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PROJECT TOPIC: IMPACT OF NON-TRADITIONAL VARIABLES IN HEALTH CARE RISK ADJUSTMENT (A CASE STUDY OF UTH, UYO, AKWAIBOM)

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CHAPTER ONE INTRODUCTION Background of the study The business of risk adjustment has come a long way since the publication of the Academy’s “Monograph Number One” with the title, “Health Risk Assessment and Health Risk Adjustment—Crucial Elements in Effective Health Care Reform” in May 1993. Less than ten years later, we had hospital inpatient diagnosis-based approaches, such as the model used by the Market Stabilization Pool for small group and individual coverage in NYS in conjunction with mandated community rating. The PIP-DCG approach for Medicare + Choice, also inpatient only, soon followed. Risk adjustment models have included variables such as demographic (i.e. age and gender) and clinical markers based either on ICD-9 diagnosis codes and/or pharmacy codes such as the National Drug Codes (NDCs). Literature points to other variables such as geography, Body Mass Index (BMI), education, and income that also explain the variation in healthcare cost – but have hitherto not been included in risk adjustment programs mainly because such variables are not typically found in claim data. If these nontraditional variables explain meaningful variation in cost beyond traditional risk adjustment models – then this may provide incentives for issuers to select certain members. If such incentives lead to selection that Health Care:The organized provision of medical care to individuals or a community. Non-traditional:Not conforming to or in accord with tradition. Risk Adjustment:A concept that refines an investment’s return by measuring how much risk is involved in producing that return.


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