION

Further exploration of the value of adding functioning information into casemix systems is one promising approach to improve casemix systems ability to adequately capture the differences in patient's needs for services and to better predict resource use.

The effect of complementary and alternative medicine claims on risk adjustment

OBJECTIVE

We sought to assess how the inclusion of claims from complementary and alternative medicine (CAM) providers affects measures of morbidity burden and expectations of health care resource use for insured patients.

METHODS

Claims data from Washington State were used to create 2 versions of a case-mix index. One version included claims from all provider types; the second version omitted claims from CAM providers who are covered under commercial insurance. Expected resource use was also calculated. The distribution of expected and actual resource use was then compared for the 2 indices.

RESULTS

Inclusion of claims from CAM providers shifted 19,650 (32%) CAM users into higher morbidity categories. When morbidity categories were defined using claims from all providers, CAM users in the highest morbidity category had average (+/-SD) annual expenditures of $6661 (+/-$13,863). This was less than those in the highest morbidity category when CAM provider claims were not included in the index ($8562 +/- $16,354), and was also lower than the highest morbidity patients who did not use any CAM services ($8419 +/- $18,885).

CONCLUSIONS

Inclusion of services from CAM providers under third-party payment increases risk scores for their patients but expectations of costs for this group are lower than expected had costs been estimated based only on services from traditional providers. Risk adjustment indices may need recalibration when adding services from provider groups not included in the development of the index.

[Retrospective application of adjusted clinical groups (ACGs) at a primary care centre]

OBJECTIVE

To evaluate retrospectively the application of adjusted clinical groups (ACGs) at a primary care centre.

DESIGN

Descriptive, retrospective examination.

SETTING

Urban.

PARTICIPANTS

All patients seen by the team in 2000 were included in the study. Those who moved or died during the study period were excluded.

MAIN MEASUREMENTS

Universal variables (age and sex), dependant variables (visits, episodes, and costs), and case-mix or comorbidity variables (ACGs 2.0) were measured. The model of cost per patient was established by distinguishing the costs of the PCC from the variables. The ICPC was converted to the ICD-9-CM and a multiple linear regression analysis was performed to predict the models.

RESULTS

The total number of patients studied was 15 983, with an average of 5.0+/-3.2 episodes and 8.0+/-7.7 visits during the year. The power of explanation of the variability of the classification between the number of episodes was 71.9%; of the visits, 50.0% (with refinement, 56.3%); and cost, 30.2% (with refinement, 55.0%) (P=.000).

CONCLUSIONS

ACGs were shown to be an acceptable system for classifying patients according to the consumption of resources used in primary care. In addition, the methodology used was adequate for integrating clinical and economic information at the PCC.

Access to health care services for the disabled elderly

OBJECTIVE

To determine whether difficulty walking and the strategies persons use to compensate for this deficit influenced downstream Medicare expenditures.

DATA SOURCE

Secondary data analysis of Medicare claims data (1999-2000) for age-eligible Medicare beneficiaries (N=4,997) responding to the community portion of the 1999 National Long Term Care Survey (NLTCS).

STUDY DESIGN

Longitudinal cohort study. Walking difficulty and compensatory strategy were measured at the 1999 NLTCS, and used to predict health care use as measured in Medicare claims data from the survey date through year-end 2000.

DATA EXTRACTION

Respondents to the 1999 community NLTCS with complete information on key explanatory variables (walking difficulty and compensatory strategy) were linked with Medicare claims to define outcome variables (health care use and cost).

PRINCIPAL FINDINGS

Persons who reported it was very difficult to walk had more downstream home health visits (1.1/month, p<.001), but fewer outpatient physician visits (-0.16/month, p<.001) after controlling for overall disease burden. Those using a compensatory strategy for walking also had increased home health visits/month (0.55 for equipment, 1.0 for personal assistance, p<.001 for both) but did not have significantly reduced outpatient visits. Persons reporting difficulty walking had increased downstream Medicare costs ranging from 163 US dollars to 222 US dollars/month (p<.001) depending upon how difficult walking was. Less than half of the persons who used equipment to adapt to walking difficulty had their difficulty fully compensated by the use of equipment. Persons using equipment that fully compensated their difficulty used around 300 US dollars/month less in Medicare-financed costs compared with those with residual difficulty.

CONCLUSIONS

Difficulty walking and use of compensatory strategies are correlated with the use of Medicare-financed services. The potential impact on the Medicare program is large, given how common such limitations are among the elderly.