Question 1

What is risk adjustment?

Accepted Answer

an important part of any well-functioning healthcare system is being able to evaluate utilisation, effectiveness and/or cost of healthcare given when peforming such evaluation, it is is essential to understand the underlying factors influencing demand factors. adjusting for these underlying demand factors is referred to as risk adjustment.

Question 2

Briefly list what risk adjustment is useful for

Accepted Answer

Budgeting Measuring efficiency ​Risk management Measuring healthcare outcomes Provider profiling

Question 3

Describe how risk adjustment may be used for budgeting

Accepted Answer

Many countries distribute hospital budgets according to underlying demand of patients in districts measure by diagnosis related groups. DRG are clinical classification systems used to risk-adjust hospital costs. Risk-adjustment models can be used to calculate actual/true expected cost of new group of lives purchasing PMI products for pricing or reserving

Question 4

Describe how risk adjustment may be used for measuring effeciency

Accepted Answer

Adjusting for patient mix is necessary when comparing provider costs, as costs may differ due to various factors eg when comparing two hospital costs... ....hopsital A may be getting more cases of neurosurgery than hospital B... hence, hospital B would have a higher average costs per admission This is useful for price negotiations for purchasers/suppliers of healthcare network selection for insurance managing facilities efficiently

Question 5

Describe how risk adjustment may be used for risk management.

Accepted Answer

when a healthcare budget has been exceeded, it is important to determine if Supply and/or Demand factors have caused the potential excess appropriate risk management strategies can then be devised to curtail cost increases. for State hospitals, difficult to influence demand factors in open enrolment/community rating setting, difficult to influence demand through selection when healthcare budget is exceeded it is important to know whether this is due to demand or supply side factors.

Question 6

Describe how risk adjustment may be used for measuring healthcare outcomes.

Accepted Answer

measuring healthcare quality is important because value is both a function of cost efficiency and quality healthcare inflation has exceeded general inflation, thus want to channel patients to cost-efficient providers. risk adjustment is required for this comparison

Question 7

Describe how risk adjustment may be used for provider profiling.

Accepted Answer

in order to support sustainable healthcare insurers both locally and internationally share information with doctors on their generated costs compared to their peers on a like-for-like basis (i.e. risk adjusted basis). this information increases awareness amongst doctors on the economic impact of their clinical decisions.

Question 8

What should be factored in when considering the approach to take for a risk adjustment exercise?

Accepted Answer

The approach to risk adjustment depends on the purpose of the risk adjustment exercise. Approaches used may be: simple empirical risk adjustment/statistical modelling may be applied to the risk adjust data OR numerous off-the-shelf classification systems can be used for risk adjustment. data may be risk adjusted using these off-the-shelf software systems software packages typically require demographic info and clinical diagnosis

Question 9

What do we mean by a 'risk adjustment factor'? What needs to be considered when deciding on the risk adjustment factors to use in a risk adjustment exercise? List the 'categories' according to which risk factors may be classified.

Accepted Answer

Risk adjustment factors are factors which can be applied to healthcare data when we want to perform a risk adjustment exercise Cosiderations for risk adjustment factors The purpose of the risk adjustment excercise; pricing, contracting with new healthcare provider insured peril; eg if it is related to mortality, morbidity or retrenchment time frame under consideration; eg during acute in-hospital admission, next month or year? population being considered; eg in-hospital, paediatric patients, etc Risk adjustment factors fall into the followign major categories demographic factors clinical factors health-related behaviours socio-economic factor attitudes and perceptions

Question 10

List some examples of risk adjustment factors: demographic factors clinical factors health-related behaviours socio-economic factor attitudes and perceptions

Accepted Answer

Demographic factors 1. age 2. gender/sex 3. race Clinical factors 1. principal diagnosis 2. severity of principal diagnosis 3. mental health 4. physical functional status 5. acute physiological stability Health related factors 1. tobacco use 2. alcohol use 3. sexual practices 4. diet and nutrition 5. obesity Socio economic factors 1. educational attainment 2. housing characteristics 3. health insurance coverage 4. cultural beliefs Attitudes and perceptions 1. overall health status 2. religious behaviours 3. references and expectations for health care services

Question 11

In what way does age influence utilisation, effectiveness and/or cost of healthcare given?

Accepted Answer

ability of human body to recover from illnesses reduces with age older patients have worse clinical outcomes

Question 12

In what way does gender influence utilisation, effectiveness and/or cost of healthcare given?

Accepted Answer

Certain clinical conditions are sex specific male - prostate cancer femaile - breast cancer

Question 13

In what way does race influence utilisation, effectiveness and/or cost of healthcare given?

Accepted Answer

well-documented differences exist in disease prevalence by race once adjusted for socio-economic factors, disparities in healthcare between different enthic groups are greatly reduced, but still not elimininated.

Question 14

In what way does acute clinical stability influence utilisation, effectiveness and/or cost of healthcare given?

Accepted Answer

this relates to measures of a person's physiological functioning using homeostatic measures: eg. heart rate, body temperature, blood pressure these measures of acute clinical stability are needed to check if a given patient is facing imminent risk of death, and will thus influence the chance that healthcare provided will help in the intended way

Question 15

In what way does principal diagnosis influence utilisation, effectiveness and/or cost of healthcare given?

Accepted Answer

it is often necessary to understand the extent and severity of a principal diagnosis eg type of bacterial or viral infection for a patient diagnosed with gastritis this can play a role on the utuilisation, effectiveness and/or cost of healthcare given

Chapter 10 Risk adjustment Flashcards

-Evaluate the nature of risk facing the insurer. -Describe the principal modelling techniques appropriate to health and care insurance.

Brainscape's Knowledge GenomeTM

Chapter 10 Risk adjustment Flashcards

-Evaluate the nature of risk facing the insurer. -Describe the principal modelling techniques appropriate to health and care insurance.

Brainscape's Knowledge Genome^TM