This Article  • References  • Full text PDF  • Send to a friend  • Save in My Folder  • Save to citation manager  • Permissions  Citing Articles  • Citation map  • Citing articles on HighWire  • Contact me when this article is cited  Related Content  • Similar articles in this journal  Social Bookmarking   What's this?

The Use of Disease-Specific Conditions as Risk Adjusters in Capitated Payment Systems

John S. Andrews, MD; Gerard F. Anderson, PhD; Carol Han, MHS; John M. Neff, MD

Arch Pediatr Adolesc Med. 1997;151(3):236-242.

Abstract
Objective
To address the issue of adverse selection in capitated payment systems by developing a list of diseasespecific pediatric conditions (ie, "carve outs") to be considered for separate reimbursement.

Design
A descriptive study using a large Medicaid database.

Intervention
With the use of fiscal year 1993 Washington State Medicaid cost data for 302 240 pediatric patients, a list of disease-specific carve outs was developed to meet the following criteria: high cost, low variability in cost, and association with a large proportion of medical spending.

Results
Six-hundred seventy-three patients (0.2%) in the database had annual costs totaling $25 000 or more. Ten percent of the cases accounted for approximately two thirds of spending, while the least expensive 70% of cases made up only 15% of the expenditures. Prematurity and complications of prematurity, neoplasms, congenital heart disease, organ transplantations, congenital anomalies, and respiratory problems were general categories of disease that met our criteria for a carve out. The association of a major surgical procedure with a diagnosis increased the predictive accuracy for high cost.

Conclusion
Lists of disease-specific carve outs such as this one can be used by Medicaid plans and other insurers who are concerned about risk selection to identify conditions for separate reimbursement in capitated payment systems.

Arch Pediatr Adolesc Med. 1997;151:236-242

Author Affiliations
From the Departments of Pediatrics (Dr Andrews) and Health Policy and Management (Dr Anderson and Ms Han), The Johns Hopkins Medical Institutions, Baltimore, Md; and the Children's Hospital and Medical Center and the Department of Pediatrics, University of Washington, Seattle, Wash (Dr Neff).

CiteULike    Connotea    Del.icio.us    Digg    Reddit    Technorati    Twitter     What's this?

THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES

Access to Health Care: Health Insurance Considerations for Young Adults With Special Health Care Needs/Disabilities
White
Pediatrics 2002;110:1328-1335.
ABSTRACT | FULL TEXT  

Use of risk adjustment in setting budgets and measuring performance in primary care II: advantages, disadvantages, and practicalities
Majeed et al.
BMJ 2001;323:607-610.
FULL TEXT  

Deaths Attributed to Pediatric Complex Chronic Conditions: National Trends and Implications for Supportive Care Services
Feudtner et al.
Pediatrics 2001;107 :e99-e99.
ABSTRACT | FULL TEXT  

The Academic Children's Hospital Primary Care Clinic: Responding to tie Challenges of a Changing Health Care Environment
Berman
CLIN PEDIATR 2000;39:473-478.
ABSTRACT  

Pediatric Deaths Attributable to Complex Chronic Conditions: A Population-Based Study of Washington State, 1980-1997
Feudtner et al.
Pediatrics 2000;106:205-209.
ABSTRACT | FULL TEXT  

Pediatric Death Certification
Bowen and Marshall
Arch Pediatr Adolesc Med 1998;152:852-854.
ABSTRACT | FULL TEXT