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

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Sources Ash A, Porell F, Gruenberg Let al: Adjusting Medicare capization
payments using prior hospitalization data. Health <strong>Care</strong> Financing
Review. 10:17-S0, 1989.
3. Disabilty Payment System (DPS)
Ellis RP, Pope GC, lezzoni LI, Ayanian JZ, Bates DW, Burstin H.
Ash AS: Diagnosis-based risk adjustment for Medicare capitation
payments. Health <strong>Care</strong> Financing Review. 17:101-128, 1996.
Ellis RP, Ash A: Refining the diagnostic cost group model: a
proposed modifcation to the AAPCCfor HMO reimbursement.
Report prepared under HCFA Cooperative Agreement No. 18-C-
98526/1-03. Boston University, 1988.
Purpose Capitation and risk adjustment for disabled <strong>Medicaid</strong> recipients
Predictors Diagnosis, age, and gender
Method Classification system based on groups of diagnoses that are associated
with elevated future costs. These are divided into 18 major
categories that correspond to either body system or specific types of
illness or disability. These 18 categories are divided into 43
subcategories according to degree of elevated future costs (high,
medium, and low cost).
Testing and Use Claims data for disabled <strong>Medicaid</strong> SSI recipients in Ohio and
Missouri and then tested on <strong>Medicaid</strong> claims data from Colorado,
Michigan, and New York. Colorado and Missouri are planning to
use this method. Maryland, Massachusetts, Minnesota, and
Washington are also considering it.
Strengths * Individuals can be classified into more than one group.
* Adjusts for degree of elevated costs.
* Data to implement DPS are available.
limits * Developed originally for SSI adults, now being applied to SSI
adults and children, and AFDC populations.
* Less serious diagnoses associated with lower future costs were
excluded from the system.
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