title: Risk adjustment for health plans disproportionately enrolling frail Medicare beneficiaries.
abstract: There is concern about the adequacy of diagnosis-based risk adjusters for paying health plans that disproportionately enroll frail Medicare beneficiaries. The Medicare Current Beneficiary Survey (MCBS) was used to examine the ability of two risk-adjustment models to predict Medicare costs for groups defined by institutional status and difficulty with activities of daily living (ADLs). Both models underpredicted average costs for non-institutionalized frail beneficiaries; however, the models slightly overpredicted expenses for most frail individuals and severely underpredicted for a minority. Further refinements are needed if diagnosis-based models are used to pay plans that disproportionately enroll frail beneficiaries.
authors.affiliation: Office of Strategic Planning, Health Care Financing Administration, Baltimore 21244, MD, USA. griley@hcfa.gov
authors.forename: G F
authors.initials: GF
authors.lastname: Riley
mesh_terms: D000203:Activities of Daily Living; D000368:Aged; D003953:Diagnosis-Related Groups / Q000191:economics / Q000706:statistics & numerical data*; D005260:Female; D016330:Frail Elderly; D005102:Health Expenditures / Q000706:statistics & numerical data; D006279:Health Maintenance Organizations / Q000191:economics / Q000706:statistics & numerical data*; D006801:Humans; D015273:Insurance Selection Bias; D008137:Longitudinal Studies; D008297:Male; D020398:Medicare Part C / Q000191:economics*; D020379:Risk Adjustment / Q000379:methods*; D012866:Skilled Nursing Facilities / Q000191:economics / Q000706:statistics & numerical data; D014481:United States