Table 5. Determining Year 2 Capitation Rates For Five Health Plan Enrollees Using Year 1 Risk Measures.
| Enrollee | Risk-Adjustment Models | ||
|---|---|---|---|
|
| |||
| ADG-MDC | ADG-Hosdom | “AAPCC” | |
| Enrollee 1 (No Health System Encounters) | |||
| Male | $604 | $613 | $732 |
| 85 Years (20 Years * Payment Weight) | 1,340 | 1,280 | 2,160 |
| Base Cost (Model Intercept) | 608 | 434 | 1.893 |
|
|
|
|
|
| Capitation Rate | 2,552 | 2,327 | 4,785 |
| Enrollee 2 (No MDCs, 3 ADGs) | |||
| Male | 604 | 613 | 732 |
| 85 Years | 1,340 | 1,280 | 2,160 |
| Base Cost (Model Intercept) | 608 | 434 | 1,893 |
|
|
|||
| Depression (ADG 23) | 698 | 1,222 | |
| Gastric Ulcer (ADG 7) | 225 | 365 | |
| Coronary Atherosclerosis (ADG 11) | 1,345 | 1,415 | |
|
|
|
||
| Capitation Rate | 4,820 | 5,329 | 4,785 |
| Enrollee 3 (No MDCs, 3 ADGs, Hosdom Marker) | |||
| Male | 604 | 613 | 732 |
| 85 Years | 1,340 | 1,280 | 2,160 |
| Base Cost (Model Intercept) | 608 | 434 | 1,893 |
|
|
|||
| Depression (ADG 23) | 698 | 1,222 | |
| Gastric Ulcer (ADG 7) | 225 | 356 | |
| Coronary Atherosclerosis (ADG 11) | 1,345 | 1,415 | |
| Hosdom Diagnosis Marker | 0 | 1.749 | |
|
|
|
||
| Capitation Rate | 4,820 | 7,078 | 4,785 |
| Enrollee 4 (2 MDCs, 6 ADGs, Hosdom Marker) | |||
| Male | 604 | 613 | 732 |
| 85 Years | 1,340 | 1,280 | 2,160 |
| Base Cost (Model Intercept) | 608 | 434 | 1,893 |
|
|
|||
| Depression (ADG 23) | 698 | 1,222 | |
| Gastric Ulcer (ADG 7) | 225 | 365 | |
| Coronary Atherosclerosis (ADG 11) | 1,345 | 1,415 | |
| Corneal Edema (ADG 3) | 542 | 663 | |
| Diabetes (ADG 9) | 965 | 1,696 | |
| Heart Palpitations (ADG 27) | 460 | 568 | |
| 2 Circulatory Admissions (MDC 5 × 2) | 3,794 | 0 | |
| or 1 Hosdom Diagnosis Marker | 0 | 1,749 | |
|
|
|
||
| Capitation Rate | 10,581 | 10,005 | 4,785 |
| Enrollee 5 (4 MDCs, 6 ADGs, Hosdom Marker) | |||
| Male | 604 | 613 | 732 |
| 85 Years | 1,340 | 1,280 | 2,160 |
| Base Cost (Intercept) | 608 | 434 | 1.893 |
|
|
|||
| Depression (ADG 23) | 698 | 1,222 | |
| Gastric Ulcer (ADG 7) | 225 | 365 | |
| Coronary Atherosclerosis (ADG 11) | 1,345 | 1,415 | |
| Corneal Edema (ADG 3) | 542 | 663 | |
| Diabetes (ADG 9) | 965 | 1,696 | |
| Heart Palpitations (ADG 27) | 460 | 568 | |
| 2 Circulatory Admissions (MDC 5 × 2) | 3,794 | 0 | |
| or 1 Hosdom Diagnosis Marker | 0 | 1,749 | |
| 2 Respiratory Admissions (MDC 3 × 2) | 6.474 | 0 | |
|
|
|
||
| Capitation Rate | 17,055 | 10,005 | 4,785 |
NOTES: ADG-MDC is ambulatory diagnostic group-major diagnostic category. ADG-Hosdom is ambulatory diagnostic group-hospital dominant diagnosis. AAPCC is adjusted average per capita cost. HCFA's actual AAPCC system is approximated in this study by incorporating age, sex, Medicaid eligibility, and prior disability status into a linear regression model. See Tables 2 and 3 for weights associated with each risk measure.
SOURCE: Analyses on 1991-92 project data by authors during 1994-95.