Comparison of Risk Adjusters for Medicaid-Enrolled Children With and Without Chronic Health Conditions

  • Wenke Hwang
    Address correspondence to Wenke Hwang, PhD, Center for Hospital Finance and Management, Department of Health Policy and Management, 624 North Broadway, Hampton House 307, Baltimore, Md 21205
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  • Henry T. Ireys
    From the Department of Health Policy and Management, School of Hygiene and Public Health, Johns Hopkins University, Baltimore, Md (Dr Hwang and Dr Anderson) and Mathematica Policy Research Inc (Dr Ireys).
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  • Gerard F. Anderson
    From the Department of Health Policy and Management, School of Hygiene and Public Health, Johns Hopkins University, Baltimore, Md (Dr Hwang and Dr Anderson) and Mathematica Policy Research Inc (Dr Ireys).
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      Objective.—Several capitation payment systems have been developed and implemented recently by public and private insurers as well as by individual managed care organizations. Many pediatricians have expressed concern that methods for establishing capitation rates may not adequately account for the higher expected expenditures for children with chronic health conditions. In this study, we evaluate a demographic- and 4 diagnosis-based models, paying particular attention to their performance for children with chronic health conditions.
      Methods.—We selected children 18 years of age and under who were enrolled in the Maryland Medicaid Program in 1995 and 1996. We defined the population of children with chronic health conditions using ICD-9 codes. Individual and group-level analyses were utilized to measure the ability of the different risk adjustment models to predict expenditures in 1996 based upon information available in 1995.
      Results.—All 4 diagnosis-based models significantly outperformed the demographic model for children overall and for children with chronic health conditions. Differences between diagnosis-based models were small, especially as the size of test populations increased.
      Conclusions.—Risk adjustment methods that account directly for health status promise to reduce incentives to exclude children with chronic illnesses from managed care plans and to provide a foundation for more appropriate payments to pediatricians who care for these children.


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        • Newacheck P
        • Strickland B
        • Shonkoff J
        • et al.
        An epidemiologic profile of children with special health care needs.
        Pediatrics. 1998; 102: 117-123
        • Stein R
        • Johnson E
        Operationalizing a conceptually based noncategorical definition: a first look at US children with chronic conditions.
        Arch Pediatr Adolesc Med. 1999; 153: 68-74
        • Curtis D
        • Kaye N
        • Riley T
        Transitioning to Medicaid Managed Care: Children with Special Health Care Needs. National Academy for State Health Policy, Portland, Maine1999
        • Iglehart JK
        The American health system—Medicaid.
        N Engl J Med. 1999; 340: 403-408
        • McManus M
        • Fox H
        • Newacheck P
        • et al.
        Strengthening Partnerships Between State Programs for Children with Special Health Care Needs and Managed Care Organizations. Maternal and Child Health Policy Research Center, Washington, DC1996
        • Neff JM
        • Anderson GF
        Protecting children with chronic illness in a competitive marketplace.
        JAMA. 1995; 274: 1866-1869
        • Ireys HT
        • Grason HA
        • Guyer B
        Assuring quality of care for children with special needs in managed care organizations: roles for pediatricians.
        Pediatrics. 1996; 98: 178-185
        • Finkelstein JA
        Defining the challenge and opportunities for children in managed health care: a pediatrician's perspective.
        Future Children. 1998; 8: 138-140
        • Szilagyi PG
        Managed care for children: effect on access to care and utilization of health services.
        Future Children. 1998; 8: 39-59
        • American Medical Association.
        1998 Socioeconomic Monitoring System Surveys. American Medical Association, Chicago, Ill1999
        • Ireys HT
        • Anderson GF
        • Shaffer TJ
        • Neff JM
        Expenditures for care of children with chronic illnesses enrolled in the Washington State Medicaid program, fiscal year 1993.
        Pediatrics. 1997; 100: 197-204
        • Kronick R
        • Drefus T
        • Lee L
        • Zhou Z
        Diagnostic risk adjustment for Medicaid: the disability payment system.
        Health Care Financing Rev. 1996; 17: 7-33
        • Anderson GF
        • Bilenker JH
        Capitation payment rates and implications for the general pediatrician.
        Curr Opin Pediatr. 1998; 10: 480-485
        • Fowler EJ
        • Anderson GF
        Capitation adjustment for pediatric populations.
        Pediatrics. 1996; 98: 10-17
        • Weiner JP
        • Dobson A
        • Maxwell S
        • et al.
        Risk-adjusted Medicare capitation rates using ambulatory and inpatient diagnoses.
        Health Care Financing Rev. 1996; 17: 77-99
        • Dunn DL
        • Rosenblatt A
        • Taira DA
        • et al.
        A Comparative Analysis of Methods of Health Risk Assessment. Society of Actuaries, Schaumburg, Ill1996
        • Medicare Payment Advisory Commission.
        Report to the Congress: Medicare Payment Policy. Medicare Payment Advisory Commission, Washington, DC1999
        • Ingber M
        The current state of risk adjustment technology for capitation.
        J Ambu Care Manage. 1998; 21: 4-28
        • Johns Hopkins University, School of Hygiene and Public Health, Health Service Research Development Center.
        The Johns Hopkins University ACG Case Mix Adjustment system, Version 4.1. Johns Hopkins University, Baltimore, Md1998
        • DxCG Inc.
        Guide to the Diagnostic Cost Groups (DCGs) and DxCG Software, Release 3. DxCG Inc, Waltham, Mass1998
        • Ellis RP
        • Pope GC
        • Iezzoni LI
        • et al.
        Diagnosis-based risk adjustment for Medicare capitation payments.
        Health Care Financing Rev. 1996; 17: 101-128
        • Kronick R
        • Lee L
        • Dreyfus T
        • Zhou Z
        Disability Payment System SAS Program. University of California, San Diego, Ca1996
        • Dunn DL
        Application of health risk adjustment: what can be learned from experience to date?.
        Inquiry. 1998; 35: 132-147
        • Weiner J
        • Tucker A
        • Collins M
        • et al.
        The development of a risk-adjusted capitation payment system: the Maryland Medicaid model.
        J Ambu Care Manage. 1998; 21: 29-52
        • Kuhlthau DA
        • Perrin JM
        • Ettner S
        • et al.
        Characteristics of children with high expenditures enrolled in SSI.
        Pediatrics. 1998; 102: 610-615
        • Perrin JM
        • Kuhlthau K
        • McLaughlin TJ
        • et al.
        Changing patterns of conditions among children receiving SSI disability benefits.
        Arch Pediatr Adolesc Med. 1999; 153: 80-84
        • Anderson GF
        • Weller W
        Methods of reducing the financial risk to physicians under capitation.
        Arch Fam Med. 1999; 8: 149-155
        • Newacheck PW
        • Stoddard JJ
        • Huges DC
        • Pearl M
        Health insurance and access to primary care for children.
        N Engl J Med. 1998; 338: 513-519
        • Madden C
        • Skillman S
        • Mackay B
        Risk Distribution and Risk Assessment Among Enrollees in Washington State's Medicaid SSI Population. Center for Health Care Strategies Inc, Princeton, NJ1999
        • Muldoon JH
        Structure and performance of different DRG classification systems for neonatal medicine.
        Pediatrics. 1999; 103: 302-318
        • Muldoon JH
        • Neff JM
        • Gay JC
        Profiling health service needs of populations using diagnosis-based classification systems.
        J Ambu Care Manage. 1997; 20: 1-18
        • Shenkman EA
        • Breiner J
        Characteristics of risk adjustment systems Working paper series, no. 2. Institute for Child Health Policy, University of Florida, Gainesville, Fla2001