Medicaid Managed Care - U.S. Senate Special Committee on Aging

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Ckspt. 4
JUek-Mtod Rate Wd HIa hn. Ca
fldP Rdi l.wtr to Utr e
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Figur 4.1: Ohio's Risk-Adjustsd
Capitation Rats. and the Parsmntge of P.nbtp d Doll PWInW
Disabled Populston at Each Rals
person spent several days in the hospital in the last year or a
lower-than-average rate if the person spent no time in the hospital or did
not visit the doctor in the last year.
To set capitation rates for its disabled population, Ohio is moving forward
with a pilot project that uses a beneficiary's prior utilization (measured in
dollars) in the fee-for-service system. This program, called Accessing
Better <strong>Care</strong>, uses eight rate cells for the disabled population. Seven of the
cells are based on prior expenditures, and the eighth is for newly eligible
beneficiaries. Monthly capitation rates range from $165 (for beneficiaries
with prior annual costs of $1,000 or less) to $4,501 (for beneficiaries with
prior annual costs of $50,000 or more). Figure 4.1 shows how Ohio's
disabled beneficiaries are distributed among the seven prior-expenditure
categones3' More than half of all disabled beneficiaries are in the
lowest-cost cell.
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40
Risk Adjustmrent Using Another approach predicts future health care costs using beneficiaries'
Clinical Diagnosis individual clinical diagnoses. Various methods to identify or classify
diagnoses can be used, employing inpatient data, outpatient data, or both.
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