RESUMEN
OBJECTIVES: This study compares the ability of 3 risk-assessment models to distinguish high and low expense-risk status within a managed care population. Models are the Global Risk-Assessment Model (GRAM) developed at the Kaiser Permanente Center for Health Research; a logistic version of GRAM; and a prior-expense model. GRAM was originally developed for use in adjusting Medicare payments to health plans. METHODS: Our sample of 98,985 cases was drawn from random samples of memberships of 3 staff/group health plans. Risk factor data were from 1992 and expenses were measured for 1993. Models produced distributions of individual-level annual expense forecasts (or predicted probabilities of high expense-risk status for logistic) for comparison to actual values. Prespecified "high-cost" thresholds were set within each distribution to analyze the models' ability to distinguish high and low expense-risk status. Forecast stability was analyzed through bootstrapping. RESULTS: GRAM discriminates better overall than its comparators (although the models are similar for policy-relevant thresholds). All models forecast the highest-cost cases relatively well. GRAM forecasts high expense-risk status better than its comparators within chronic and serious disease categories that are amenable to early intervention but also generates relatively more false positives within these categories. CONCLUSIONS: This study demonstrates the potential of risk-assessment models to inform care management decisions by efficiently screening managed care populations for high expense-risk. Such models can act as preliminary screens for plans that can refine model forecasts with detailed surveys. Future research should involve multiple-year data sets to explore the temporal stability of forecasts.
Asunto(s)
Predicción , Costos de la Atención en Salud/tendencias , Necesidades y Demandas de Servicios de Salud/tendencias , Tecnología de Alto Costo/estadística & datos numéricos , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Manejo de Caso/estadística & datos numéricos , Manejo de Caso/tendencias , Niño , Preescolar , Femenino , Costos de la Atención en Salud/estadística & datos numéricos , Humanos , Lactante , Recién Nacido , Masculino , Persona de Mediana Edad , Medio Oeste de Estados Unidos , Noroeste de Estados Unidos , Curva ROC , Medición de Riesgo/estadística & datos numéricos , Medición de Riesgo/tendencias , Sensibilidad y EspecificidadRESUMEN
This study is a retrospective examination of data from a prepaid group practice that introduced a change in surgical services so that about 35 per cent of patients having surgery in the operating room were not admitted to the hospital. The study population is the membership of the Oregon Region of the Kaiser Foundation Health Plan for the period 1966 through 1974. The data come from 100 per cent of the hospital admissions and 100 per cent of the ambulatory (nonadmit) surgical procedures. This study examines the costs, quality of care, and satisfaction of providers and patients with ambulatory surgery. Cost savings for the ambulatory procedures averaged +192.19 per procedure (based on 1977 costs). National savings for 1977 were projected at +773,947,208. In addition, ambulatory surgery absorbed an increasing demand for surgical procedures without requiring additional hospital beds. No difference in quality of care were found for inpatients and ambulatory patients (both used the same operating rooms and staff), and both providers and patients were found to be very satisfied with ambulatory surgery services.