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Developing and evaluating performance measures for ambulatory care quality: a preliminary report of the DEMPAQ project

Jt Comm J Qual Improv 19:552-565. Department of Health Policy and Management, Harvard School of Public Health, Boston, MA, USA Because of the focus on […]

Adjusting for risk selection in state health insurance exchanges will be critically important and feasible, but not easy

Health Aff 31:306-315. Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA The Affordable Care Act calls for the establishment of state-level health insurance […]

Abdominal fat from spine dual-energy x-ray absorptiometry and risk for subsequent diabetes

J Clin Endocrinol Metab 95:3272-3276. University of Manitoba, Winnipeg, MB, Canada CONTEXT: Abdominal obesity is a major risk factor for diabetes. Dual-energy x-ray absorptiometry (DXA) […]

Reducing the burden of morbidity and medical utilization of older patients by outpatient geriatric services: Implications to primary health-care settings

Geriatr Gerontol Int 12:612-621. Department of Medical Affairs and Planning, National Yang Ming University, Taipei, Taiwan. AIM: That geriatric evaluation and management (GEM) is associated […]

Predicting resource utilization in a Veterans Health Administration primary care population: comparison of methods based on diagnoses and medications

Med Care 42:123-128. Medical Service, Iowa City VA Medical Center, Iowa City, IA, USA BACKGROUND: Valid methods of predicting resource utilization in primary care populations […]

Predictors of children’s healthcare use: the value of child versus parental perspectives on healthcare needs

Med Care 42:232-238. Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA OBJECTIVE: The objective of this study […]

Comparing self-reported health status and diagnosis-based risk adjustment to predict 1- and 2 to 5-year mortality

Health Serv Res 42:629-643. Houston Center for Quality of Care and Utilization Studies, Health Services Research and Development Service, Michael E. DeBakey VA Medical Center, […]

Does the pharmacy expenditure of patients always correspond with their morbidity burden? Exploring new approaches in the interpretation of pharmacy expenditure

BMC Public Health 10:244. Aragon Health Sciences Institute, Zaragoza, Spain BACKGROUND: The computerisation of primary health care (PHC) records offers the opportunity to focus on […]

Influenza vaccination and all-cause mortality in community-dwelling elderly in Ontario, Canada, a cohort study

Vaccine 29:240-246. Institute for Clinical Evaluative Sciences, Toronto, ON, Canada The objective of this study was to evaluate the effectiveness of influenza vaccines in reducing […]

Estimating influenza vaccine effectiveness in community-dwelling elderly patients using the instrumental variable analysis method

Arch Intern Med 172:484-491. Institute for Clinical Evaluative Sciences, Toronto, ON, Canada BACKGROUND: Estimates of influenza vaccine effectiveness in elderly individuals are largely from observational […]

Short-run associations between medical care expenditures and adherence to clinical practice guideline-based measures for diabetes

Value Health 3 Suppl 1:29-38. MEDSTAT Group, Inc., Ann Arbor, MI, USA OBJECTIVES: To estimate relationships between medical care expenditures in 1996 and adherence to […]

Prospects of Adjusted Clinical Groups (ACG’s) in capitated payment risk adjustment

Rev Esp Salud Publica 80:55-65. Published in Spanish. Dirección de Planificación y Desarrollo Organizativo, Badalona, Serveis Assistencials, Badalona, Barcelona, Spain BACKGROUND: Most patient classification systems […]

Trend and variation of prescription drug cost in the veterans health-care system

Health Serv Manage Res 21:14-22. Department of Veterans Affairs Healthcare Network Upstate New York, Albany, NY, USA Using descriptive statistics, this paper revealed that the […]

Validating the Adjusted Clinical Groups [ACG] case-mix system in a Spanish population setting: a multicenter study

Gac Sanit 23:228-231. Published in Spanish. Dirección de Planificación, Badalona Servicios Asistenciales, S.A., Badalona, Barcelona, España. PURPOSE: To validate the Johns Hopkins ACG case-mix system […]

Co-morbidity and health care utilisation five years prior to diagnosis for depression

A register-based study in a Swedish population. BMC Public Health 11:552. Department of Medical and Health Sciences, Family Medicine, Linköping University, Linköping, Sweden BACKGROUND: Depressive […]

Modeling factors influencing the demand for emergency department services in Ontario: a comparison of methods

BMC Emerg Med 11:13. Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada BACKGROUND: Emergency departments are medical treatment facilities, designed to […]

Clinical outcomes after bariatric surgery: a five-year matched cohort analysis in seven US states

Obes Surg 22:749-763. Center for Health Care Research and Policy, MetroHealth Medical Center/Case Western Reserve University, Cleveland, OH, USA BACKGROUND: Bariatric surgery is the most […]

Treatment profiles and costs of patients with chronic pain in the population setting

Clinicoecon Outcomes Res 4:39-47. Dirección de Planificación, Badalona Serveis Assistencials, Barcelona, Spain BACKGROUND: The purpose of this study was to gather information about analgesic drug […]

Multi-institutional sharing of electronic health record data to assess childhood obesity

PLoS One 8:e66192. Children’s Hospital of Philadelphia, Philadelphia, PA, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA OBJECTIVE: To evaluate the validity […]

Cardiovascular safety of inhaled long-acting bronchodilators in individuals with chronic obstructive pulmonary disease

JAMA Intern Med 173:1175-1185. Institute for Clinical Evaluative Sciences, Toronto, ON, Canada; Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Child Health Evaluative […]

The disconnect between better quality of glucocorticoid-induced osteoporosis preventive care and better outcomes: a population-based cohort study

J Rheumatol 40:1736-1741. University of Alberta, Edmonton, AB, Canada; University of Manitoba, Winnipeg, MB; McGill University, Montreal, QC, Canada OBJECTIVE: The quality of glucocorticoid-induced osteoporosis […]

Glucagonlike peptide 1-based therapies and risk of hospitalization for acute pancreatitis in type 2 diabetes mellitus: a population-based matched case-control study

JAMA Intern Med 173:534-539. Department of Medicine, Johns Hopkins University Schools of Medicine and Public Health, Baltimore, MD, USA IMPORTANCE: Acute pancreatitis has significant morbidity […]

The association between obesity and outpatient visits for acute respiratory infections in Ontario, Canada

Int J Obes 38:113-119. Institute for Clinical Evaluative Sciences, Toronto, ON, Canada; Public Health Ontario, Toronto, ON, Canada; University of Toronto, Toronto, ON, Canada OBJECTIVE: […]

Effects of impairment in activities of daily living on predicting mortality following hip fracture surgery in studies using administrative healthcare databases

BMC Geriatr 14:9. Queen’s University, Kingston, ON, Canada BACKGROUND: Impairment in activities of daily living (ADL) is an important predictor of outcomes although many administrative […]

Variation in inpatient hospital prices and outpatient service quantities drive geographic differences in private spending in Texas

Health Serv Res. University of Texas School of Public Health, Houston, TX, USA OBJECTIVE: To measure the contribution of market-level prices, utilization, and health risk […]

Predictive validity of tools used to assess the risk of unplanned admissions: a rapid review of the evidence

York, UK: University of York. University of York, York, UK CRD has developed an evidence briefing and support service tailored to the needs of commissioners […]

Physician integrated network: a second look

Winnipeg, MB, Canada: Manitoba Centre for Health Policy. Manitoba Centre for Health Policy, Winnipeg, MB, Canada This is the second report from Manitoba Centre for […]

Putting your faith in data

Commissioning Success :34-36. No abstract. Article a PDF.

Does surgical setting or wait-time incentive improve return to work following knee surgery among injured workers?

Final report to WorkSafeBC. Vancouver, BC, Canada: University of British Columbia. University of British Columbia, Vancouver, BC, Canada; University Health, Toronto, ON, Canada; University of […]

The faces of Medicaid: the complexities of caring for people with chronic illnesses and disabilities

Hamilton, NJ, USA: Center for Health Care Strategies. Center for Health Care Strategies, Hamilton, NJ, USA A complex question has persisted in our minds since […]

Employer purchasing coalitions and Medicaid: experiences with risk adjustment

New York, NY, USA: Commonwealth Fund. Commonwealth Fund, New York, NY, USA Choice among health plans increases patient satisfaction with care and enables families to […]

Clinical and economic features of categories of patients in defined populations

Stockholm, Sweden: Karolinska Institute (doctoral dissertation). Department of Clinical Services, Center for Family and Community Medicine, Karolinska Institute, Stockholm, Sweden This thesis addresses the use […]

Use predictive modeling to improve profitability under cap

National Health Information LLC. Capitation Rates and Data 9:61-65. National Health Information LLC, Atlanta, GA, USA Health plans and capitated provider organizations live or die […]

Health-based risk assessment: risk-adjusted payments and beyond

Washington, DC, USA: AcademyHealth. AcademyHealth, Washington, DC, USA A number of payers across the country, including Medicaid managed care programs, the Medicare+Choice program, some state […]

Cost benefit analysis of pharmaceutical care in a Medicaid population – from a budgetary perspective

J Managed Care Pharm 4:303-308. Nova Southeastern University, Ft. Lauderdale, FL, USA The objective was to evaluate the economic impact of Medicaid pharmaceutical care services […]

Comparing the value of three main diagnostic-based risk-adjustment systems (DBRAS)

Ottawa, ON, Canada: Canadian Health Services Research Foundation. Canadian Health Services Research Foundation, Ottawa, ON, Canada Diagnostic-Based Risk-Adjustment Systems (DBRAS) are now widely used in […]

Using pharmacy information in a decision support system to improve efficient delivery of primary health care

A study focusing on the Swedish national drug register. BMC Health Serv Res 0:A6. Ensolution, Stockholm, Sweden INTRODUCTION: The aim of the project was to […]

Utilización de los grupos clínicos ajustados en un centro de atención primaria español: estudio retrospectivo de base poblacional

Rev Panam Salud Publica 27:49-55. Published in Spanish. Dirección de Planificación, Badalona Serveis Assistencials, S.A., Barcelona, Spain OBJETIVOS. Evaluar los resultados de la aplicación del […]

Disparities in antipsychotic medication use

Vancouver, BC, Canada: University of British Columbia (masters thesis). University of British Columbia, Vancouver, BC, Canada OBJECTIVES: To examine ethnic and income-related disparities in the […]

Pilot projects carried out in Lithuania and Latvia: quality indicators for high quality PHC performance

ImPrim Report #3. Karlskrona, Sweden: ImPrim. Klaipeda University, Klaipeda, Lithuania Quality improvement of primary health care is the topic requiring attention from all stakeholders  throughout […]

Who is in our hospitals … and why?

Winnipeg, MB, Canada: Manitoba Centre for Health Policy. Manitoba Centre for Health Policy, Winnipeg, MB, Canada This report provides a snapshot of patients in acute […]

Kronik: Datafangst fra nyt system kan anvendes både administrativt og sundhedspolitisk

Ugeskrift for Laeger 176:380-381. Published in Danish. Syddansk University, Odense, Denmark

ACG System Predictive Models Overview

This document provides a high-level overview of how the predictive models within the Johns Hopkins Adjusted Clinical Groups® (ACG) System are designed and the factors […]

Morbidity Burden in Persons with Multiple Chronic Conditions

Morbidity Burden in persons with Multiple Chronic Conditions and Identification of inequitable resource use in Israel Dr. Efrat Shadmi Faculty of Social Welfare and Health […]

Application of ACGs to Medical Claim Records in Japan

Tokyo Medical and Dental University Application of the ACG System to Medical Claim Records in Japan Koichi Kawabuchi

Tuesday-Utilization-Chang

Johns Hopkins ACG System Consistent High Users: Characteristics and Identification Hsien-Yen Chang, PhD. Research Associate

Tuesday-Keynote III-Weiner

Johns Hopkins ACG System Risk Adjustment and Predictive Modeling in Health Reform Jonathan Weiner

Monday-Care Coordination I-Pollack

Johns Hopkins ACG System Innovations in Measuring and Managing Care Coordination Craig Pollack, MD, MHS

The future of integrated care in the NHS

The King’s Fund The Future of Integrated Care in the NHS Professor Chris Ham Chief Executive  

Monday(P1)-A New Day in Population Health Management: Innovations in Risk Adjustment and Predictive Modeling-Weiner

A New Day in Population Health Management: Innovations in Risk Adjustment and Predictive Modeling Welcome and Opening Remarks  Jonathan P. Weiner, DRPH Professor and CEO […]

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Reducing Readmissions

Is your hospital or health system interested in reducing readmissions? Turning data points into actionable insights is key to understanding and addressing the drivers of readmission rates. Learn more in this step-by-step instructional video.

The uptake of active surveillance for the management of prostate cancer: A population-based analysis

Introduction: Active surveillance (AS) is a strategy for the management of low-risk prostate cancer (PCa). However, few studies have assessed the uptake of AS at […]

Apples and Oranges: Four Definitions of Multiple Chronic Conditions and their Relationship to 30-Day Hospital Readmission

Health Innovation Program, the University of Wisconsin School of Medicine and Public Health from The Wisconsin Partnership Program, and the Community–Academic Partnerships core of the […]

Primary care utilization in people who experience imprisonment in Ontario, Canada: a retrospective cohort study

Abstract Background Access to primary care is an important determinant of health, and data are sparse on primary care utilization for people who experience imprisonment. […]

Vulnerable And Less Vulnerable Women In High-Deductible Health Plans Experienced Delayed Breast Cancer Care

ABSTRACT The effects of high-deductible health plans (HDHPs) on breast cancer diagnosis and treatment among vulnerable populations are unknown. We examined time to first breast […]

Patient-reported symptoms after breast cancer diagnosis and treatment: A retrospective cohort study

Abstract Aim Breast cancer and its treatment are associated with varying symptoms. The province of Ontario (13.6 million) has implemented a provincial programme to screen for symptoms among […]

Performance on the Operant Test Battery in young children exposed to procedures requiring general anaesthesia: the MASK study

Abstract Background It is not known whether the neurotoxicity produced by anaesthetics administered to young animals can also occur in children. Exposure of infant macaques […]

Prevalence of intellectual and developmental disabilities among first generation adult newcomers, and the health and health service use of this group: A retrospective cohort study

Abstract Background Attention to research and planning are increasingly being devoted to newcomer health, but the needs of newcomers with disabilities remain largely unknown. This […]

Multimorbidity Patterns in Patients with Back Pain: A Study of Patient Records at a Primary Health Care Centre in Sweden

Abstract In Primary Care, multimorbidity is the norm in most patients. A large part of these have pain disorders, very often related to the spine. […]

Changes in primary care provider utilization by phase of care for women diagnosed with breast cancer: a CanIMPACT longitudinal cohort study

Abstract Background Primary care providers (PCPs) have always played an important role in cancer diagnosis. There is increasing awareness of the importance of their role […]

Does early palliative identification improve the use of palliative care services?

Abstract Purpose To evaluate whether the early identification of patients who may benefit from palliative care impacts on the use of palliative, community and acute-based […]

Predicting the Cost of Health Care Services : A Comparison of Case-mix Systems and Comorbidity Indices That Use Administrative Data

Abstract Background: Case-mix systems and comorbidity indices aggregate clinical information about patients over time and are used to characterize need for health care services. These […]

Use of administrative record linkage to measure medical and social risk factors for early developmental vulnerability in Ontario, Canada

Abstract Background Linkage of demographic, health, and developmental administrative data can enrich population-based surveillance and research on developmental and educational outcomes. Transparency of the record […]

Analysis of the relationship between surgeon procedure volume and complications after total knee arthroplasty using a propensity-matched cohort study

Abstract Objectives This study aimed to identify a threshold in annual surgeon volume associated with increased risk of revision (for any cause) and deep infection […]

Determinants of vaccination uptake, and influenza vaccine effectiveness in preventing deaths and hospital admissions in the elderly population; Treviso, Italy, 2014/2015-2016/2017 seasons

ABSTRACT Objective Seasonal influenza is an important cause of morbidity and mortality, particularly among the elderly population. Determinants of vaccination uptake and its impact on […]

Frailty impact on postoperative complications and early mortality rates in patients undergoing radical cystectomy for bladder cancer: a systematic review

Abstract Objective To assess the prevalence of frailty, a status of vulnerability to stressors leading to adverse health events, in bladder cancer patients undergoing radical […]

Medical use of cocaine and perioperative morbidity following sinonasal surgery—A population study

Abstract Background Topical cocaine is favoured by many surgeons for sinonasal surgery due to its superior vasoconstrictive and anesthetic properties. However, historical reports suggesting cocaine […]

Congestive heart failure and comorbidity as determinants of colorectal cancer perioperative outcomes

Abstract Objective There has been an increase in surgical interventions in frailer elderly with concomitant chronic diseases. The purpose of this paper was to evaluate […]

Real-world Safety of Bevacizumab with First-line Combination Chemotherapy in Patients with Metastatic Colorectal Cancer: Population-based Retrospective Cohort Studies in Three Canadian Provinces

Abstract Aims To examine the real-world safety of adding bevacizumab to first-line irinotecan-based chemotherapy for patients with metastatic colorectal cancer (mCRC). Materials and methods Patients diagnosed with CRC in […]

The receipt of information by family physicians about their patient’s emergency department visits: a record linkage study of electronic medical records to health administrative data

Abstract Background Canadians are known to be frequent users of emergency department (ED) care. However, the exchange of information from ED visits to family physicians […]

The effect of frailty on post-operative outcomes and health care expenditures in patients treated with partial nephrectomy

Abstract Objective To examine the effect of frailty on short-term post-operative outcomes and total hospital charges (THCs) in patients with non-metastatic renal cell carcinoma, treated […]

Improving patient well-being in the United States through care coordination interventions informed by social determinants of health

Abstract Health and well-being are promoted when primary care teams partner with patients and provide care coordination to mitigate risks and promote optimal health. Identification […]

Performance of administrative database frailty instruments in predicting clinical outcomes and cost for patients undergoing transcatheter aortic valve implantation: a historical cohort study

Abstract Purpose Frailty instruments may improve prognostic estimates for patients undergoing transcatheter aortic valve implantation (TAVI). Few studies have evaluated and compared the performance of […]

Predicting Provider Workload Using Predicted Patient Risk Score and Social Determinants of Health in Primary Care Setting

Abstract Background Provider burnout due to workload is a significant concern in primary care settings. Workload for primary care providers encompasses both scheduled visit care […]

Evaluating the impact of capitation funding top-up payments in primary care

Abstract Background Capitation payments account for approximately half of core funding for General Practitioner (GP) practices in England, allocated via the Global Sum Allocation (‘Carr-Hill’) […]

Longitudinal costs and health service utilisation associated with primary care reforms in Ontario: a retrospective cohort study protocol

ABSTRACT Introduction Over the last 20 years, the Canadian province of Ontario implemented several new models of primary care focusing on changes to physician remuneration, […]

Influence of socioeconomic status on health outcomes after treatment of spinal metastases

ABSTRACT OBJECTIVE The aim of this study was to investigate the association of home socioeconomic status (SES) with days at home and survival after treatment […]

Impact of frailty on outcomes following percutaneous coronary intervention for acute myocardial infarction: A propensity-score matched analysis of 45,362 pairs

Introduction Percutaneous coronary intervention (PCI) is the cornerstone of rapid revascularization in acute myocardial infarction (AMI) [1]. Patients undergoing PCI frequently present with multiple comorbidities, […]

Social inequalities in COVID-19 death by area-level income in 11.2 million people in Ontario, Canada: patterns over time and the mediating role of vaccination

Abstract Knowledge of patterns in COVID-19 deaths by area-level income over time and the mediating role of vaccination in inequality patterns remains limited. We used […]

Regional variation in healthcare spending and mortality among senior high-cost healthcare users in Ontario, Canada: a retrospective matched cohort study

Abstract Background Senior high cost health care users (HCU) are a priority for many governments. Little research has addressed regional variation of HCU incidence and […]

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Seven Quick Wins (International Version)

Are you a provider, payor or population health organization looking for a quick tune-up to your existing strategy and planning? Then look no further. We […]

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Visualization & Use of the ACG System in the Military Health System

Presented by:David H. Carnahan, Colonel, USAF, MD, MSCE

Relation between surgeon volume and risk of complications after total hip arthroplasty: propensity score matched cohort study

BMJ 348:g3284. University of Toronto, Toronto, ON, Canada; Institute for Clinical Evaluative Sciences, Toronto, ON, Canada OBJECTIVES: To identify a cut point in annual surgeon […]

Mothers of children diagnosed with attention-deficit/hyperactivity disorder: health conditions and medical care utilization in periods before and after birth of the child

Med Care 47:105-114. Division of Research, Kaiser Permanente Medical Care Program, Northern California Region, Oakland, CA, USA BACKGROUND: Analyzing health conditions and medical utilization of […]

Elective, major noncardiac surgery on the weekend: a population-based cohort study of 30-day mortality

Med Care 52:557-564. University of Ottawa, Ottawa, ON, Canada; Ottawa Hospital Research Institute, Ottawa, ON, Canada IMPORTANCE: Previous research has demonstrated that patients undergoing elective […]

Multimorbidity in people with type 2 diabetes in the Basque Country (Spain): Prevalence, comorbidity clusters and comparison with other chronic patients

Eur J Intern Med 26:197-202. Basque Institute for Healthcare Innovation, Barakaldo, Spain; Osakidetza (Basque Health Service), Erandio, Spain; Department of Health, Vitoria-Gasteiz, Spain; World Health […]

Predictors of hospital stay and home care services use: A population-based, retrospective cohort study in stage IV gastric cancer

Palliat Med 29:147-156. Queen’s University, Kingston, ON, Canada; University of Toronto, Toronto, ON, Canada; Institute for Clinical Evaluative Sciences, Toronto, ON, Canada; Queen’s University, Kingston, […]

How profitable is risk selection? A comparison of four risk adjustment models

Health Econ 11:165-174. Department of Health Services, Boston University School of Public Health, Boston, MA, USA To mitigate selection triggered by capitation payments, risk-adjustment models […]

Macrolide antibiotics and the risk of ventricular arrhythmia in older adults

CMAJ Western University, London, ON, Canada; London Health Sciences Centre, London, ON, Canada; Institute for Clinical Evaluative Sciences (ICES) Western, London, ON, Canada BACKGROUND: Many […]

A cross-sectional, population-based study of HIV physicians and outpatient health care use by people with HIV in Ontario

BMC Health Serv Res 15:63. Bruyère Research Institute, Ottawa, ON, Canada; University of Ottawa, Ottawa, ON, Canada; McGill University, Montreal, QC, Canada; Ottawa Hospital Research […]

Improved Survival in Patients with Viral Hepatitis-Induced Hepatocellular Carcinoma Undergoing Recommended Abdominal Ultrasound Surveillance in Ontario: A Population-Based Retrospective Cohort Study

PLoS One 10:e0138907. University of Toronto, Toronto, ON, Canada; Ontario Institute for Cancer Research/Cancer Care Ontario, Toronto, ON, Canada; Institute for Clinical Evaluative  Sciences, Toronto, ON, […]

What, if anything, does amenable mortality tell us about regional health system performance?

Healthc Policy 8:79-90. University of British Columbia, Vancouver, BC, Canada OBJECTIVES: Amenable mortality is proposed as a health system performance measure, and has been used […]

A chronic disease score with empirically derived weights

Med Care 33:783-795. Indiana University Department of Medicine, Indianapolis, IN, USA. Different types of medication prescribed during a 6-month period for the treatment and management […]

Assessing socioeconomic health care utilization inequity in Israel: impact of alternative approaches to morbidity adjustment

BMC Public Health 11:609. Faculty of Social Welfare and Health Sciences, University of Haifa, Mount Carmel, Israel BACKGROUND: The ability to accurately detect differential resource […]

Capitation and enhanced fee-for-service models for primary care reform: a population-based evaluation

CMAJ 180:E72-E81. Institute for Clinical Evaluative Sciences, Toronto, ON, Canada BACKGROUND: Primary care reform in Ontario, Canada, included the initiation of a blended capitation model […]

Variability in prescription drug expenditures explained by Adjusted Clinical Groups (ACG) case-mix: a cross-sectional study of patient electronic records in primary care

BMC Health Serv Res 8:53. Catalan Institute of Oncology, IDIBELL, L’Hospitalet, Barcelona, Spain BACKGROUND: In view of rapidly increasing prescription costs, case-mix adjustment should be […]

The importance of comorbidity in analysing patient costs in Swedish primary care

BMC Public Health 6:36. Ryd Primary Health Care Centre, Linköping, Sweden BACKGROUND: The objective was to explore the usefulness of the morbidity risk adjustment system […]