Field TS, Perrone C, Himmelstein J, Sachs-Leicher E; Association for Health Services Research. Meeting.
Abstr Book Assoc Health Serv Res Meet. 1998; 15: 144-5.
Medical School and Meyers Primary Care Clinic, University of Massachusetts, Worchester 01608, USA.
RESEARCH OBJECTIVES: The Commonwealth of Massachusetts has submitted a waiver application to HCFA requesting authority to implement a voluntary program which will integrate the service delivery and financing of Medicare and Medicaid services for dually eligible elders. If approved, the State would capitate Senior Care Organizations (SCOs) to provide the full range of acute and long term care services covered by the two programs. This paper assesses the advantages and disadvantages of survey-based and claims-based methodologies for risk adjusting Medicaid and Medicare payments for dually eligible elders in capitated programs. STUDY DESIGN: We conducted a review of the literature to assess the potential value of survey-based and claims-based methodologies for risk adjusting Medicaid and Medicare capitation payments for dually eligible elders. We also conducted structured interviews with selected public and private purchasers, health care organizations, and researchers. We compared survey-based and claims-based methodologies along six dimensions: ability to predict costs; impact on a provider's incentives and ability to engage in risk selection; impact on enrollee and provider participation; opportunities for gaming; and implementation costs. PRINCIPAL FINDINGS: Published research has focused on predicting Medicare's portion of the medical costs for this group and indicates that claims-based methods are modestly better than survey-based methods at estimating the cost of acute care. Among elders with functional limitations, however, survey-based risk adjustment methods contribute significantly to prediction of future Medicare expenditures, beyond that predicted by claims-based methods. There is scant published evidence on potentially important impacts of risk adjustment methodologies beyond their ability to predict expenditures. Little research has been conducted on risk adjustment of Medicaid payments for dually eligible elders. Indirect evidence suggests that survey-based methods are likely to provide more accurate prediction of Medicaid's portion of the costs for this population. CONCLUSIONS: Currently available evidence provides only a partial basis for selection of risk adjustment strategies by state Medicaid programs establishing capitated systems of care for dually eligible elders. Future research should focus on the development and testing of additional approaches to risk adjustment in this highly vulnerable and expensive population. IMPLICATIONS FOR POLICY: Dually eligible beneficiaries represent a disproportionate share of both Medicare and Medicaid program expenditures, but have largely been ignored by Medicare managed care organizations and excluded from state managed care initiatives. Since HCFA requires that enrollment in Medicare managed care be voluntary, states choosing to establish fully integrated programs for dually eligible beneficiaries must design payment systems which adequately address the potential for risk selection and support the development of responsive systems of care. Currently, however, there is very little information available to support decisions about what type of risk adjustment methodology would be most appropriate for capitating acute and long term care services for this population. Survey-based data appear to offer the greatest potential for capturing the information necessary to appropriately risk adjust payments for long term care services, but additional research is necessary to develop appropriate methodologies.
Publication Types:
Keywords:
- Data Collection
- Health Expenditures
- Managed Care Programs
- Massachusetts
- Medicaid
- Medicare
- Mental Health Services
- Risk Adjustment
- economics
- hsrmtgs
Other ID:
UI: 102234261
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