Chapter 10 Risk adjustment Flashcards

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

1
Q

What is risk adjustment?

A
  • evaluation of utilisation levels and and/or cost is essential to understand the underlying factors influencing demand factors.
  • Adjusting for these underlying demand factors is referred to as risk adjustment.
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2
Q

Choosing risk-adjustment method requires what considerations?

A
  • PERIL (Is the insured peril related to mortality, morbidity or retrenchment?)
  • TIME FRAME (What is the time frame under consideration eg during acute in-hospital admission, next month or year?)
  • POPULATION (What population is being considered? eg in-hospital, paediatric patients, etc)
  • PURPOSE (What is the purpose eg pricing, contracting with healthcare provider?)
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3
Q

Example of risk factors?

A

demographics

  • age
  • gender/sex
  • race

clinical factors

  • principal diagnosis
  • severity of principal diagnosis
  • metal health
  • physical functional status
  • acute physiological stability

health related

  • tobacco use
  • alcohol use
  • sexual practices
  • diet & nutrition
  • obesity

Socio economic factors

  • educational attainment
  • housing characteristics
  • health insurance coverage
  • cultural beliefs

Attitudes & perceptions

  • overall health status
  • religious behaviours
  • references and expectations for health care services
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4
Q

Risk factors can be classified into

A
  • demographics
  • clinical factors
  • health-related behaviours
  • socio-economic factors
  • attitudes and perceptions
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5
Q

Risk factor: age

A

-ability of human body to recover from illnesses reduces with age.

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6
Q

Risk factor: gender

A
  • Certain clinical conditions are sex specific.
  • male - prostate cancer
  • femaile breast cancer
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7
Q

Risk factor: race

A
  • 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.
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8
Q

Risk factor: acute clinical stability

A
  • measure a person’s physiological functioning using homeostatic measures:
  • heart rate, body temperature
  • blood pressure
  • this is needed to check if patient is facing imminent risk of death.
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9
Q

Risk factor: principal diagnosis

A

-It is often necessary to understand the extent & severity of a principal diagnosis eg type of bacterial or viral infection for a patient diagnosed with gastritis.

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10
Q

Risk factor: Co-morbidities

A
  • refers to a clinical condition which exists simultaneously with another condition, usually independently of another medical condition.
  • eg diabetes and a heart condition.
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11
Q

Risk factor: Functional status

A
  • often referes to observable basic activities of daily living(ADL) and instrumental ADLs.
  • ADL egs: feeding,washing, toileting
  • instrumental ADLs : shopping, cooking
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12
Q

Risk factors:Socio-economic status

A
  • Studies have shown that it is important to adjust for socio-economic factors when comparing healthcare outcomes.
  • poor living standard and nutrition contribute to morbidity risk.
  • doctors may keep patients with lower socio-economic status in hospitals longer they believe home conditions are not conducive for recuperation.
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13
Q

Risk factors: Lifestyle factors

A
  • many lifestyle factors influence morbidity: eg alcohol use, smoking, use of illicit drugs.
  • these can be closely linked with chronic conditions.
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14
Q

Access to benefits/insurance option

A
  • access to benefit /insurance option is a critical factor in understanding the change in healthcare costs from one time period to the next.
  • it may seem healthcare costs are decreasing over time but it means policyholders just chose cheaper insurance options with less comprehensive cover.
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15
Q

Risk adjustment is useful for ?

A
  • budgeting
  • measuring efficiency
  • risk management
  • measuring healthcare outcomes
  • provider profiling
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16
Q

Budgeting

A
  • Many countries distribute hospital budgets according to underlying demand of patients in districts measure y diagnosis related groups.
  • DRG are clinical classification systems used to risk-adjust hospital costs.
  • Risk-adjustment models can be used to calculate expected cost of new group of lives purchasing PMI products
17
Q

Measuring efficiency

A
  • Adjusting for patient mix is necessary when comparing two hospital costs.
  • Hopsital A may be getting more cases of neurosurgery than B hence higher average costs per admission.
  • Comparing facility efficiency is useful for:
  • price negotiations for purchasers
  • network selection
  • managing facilities efficiently
18
Q

Risk management

A
  • when healthcare budget is exceeded it is important to know whether this is due to demand or supply side factors.
  • Appropriate risk management strategies can then be devised to curtail cost increases.
19
Q

Measuring healthcare outcomes

A

-Measuring healthcare quality is important because value is both a function of cost efficiency and quality.

20
Q

Provider profiling

A
  • in order to support sustainable healthcare insurers both locally and internationally share information with doctors on their generated costs compared to their peers on like-for-like basis (i.e. risk adjusted).
  • this information increases awareness amongst doctors on the economic impact of their clinical decisions.
21
Q

Common population classification systems

A
  • numerous off-the-shelf classification systems can be used for risk adjustment.
  • software packages typically require demographic info and clinical diagnosis.
22
Q

Case mix index formula

A

=Sum of admission cost weighs/count of admissions