Healthcare risk adjustment and predictive modeling:
Saved in:
| Main Author: | |
|---|---|
| Format: | Book |
| Language: | English |
| Published: |
Winsted, CT
ACTEX Publ.
2011
|
| Series: | Actex Professional Series
|
| Subjects: | |
| Links: | http://bvbr.bib-bvb.de:8991/F?func=service&doc_library=BVB01&local_base=BVB01&doc_number=024595548&sequence=000002&line_number=0001&func_code=DB_RECORDS&service_type=MEDIA |
| Item Description: | Literaturverz. S. 329 - 334 |
| Physical Description: | X, 338 S. graph. Darst. |
| ISBN: | 1566987695 9781566987691 |
Staff View
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Record in the Search Index
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| adam_text | Titel: Healthcare Risk Adjustment and Predictive Modeling
Autor: Duncan, Ian
Jahr: 2011
Contents
Section One
Introduction and Background 1
Chapter 1: Introduction to Health Risk..............................................................................3
1.1 What is Health Risk?..............................................................................3
1.2 Health Risk Management........................................................................7
1.3 What are Risk Adjustment and Risk Prediction?..................................11
Appendix: Clinical Risk - The Framingham Study........................................15
Chapter 2: Models for Predicting Health Costs................................................................17
2.1 Introduction...........................................................................................17
2.2 Non-Condition Risk-Based Models......................................................17
2.3 Risk Factor-Based RiskModels.............................................................23
2.4 Medical Condition-Based Risk.............................................................24
2.5 Lifestyle-Related Risk Factors..............................................................26
2.6 Exogenous Risk Factors........................................................................31
Chapter 3: Data: The Raw Material of Modeling.............................................................35
3.1 Overview...............................................................................................35
3.2 Physician Referral and Medical Charts.................................................36
3.3 Enrollment Data....................................................................................38
3.4 Medical Claims.....................................................................................39
3.5 Claims Costs.........................................................................................43
3.6 Paid Claims vs. Allowed Charges.........................................................44
3.7 Hospital Claims.....................................................................................46
3.8 Interpretation of Claims Codes.............................................................51
3.9 Pharmacy Claims..................................................................................53
3.10 Other Data Available from Non-Claims Sources.................................54
3.11 Survey Data...........................................................................................55
3.12 Conclusion............................................................................................56
Appendix 3.1 HCPCS Codes.........................................................................57
Appendix 3.2 CMS: Place of Service Codes.................................................58
Appendix 3.3 Type of Bill (TOB) Code.........................................................59
Appendix 3.4 Revenue Code Categories........................................................60
Appendix 3.5 Legislation Affecting the Use of Data.....................................62
Chapter 4: Clinical Identification Algorithms..................................................................65
4.1 Sensitivity-Specificity Trade-Off..........................................................70
4.2 Constructing an Identification Algorithm.............................................74
4.3 Sources of Algorithms..........................................................................75
Chapter 5: Grouper Models..............................................................................................79
5.1 Use of Grouper Models.........................................................................79
5.2 Drug Grouper Models...........................................................................88
Chapter 6: Development and Construction of DRGs, DCGs, and ETGs.........................93
6.1 History, Development, and Use of Diagnosis-Related Groups
(DRGs)..................................................................................................93
6.2 DxCG s Clinical Classification System................................................99
6.3 Comparison of Different Grouper Models.......................................... 107
Appendix: Examples of DRGs.....................................................................108
Section Two
Model Construction
109
Introduction to Modeling..............................................................................Ill
7.1 What is aModel?..................................... ZZZZZ......................Ill
7.2 Example of a Model Application........................................................112
7.3 Modeling Tools...................................................................................113
7.4 The Sample Database..........................................................................114
7.5 Modeling.............................................................................................117
7.6 Testing a Model s Reproducibility.....................................................131
7.7 Selecting Between Models.................................................................. 133
7.8 Variable Transformation.....................................................................134
7.9 Implementation and Computation.......................................................134
Appendix: List of Variables Available in the Test Dataset.........................136
Linear Regression Models............................................................................139
8.1 Model Specification and Assumptions...............................................139
8.2 Least Squares Estimation . .......140
8.3 ANOVA........................................ ^ ....................... ..............141
8.4 Statistical Inference...........ZZZZZZZZ! .....I. . ... .. ........I43
8.5 Prediction.............................. I . ......................ZZZ.........i43
8.6 Model Diagnostics............................... ™ ....................] ...................144
8.7 Example of Linear Regression................ . [....................I45
8.8 Flexibility of Linearity..........................ZIZZZZZ...................153
8.9 Summary........................... ................................. 156
The Generalized Linear Model................. ................157
9-1 Components of GLM..........................................................................158
9.2 Maximum Likelihood Estimation (MLE) Æ...............Z ZZZ......158
Ë ÉÔÔë1 Inference in GLM: LRT, Wald, and Score Tests...............I60
9.4 Model Selection in GLM.......... ...........162
9.5 Summary....................... ................................................ 164
Chapter 10: Logistic Regression Models.........................................................................165
10.1 Odds and Odds Ratio..........................................................................165
10.2 Estimation...........................................................................................167
10.3 Example of Logistic Regression.........................................................168
10.4 Predictive Accuracy............................................................................171
10.5 Optimal Cutoff Point...........................................................................172
10.6 ROC Curve.........................................................................................173
10.7 Summary.............................................................................................180
Chapter 11: Tree-Based Methods.....................................................................................181
11.1 Introduction.........................................................................................181
11.2 Tree Terminology...............................................................................182
11.3 Finding the Best Split..........................................................................184
11.4 Pruning and Tree Size Determination.................................................186
11.5 Use and Advantages of Tree-Based Methods.....................................187
11.6 Decision Tree: Example......................................................................188
11.7 Summary.............................................................................................194
Chapter 12: Artificial Neural Networks...........................................................................195
12.1 Multilayer Perceptron (MLP).............................................................196
12.2 Radial Basis Function (RBF) Networks..............................................197
12.3 Fitting Neural Networks.....................................................................199
12.4 Example of Artificial Neural Networks..............................................200
12.5 Summary.............................................................................................202
Section Three
Applications 203__________________
Chapter 13: Medicaid Risk Adjustment...........................................................................205
13.1 Background.........................................................................................205
13.2 Methodology.......................................................................................206
13.3 Newborn Model..................................................................................211
13.4 Application of the Methodology to Capitation Rate Adjustment.......213
Appendix: Acronyms and Other Regulatory References Used
in this Chapter...........................................................................217
Chapter 14: Risk Adjustment in Medicare.......................................................................219
14.1 Introduction.........................................................................................219
14.2 Medicare Risk Adjuster Methodology................................................220
14.3 Basic Steps Required to Prepare a Medicare Advantage Bid.............221
Appendix 14.1: Acronyms............................................................................230
Appendix 14.2: Plans Made Available to the Medicare Population.............234
Appendix 14.3: Key Acts Affecting Medicare Plans...................................236
Chapter 15: Risk Adjustment and Health Care Reform:
The Example of Massachusetts....................................................................239
15.1 Background.........................................................................................239
15.2 Risk Adjustment in the Commonwealth Care Program......................243
15.3 Choice and Calibration of the Risk Adjustment Model......................248
15.4 Practical Application of Adjustment in the Exchange........................251
Chapter 16: Developing and Using Predictive Models for
Care Management Programs.........................................................................253
16.1 Identification, Stratification, and Prediction.......................................253
Step 1: Choose a Disease or Condition..............................................254
Step 2: Intervenability........................................................................254
Step 3: Identify the Population..........................................................255
Step 4: Plan the Intervention..............................................................255
Step 5: Economic Modeling of the Proposed Program......................255
Step 6: Develop the Predictive Model...............................................262
Step 7: Test Actual Outcomes Against Predictions...........................262
Chapter 17: Provider Efficiency Assessment and Reimbursement Using
Risk Adjustment...........................................................................................263
17.1 Provider Efficiency Assessment.........................................................263
17.2 Impact of Provider Practice and Care Management on
Risk Adjustment.................................................................................267
17.3 An Empirical Study of Provider Reimbursement
and Independence of Outcomes..........................................................270
17.4 Implications for Exchanges.................................................................275
17.5 Conclusions.........................................................................................276
Chapter 18: Developing a Predictive Model for Depression Severity.............................277
18.1 Background..................... .....277
18.2 The Study....................... . . . . !!!. . . !!. . . !. . . . !. . !!. . . !!!. . . . . . . !!!. !!. . . .... 278
18.3 Conclusion............................................ ....I .!!! . ..!. !.......................286
Chapter 19: A Predictive Model for
19.2 The Modei.....zz;;;;;;;.....................................................................288
J94 Si10!06 °{p.ecision Tree-I;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;; 288
I9.5 SETEvaSn ** ^^^ °f Ì M°dd......................gj
19.6 Using the Model for Under^aZZ. . .....................................1298
Chapter 20: ncuiuuve éíéçðñßéç,,-,„^ n- v . ,. „ Ë „ç1
é Kisk Adjustment Outside the United States.........301
^fSS, f e United Stat
202 Sah °delmgtatheUnitedKingdom......................................301
20 3 SI ^JUStment ù the Netherlands...!.........................................311
I Adt i
204 R!T^JustmentinIsrael................. .................................... .318
?0A Risk Adjustment in South Africa.........ÉÉÉÆÉÎÉÆÎÆ... 321
Bibliography .
Index ................................................................................................................ 329
...............................................................................................................................335
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| id | DE-604.BV039748027 |
| illustrated | Illustrated |
| indexdate | 2024-12-20T16:01:26Z |
| institution | BVB |
| isbn | 1566987695 9781566987691 |
| language | English |
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| owner_facet | DE-83 |
| physical | X, 338 S. graph. Darst. |
| publishDate | 2011 |
| publishDateSearch | 2011 |
| publishDateSort | 2011 |
| publisher | ACTEX Publ. |
| record_format | marc |
| series2 | Actex Professional Series |
| spellingShingle | Duncan, Ian 1950- Healthcare risk adjustment and predictive modeling Prognose (DE-588)4047390-9 gnd Modellierung (DE-588)4170297-9 gnd Krankheitskosten (DE-588)4247917-4 gnd Gesundheitsgefährdung (DE-588)4071808-6 gnd |
| subject_GND | (DE-588)4047390-9 (DE-588)4170297-9 (DE-588)4247917-4 (DE-588)4071808-6 |
| title | Healthcare risk adjustment and predictive modeling |
| title_auth | Healthcare risk adjustment and predictive modeling |
| title_exact_search | Healthcare risk adjustment and predictive modeling |
| title_full | Healthcare risk adjustment and predictive modeling Ian Duncan |
| title_fullStr | Healthcare risk adjustment and predictive modeling Ian Duncan |
| title_full_unstemmed | Healthcare risk adjustment and predictive modeling Ian Duncan |
| title_short | Healthcare risk adjustment and predictive modeling |
| title_sort | healthcare risk adjustment and predictive modeling |
| topic | Prognose (DE-588)4047390-9 gnd Modellierung (DE-588)4170297-9 gnd Krankheitskosten (DE-588)4247917-4 gnd Gesundheitsgefährdung (DE-588)4071808-6 gnd |
| topic_facet | Prognose Modellierung Krankheitskosten Gesundheitsgefährdung |
| url | http://bvbr.bib-bvb.de:8991/F?func=service&doc_library=BVB01&local_base=BVB01&doc_number=024595548&sequence=000002&line_number=0001&func_code=DB_RECORDS&service_type=MEDIA |
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