reports

Understanding approaches to case-mix assessment and case-mix adjustment

JHQ Online :W5-24 – W5-29.

McKesson Medical Management Group, Newton, MA.

Rising healthcare costs coupled with diminishing financial  resources are stimulating changes in the organization and  financing of healthcare delivery systems. Government payers  (i.e., Medicare and Medicaid) continue to demand more for less.  Health plans, faced with the growing cost shift from government  programs, are being forced by employers and consumers to  reduce costs. Traditionally, health plans have used demographic  data such as age and sex as risk adjusters to level the playing  field when determining provider payment in risk-pool situations  or when setting premiums for employer groups. However,  these measures explain less than 5% of the variance in healthcare  resource consumption. Recently, case-mix assessment  tools, which make use of demographic and/or health status  data from claims, are gaining increasing popularity as methods  for explaining variations in healthcare utilization and cost  for provider groups, employer groups, or physicians’ patient  populations for either the same year in which diagnoses  were assigned (explanatory or concurrent) or in the future  (prospective). The goal is to more equitably compensate  providers based on the health status of their patients, as well  as to support disease management activities.