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Prediction of Health Care Cost Using the Hierarchical Condition Category Risk Adjustment Model

위계적 질환군 위험조정모델 기반 의료비용 예측

  • Han, Ki Myoung (Department of Preventive Medicine and Public Health, Ajou University School of Medicine) ;
  • Ryu, Mi Kyung (Department of Sport and Leisure Studies, Kyonggi University College of Physical Education) ;
  • Chun, Ki Hong (Department of Preventive Medicine and Public Health, Ajou University School of Medicine)
  • 한기명 (아주대학교 의과대학 예방의학과) ;
  • 유미경 (경기대학교 체육대학 사회체육학과) ;
  • 전기홍 (아주대학교 의과대학 예방의학과)
  • Received : 2017.02.09
  • Accepted : 2017.03.31
  • Published : 2017.06.30

Abstract

Background: This study was conducted to evaluate the performance of the Hierarchical Condition Category (HCC) model, identify potentially high-cost patients, and examine the effects of adding prior utilization to the risk model using Korean claims data. Methods: We incorporated 2 years of data from the National Health Insurance Services-National Sample Cohort. Five risk models were used to predict health expenditures: model 1 (age/sex groups), model 2 (the Center for Medicare and Medicaid Services-HCC with age/sex groups), model 3 (selected 54 HCCs with age/sex groups), model 4 (bed-days of care plus model 3), and model 5 (medication-days plus model 3). We evaluated model performance using $R^2$ at individual level, predictive positive value (PPV) of the top 5% of high-cost patients, and predictive ratio (PR) within subgroups. Results: The suitability of the model, including prior use, bed-days, and medication-days, was better than other models. $R^2$ values were 8%, 39%, 37%, 43%, and 57% with model 1, 2, 3, 4, and 5, respectively. After being removed the extreme values, the corresponding $R^2$ values were slightly improved in all models. PPVs were 16.4%, 25.2%, 25.1%, 33.8%, and 53.8%. Total expenditure was underpredicted for the highest expenditure group and overpredicted for the four other groups. PR had a tendency to decrease from younger group to older group in both female and male. Conclusion: The risk adjustment models are important in plan payment, reimbursement, profiling, and research. Combined prior use and diagnostic data are more powerful to predict health costs and to identify high-cost patients.

Keywords

References

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