Risk adjustment

Within a population, health status varies across networks and regions. To account for differences, cost categories are risk adjusted for each clinical and demographic cohort.

Risk adjustment standards

Risk adjusting aligns the analysis of population groups to a common standard and allows an accurate performance comparison. Risk adjusting data for each population group involves three concepts:

  • Observed value—could be expressed by the number of visits or cases for members attributed to that network
  • Budget value—the expected utilization of a population adjusted for gender, age cohort, enrollment status and 3M clinical risk groups (CRGs)
  • CRGs use standard claims data to assign each patient to a single, mutually exclusive risk category, and risk groups are weighted appropriately
  • Percent difference