The adjustment of premiums to compensate health plans for the risks associated with individuals who are more likely to require costly treatment. Risk adjustment takes into account the health status and risk profile of patients.
The statistical adjustment of outcomes measures to account for risk factors that are independent of the quality of care provided and beyond the control of the plan or provider, such as the patient's gender and age, the seriousness of the patient's illness, and any other illnesses the patient might have. Also known as case-mix adjustment. (2)
Comparing hospitals on their outcomes is difficult because different hospitals treat different types of patients. Some hospitals treat patients who are older or sicker than those at other hospitals. A technique called risk-adjustment accounts for these differences in patient characteristics. Risk factors are the patient demographic (e.g. age, gender) and clinical (e.g. diabetes, hypertension) characteristics that might influence the outcome of medical care.
A standardised method used to ensure intrinsic and extrinsic risk factors for a hospital acquired infection are considered in the calculation of hospital acquired infection rates
Method for adjusting capitation rates paid to health plans that takes into account a person's health status.
A system of adjusting rates paid to managed care providers to account for the differences in beneficiary demographics, such as age, gender, race, ethnicity. Medical condition, geographic location, at-risk population (i.e. homeless), etc.
Correction of capitation or fee rates based upon factors that can cause an increase in medical costs such as age or sex. In a broader context, it is the attempt to compensate insurers that take on a disproportionate share of those with medical conditions.
A statistical process used to identify and adjust for variation in patient outcomes that stem from the differences in patient characteristics (risk factors) from one home health agency to the next.
A process that takes into account the health status and risk profile of enrollees in certain health plans (e.g., severity of illness, comorbidity, consumption of cigarettes and alcohol) and shifts premium dollars from a plan with relatively healthy enrollees to another with sicker members; this process minimizes financial incentives plans may have to select healthier than average enrollees. Those that attract higher risk enrollees are thus compensated for any differences in the proportion of their members that require high levels of care.
A process by which premium dollars is shifted from a plan with relatively healthy enrollees to another with sicker members. It is intended to minimize any financial incentives health plans may have to select healthier than average enrollees. In this process health plans which attract higher risk providers and members would be compensated for any differences in the proportion of their members that require high levels of care compared to other plans.
This guide takes into account the fact that some hospitals take care of patients who are sicker or at greater risk of developing complications, than the "average" patient. Therefore, a “risk adjustment†method is used to make fair comparisons between hospitals. The actual numbers for length of stay and readmission are adjusted according to the severity of illness of each hospital’s patients. Each patient's other medical conditions, age, and other factors are considered in this calculation. For more information on risk adjustment, , select Technical Information on the sidebar and look in the “Risk Adjustment Methodology†section, or click here to select Technical Information.
A method used to predict resource consumption. A method used to compare and monitor clinical outcomes of care.
increases or reductions in the amount of payment made to a health plan on behalf of a group of enrollees to compensate for health care expenditures that are expected to be lower or higher than average.
The statistical adjustment of data in quality assessment to control for factors outside the influence of the healthcare system; used in comparing quality among different groups of providers or systems
A statistical method of paying managed care organizations different capitated payments based on the composition and relative healthiness of their beneficiaries. This procedure would generally compensate providers of HIV services with a higher capitated payment than providers of other (often less costly) health care services.
