Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 1996 Spring;17(3):77-99.

Risk-adjusted Medicare capitation rates using ambulatory and inpatient diagnoses

J P Weiner  1 , A Dobson, S L Maxwell, K Coleman, B Starfield, G F Anderson
Affiliations

Risk-adjusted Medicare capitation rates using ambulatory and inpatient diagnoses

J P Weiner et al. Health Care Financ Rev. 1996 Spring.

Abstract

Researchers at The Johns Hopkins University (JHU) developed two new diagnosis-oriented methodologies for setting risk adjusted capitation rates for managed care plans contracting with Medicare. These adjusters predict the future medical expenditures of aged Medicare enrollees based on demographic factors and diagnostic information. The models use the Ambulatory Care Group (ACG) algorithm to categorize ambulatory diagnoses. Two alternative approaches for categorizing inpatient diagnoses were used. Lewin-VHI, Inc. evaluated the models using data from 624,000 randomly selected aged Medicare beneficiaries. The models predict expenditures far better than the Adjusted Average per Capita Cost (AAPCC) payment method. It is possible that risk adjusted capitation payments could encourage health plans to compete on the basis of efficiency and quality and not risk selection.

PubMed Disclaimer

References

    1. Anderson G, Lupu D, Powe N, et al. Payment Amounts for Capitated Systems. Baltimore, MD.: Johns Hopkins University; Dec, 1989. Report prepared for the Health Care Financing Administration under Contract Number 17-C-98990/3.
    1. Anderson G, Steinberg EP, Powe NR, et al. Setting Payment Rates for Capitated Systems: A Comparison of Various Alternatives. Inquiry. 1990 Fall;27:225–233. - PubMed
    1. Beebe J, Lubitz J, Eggers P. Using Prior Utilization Information to Determine Payments for Medicare Enrollees in HMOs. Health Care Financing Review. 1985;6(3):27–38. - PMC - PubMed
    1. Brown R, Luft H, editors. HMOs and the Elderly. Ann Arbor, MI.: Health Administration Press; 1994.
    1. Ellis RP, Pope GC, Iezzoni LI, et al. Diagnosis-Based Risk Adjustment for Medicare Capitation Payments. Health Care Financing Review. 1996 Spring;17(3):XX–XX. - PMC - PubMed

Publication types

LinkOut - more resources