[Federal Register Volume 63, Number 173 (Tuesday, September 8, 1998)]
[Notices]
[Pages 47506-47513]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 98-24085]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Care Financing Administration
[HCFA-1045-N]
RIN 0938-AJ16


Medicare Program: Request for Public Comments on Implementation 
of Risk Adjusted Payment for the Medicare+Choice Program and 
Announcement of Public Meeting

AGENCY: Health Care Financing Administration (HCFA), HHS.

ACTION: Solicitation of comments; announcement of meeting.

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SUMMARY: This notice solicits further public comments on issues related 
to the implementation of risk adjusted payment for Medicare+Choice 
organizations. Section 1853(a)(3) of the Social Security Act (the Act) 
requires the Secretary to implement a risk adjustment methodology that 
accounts for variation in per capita costs based on health status and 
demographic factors for payments no later than January 1, 2000. The 
methodology is to apply uniformly to all Medicare+Choice plans. This 
notice outlines our proposed approach to implementing risk adjusted 
payment.
    In order to carry out risk adjustment, section 1853(a)(3) of the 
Act also requires Medicare+Choice organizations, as well as other 
organizations with risk sharing contracts, to submit encounter data. 
Inpatient hospital data are required for discharges on or after July 1, 
1997. Other data, as the Secretary deems necessary, may be required 
beginning July 1998.
    The Medicare+Choice interim final rule published on June 26, 1998 
(63 FR 34968) describes the general process for the collection of 
encounter data. We also included a schedule for the collection of 
additional encounter data. Physician, outpatient hospital, skilled 
nursing facility, and home health data will be collected no earlier 
than October 1, 1999, and all other data we deem necessary no earlier 
than October 1, 2000. Given any start date, comprehensive risk 
adjustment will be made about three years after the year of initial 
collection of outpatient hospital and physician encounter data. 
Comments on the process for encounter data collection are requested in 
that interim final rule. We intend to consider comments received in 
response to this solicitation as we develop the final methodology for 
implementation of risk adjustment.
    This notice also informs the public of a meeting on September 17, 
1998, to discuss risk adjustment and the collection of encounter data. 
The meeting will be held at the Health Care Financing Administration 
headquarters, located at 7500 Security Boulevard, Baltimore, MD, 
beginning at 8:30 a.m. Additional materials on the risk adjustment 
model will be available on or after October 15, 1998, and may be 
requested in writing from Chapin Wilson, Health Care Financing 
Administration, Department of Health and Human Services, 200 
Independence Avenue, S.W., Room 435-H, Washington, DC 20201.

DATES: We request that comments be submitted on or before October 6, 
1998.

ADDRESSES: Mail written comments (1 original and 3 copies) to the 
following address: Health Care Financing Administration, Department of 
Health and Human Services, Attention: HCFA-1045-N, P.O. Box 26688, 
Baltimore, MD 21207.
    If you prefer you may deliver your written comments (1 original and 
3 copies) to one of the following addresses:

Room 309-G, Hubert H. Humphrey Building, 200 Independence Avenue, SW., 
Washington, DC 20201, or
Room C5-09-26, 7500 Security Boulevard, Baltimore, MD 21244-1850

    Because of staffing and resource limitations, we cannot accept 
comments by facsimile (FAX) transmission. In commenting, please refer 
to file code HCFA-1045-N. Comments received timely will be available 
for public inspection as they are received, generally beginning 
approximately 3 weeks after publication of a document, in Room 309-G of 
the Department's offices at 200 Independence Avenue, SW., Washington, 
DC, on Monday through Friday of each week from 8:30 a.m. to 5 p.m. 
(phone (202) 686-7890).

FOR FURTHER INFORMATION CONTACT: Cynthia Tudor, (410) 786-6499.

SUPPLEMENTARY INFORMATION:

I. Background

    Since 1985, Medicare payments to risk contracting Health 
Maintenance Organizations (HMOs) for aged and disabled beneficiaries 
living in a given county have been based on actuarial estimates of the 
per capita cost Medicare incurs paying claims on a fee-for-service 
(FFS) basis in that county. (Medicare's costs in paying claims for 
beneficiaries with end-stage renal disease are not considered in these 
county estimates, but are treated separately on a statewide basis.) 
These county estimates have been adjusted for the demographic 
composition of that county (age, gender, Medicaid eligibility status, 
and institutional status) in order to produce a figure representing the 
costs that would be incurred by Medicare on behalf of an average 
Medicare beneficiary in the county. These county per capita payment 
rates, adjusted for the average beneficiary, have been published 
annually as the county rate book. Prior to January 1998, actual 
payments for a given HMO enrollee were based on this county rate book 
amount, adjusted by demographic factors associated with each enrollee. 
Again, the demographic factors have been age, gender, Medicaid 
eligibility, and institutional status. This methodology is known as the 
``Adjusted Average Per Capita Cost'' (AAPCC) methodology, and HMOs with 
Medicare contracts under section 1876 of the Social Security Act (the 
Act) were paid on this basis between 1985 and 1997.

[[Page 47507]]

    In enacting the new Part C of Title XVIII to create the 
Medicare+Choice program, the Congress provided, a new section 1853 of 
the Act, for a new methodology for paying organizations that enter into 
Medicare+Choice contracts. Under this new methodology, the equivalent 
of the above-described county rate book (that is, the county-wide 
amount that is adjusted by an individual enrollee's demographic status 
to determine the final payment amount) is based on the greatest of 
three amounts. The first amount is a new blended payment rate 
methodology that would combine the area specific amounts with national 
data and would be subject to other adjustments. The second amount is a 
new minimum specified rate amount (for example, $367 per month per 
enrollee in 1998). The third amount is based on a 2 percent increase 
over the prior year's rates, with the rate book for 1997 serving as the 
baseline. As in the case of the AAPCC methodology described above, the 
county rates under section 1853 of the Act, are adjusted for the 
demographic status of each enrollee.
    Under section 1876(k)(3) of the Act, the new Medicare+Choice 
payment methodology under section 1853 of the Act applies to existing 
HMO contracts under section 1876 for 1998, and to Medicare+Choice plans 
beginning in 1999.
    Section 1853(a)(3) of the Act requires the Secretary to develop and 
implement a new risk adjustment methodology to be used to adjust the 
county-wide rates under section 1853 of the Act to reflect the expected 
relative health status of each enrollee. This new methodology, which 
must be implemented by January 1, 2000, would replace the current 
method of adjusting county-wide rates based on the four demographic 
factors of age, gender, Medicaid eligibility, and institutional status. 
The goal is to pay Medicare+Choice organizations based on better 
estimates of health care costs of the population they enroll (relative 
to the FFS population).
    While the Medicare+Choice legislation mandates the implementation 
of risk adjustment in general, the legislation provides the Secretary 
with broad discretion to develop a risk adjustment methodology that 
would ``account for variations in per capita costs based on health 
status and other demographic factors.'' Because Medicare+Choice 
legislation does not allow for the collection of any data other than 
inpatient hospital data (in the near term), we are constrained 
initially to using a model that requires only inpatient data. We are 
currently receiving these data. In previous public meetings on 
encounter data requirements, organizations have been briefed on the 
Principal Inpatient Diagnostic Cost Group (PIP-DCG), created by HHS-
sponsored researchers at Health Economics Research, Inc., and Boston 
and Brandeis. This is the only risk adjuster model that has been 
developed to run solely on inpatient data. The model was recently 
updated using 1995 and 1996 Medicare data.
    The remainder of this notice outlines our proposed approach for 
implementation of risk adjusted payments on January 1, 2000, discussing 
both the risk adjustment methodology and the proposed risk adjustment 
payment model. In the development of all risk adjustment payment 
models, there are two tasks that must be performed: (1) The estimation 
of the risk adjustment model, and (2) application of the risk 
adjustment model to a payment system. The estimation of the PIP-DCG 
model is described first.

A. The Principal In-Patient Diagnostic Cost Group (PIP-DCG) Model

    In constructing a risk adjustment model, it is important to 
determine which set of conditions should be used to adjust payments. 
Under the current payment system, all enrollees are placed in a base 
group paid according to demographic characteristics. In this risk 
adjustment system, all conditions that appear as inpatient principal 
diagnoses are candidates for adjusting payments. The base payment 
category decreases as more conditions are placed into separate disease 
groups. Because an inpatient hospital-based system depends on a 
person's site of service, only a subset of conditions should be 
recognized for changing payments. That is, the system should recognize 
admissions for which inpatient care is most frequently appropriate. For 
example, admissions for diseases most commonly treated on an outpatient 
basis should remain in the base group and should not be used for 
adjustment.
    The PIP-DCG model was estimated using diagnostic information for 
Medicare FFS enrollees from inpatient hospital stays during calendar 
year 1995. The sample used in the estimation analyses consisted of 
individuals included in the 5-percent sample of Medicare beneficiaries 
who were alive and enrolled in Medicare during all of 1995, and on 
January 1, 1996. Beneficiaries with certain characteristics (for 
example, HMO enrollees and end-stage renal disease enrollees, new 
Medicare eligibles in 1996) were excluded from the analyses. In 
general, these exclusions were made to increase confidence that a 
complete set of Medicare claims for each beneficiary in the sample data 
set was included in the model development. The final estimation data 
set included 1.4 million Medicare beneficiaries.
    While the PIP-DCG model uses only inpatient diagnoses in creating 
the risk adjustment classification system, the model predicts total 
expected costs for the following year across multiple sites of 
services. Consequently, all Medicare expenditures, other than those for 
hospice care, were included in the calculation. Medicare expenditures 
for hospice care were not included because Medicare+Choice 
organizations are not responsible for hospice care. The model was 
estimated assuming no time lag between the base year (diagnostic 
information) and the predicted expenditures; that is, calendar year 
1995 beneficiary diagnoses were used to predict calendar year 1996 
expenditures.
1. From Diagnosis Groups (DxGroups) to PIP-DCGs
    The risk adjustment model estimation process begins with a 
classification system, forming the inherent logic of the model. For the 
PIP-DCG model, diagnoses are classified into DxGroups based on the 
principal inpatient diagnosis. The DxGroups comprise an exhaustive 
classification of all valid International Classification of Diseases, 
Ninth Revision, Clinical Modification (ICD-9-CM) diagnostic codes. For 
example, DxGroup 1, Central Nervous System Infections, includes ICD-9-
CM diagnostic codes for such conditions as encephalitis and meningitis. 
The primary criteria in forming the DxGroups were clinical coherence 
and an adequate sample size to estimate average expenditures. 
Beneficiaries with multiple different inpatient diagnoses could have 
multiple hospital stays, and would initially be placed in multiple 
DxGroups.
    Next, DxGroups were aggregated into payment groups, or PIP-DCGs, 
using a sorting algorithm that ranked DxGroups based on 1996 actual 
expenditures. For example, DxGroup 7 (Metastatic Cancer with a mean 
future expenditure of $26,331) was placed in PIP-DCG 26. Highest 
expenditure DxGroups were grouped into the ``highest'' PIP-DCG. Once 
beneficiaries with the highest costs were placed into a DxGroup, those 
beneficiaries and all their associated expenditures were removed from 
the data for other DxGroups and then the DxGroups were re-ranked. The 
DxGroups with the next most costly diagnoses were grouped into the next 
highest numbered PIP-DCG, and those beneficiaries were removed from the

[[Page 47508]]

remaining DxGroups. The process was repeated until each beneficiary and 
his or her expenditures were assigned to a single PIP-DCG group. 
Beneficiaries with multiple inpatient diagnoses were placed in their 
highest expenditure PIP-DCG group.
    In this way, each PIP-DCG group was defined according to average 
total expenditures for beneficiaries with inpatient diagnoses, 
categorized and sorted using the DxGroups rather than diagnosis by 
diagnosis. Based upon this sorting algorithm, more than 20 initial PIP-
DCGs were defined. Lower average expenditure PIP-DCG groups had lower 
cost ranges (or intervals), while the highest average expenditure PIP-
DCG groups had wider ranges.1
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    \1\ The PIP-DCG groupings were further refined using a number of 
criteria. First, each original PIP-DCG group remained in the final 
payment model only if it contained at least 1,000 beneficiaries from 
the original sample; this minimum sample size was defined to assure 
stability of estimated payments in the final model. If sample sizes 
were smaller than 1,000, the potential PIP-DCG was expanded to 
include DxGroups with average expenditures in the next lower range 
until the sample size criteria was satisfied. If at any time during 
the sorting algorithm a DxGroup had fewer than 50 beneficiaries 
assigned to it, it was assigned to the base payment category. This 
base payment category also included all beneficiaries (and 
expenditures) for whom there was no inpatient diagnosis during 1995.
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2. Modifications to the PIP-DCG Model
    After the initial sorting of DxGroups into PIP-DCG groups was 
complete, a clinical panel reviewed the placement of the DxGroups and 
their resulting predicted expenditures, to determine the 
appropriateness of their application in a payment model. Through this 
process, 75 DxGroups (covering about \1/3\ of the admissions) were 
identified as: (1) Representing only a minor or transitory disease or 
disorder, not clinically likely to result in significant future medical 
costs, (2) rarely the main cause of an inpatient stay, or (3) vague or 
ambiguous. These groups, as recommended by the clinical panel, were 
identified as those most likely to result in inconsistent or 
inappropriate reimbursements and were placed (with their associated 
expenditures) in the base payment category (for which the payment is a 
function of demographic factors). Examples of these groups include the 
DxGroup for fluid/electrolyte disorders and malnutrition. Though the 
treatment for individuals with this diagnoses are often quite costly in 
the following year, the diagnosis is clinically vague and, therefore, 
represented a likely target for coding ``creep.'' The clinical panel 
concluded that many of the sickest individuals with this diagnosis were 
likely to have another hospitalization that would trigger appropriate 
increased reimbursements. Then, the remaining DxGroups were resorted 
and placed into revised DCGs for the payment model. A total of 10 PIP-
DCGs (above the base payment category) are included in the current 
model.
    As a second strategy to ensure consistent and appropriate payment 
levels, beneficiary diagnoses reported as a result of a short hospital 
stay (1 day or less) were left in the base payment category. Since the 
majority of 1-day stays are for diagnoses already assigned to the base 
group, the effect on payment is small. Also, short stays are often 
indicative of less serious, and, hence, less costly cases. It is 
important to note that these modifications do not mean that these 
expenditures have been excluded from the model. Rather, the payments 
associated with these diseases are captured in increased payments for 
the base payment category, where the majority of enrollees are paid 
based on demographic factors.
    Under the proposed PIP-DCG model, beneficiaries who are 
hospitalized for chemotherapy (V58.1 and V66.2) were treated as 
exceptions. These codes are indicators of a treatment method, rather 
than a particular disease. Recognizing, however, that Medicare's 
current inpatient coding rules require that the diagnoses for 
beneficiaries who are hospitalized for chemotherapy must be coded using 
these V-codes as the principal diagnoses, the most appropriate PIP-DCG 
group for these beneficiaries would be assigned based on the type of 
cancer, using a secondary diagnosis. A model will be estimated that 
uses secondary diagnoses to determine risk scores for hospitalized 
beneficiaries that were assigned chemotherapy V-codes (as defined 
above). This modification could be made for payment in calendar year 
2000. The model described in this notice has left these admissions in 
the base group.
3. Addition of Demographic and Other Factors
    The next phase in the estimation of the model was the creation of 
demographic variables (age, sex, and disability status) for the PIP-DCG 
groups. In this phase of the calibration, 24 age and sex groupings were 
created. Separate groupings were created for males and females, by 5-
year age increments, except where numbers were too small to get good 
estimates (that is, age group 0 through 34 and greater than 94 for 
males and females).
    Separate parameters were also included to estimate the unique cost 
effects of whether an aged beneficiary was formerly eligible because of 
a disability, and whether an aged or disabled beneficiary is eligible 
for Medicaid. The estimated adjustments for the demographic categories 
are the same irrespective of which PIP-DCG an enrollee falls into. The 
Medicaid adjustment, however, depends on a person's status as aged or 
disabled.
    New enrollees to Medicare, for whom there are no claims history, 
will be assigned a score based on a separate HCFA analysis of actual 
new enrollee expenditures. At this time, a separate parameter is not 
anticipated for the institutionalized because institutional status is 
not needed as an indicator of high Medicare utilization. Under the 
demographically adjusted system, institutional status was an indicator 
of a beneficiary with relatively poor health status. It, therefore, 
increased payments over the age and sex based amounts. The risk 
adjuster model has health status measures built in, and on the average, 
compensates for poor health status. In fact, preliminary estimates 
indicate that after accounting for inpatient hospital admissions, the 
institutional adjustment would be negative. Adjustments for the 
working-aged will be made in a manner similar to the current system. As 
a last step during the estimation, expenditures were adjusted to create 
an estimate of annual payments as if each beneficiary had been alive 
and enrolled for the entire year. This is equivalent to an expenditure 
per month measure. Estimation of the incremental costs associated with 
each of the variables (for example, demographics, DCGs) was made by the 
linear regression technique, which takes account of all the variables 
that apply to an individual.
4. The Current PIP-DCG Model
    The current PIP-DCG model contains a total of 37 parameters (10 
PIP-DCGs and 27 demographic or Medicaid factors). The model will 
continue to be refined over the next few months. While there are a 
number of ways to assess the ``accuracy'' of the model, payment for 
different groups of beneficiaries is improved with risk adjustment 
compared to the application of a demographic only model. Preliminary 
coefficients for the PIP-DCG model are presented in Table 1. The 
current placements of DxGroups into PIP-DCG groups are shown in Table 
2. The next section of this notice details how we are proposing to use 
the PIP-DCG model in the Medicare+Choice payment system as of January 
1, 2000.

[[Page 47509]]

B. Proposed Payment System Application of the PIP-DCG Model

    In its basic form, the PIP-DCG model is an algorithm that uses base 
year inpatient diagnoses, along with demographic factors and Medicaid 
eligibility, to predict total health spending in the following year. In 
applying the PIP-DCG model to risk adjusted payments for the 
Medicare+Choice program, however, the model will be used to determine 
relative risk scores. These relative risk scores will be used, in place 
of the current demographic factors, to adjust county rate book payments 
for the relative health status of the individual enrollee.
1. Estimating Beneficiary Relative Risk Factors
    The PIP-DCG model was developed to be ``additive'', meaning that 
incremental dollars are added together based on each beneficiary's 
characteristics. Referring to Table 3, the following examples 
illustrate how the PIP-DCG model will be used for estimating relative 
risk factors.
    A beneficiary is placed in a PIP-DCG group, based on inpatient 
diagnoses reported. In this example, ``Beneficiary A'' was hospitalized 
twice during the base year. The diagnoses reported were Asthma (PIP-DCG 
8) and Lung Cancer (PIP-DCG 18). The highest PIP-DCG category then for 
this beneficiary is PIP-DCG 18, which carries with it an estimated 
future year expenditure of $12,883. The beneficiary is also placed in 
the appropriate demographic groups. In this case, Beneficiary A is 
male, aged 82. This age group carries an estimated expenditure of 
$5,617. In addition, Beneficiary A had originally been Medicare 
eligible because of a disability (which carries an incremental 
expenditure of $2,381), but is not eligible for Medicaid (no 
expenditure increment). Adding together these increments based on the 
PIP-DCG model, the predicted expenditures for this beneficiary are 
$20,881.
    As another example, consider ``Beneficiary B.'' Beneficiary B had 
no inpatient admissions during the base year. Therefore, no specific 
PIP-DCG increment is added; expenditures for non-hospitalized 
beneficiaries are included in the demographic factors. Beneficiary B is 
placed in the appropriate age and sex grouping; in this case, female 
aged 72, which carries a predicted expenditure of $3,118. Beneficiary B 
is also placed in the Aged with Medicaid eligibility group, which adds 
$2,124 to her annual predicted expenditures. Since she has never been 
disabled, no additional expenditures are added. Therefore, total annual 
predicted expenditures for Beneficiary B are $5,242.
    Because Medicare+Choice program payments are based on the county-
wide rates determined under section 1853(c) of the Act, the predicted 
annual expenditures described above will be converted to relative risk 
scores. This is accomplished by dividing the predicted expenditures for 
each beneficiary by the national average predicted expenditure 
($5,300). Individuals whose risk scores are equal to 1.00 are 
``average.'' In the examples described above, Beneficiary A's relative 
risk score is 3.9 (indicating a high expected cost individual), while 
Beneficiary B's relative risk score is 0.99 (indicating a slightly 
lower than average risk individual).
    After Medicare+Choice organizations submit inpatient hospital 
encounter data, we will use the demographic information and diagnostic 
information from all Medicare+Choice organizations a beneficiary may 
have joined and from FFS to determine the appropriate risk factor for 
each beneficiary. When a Medicare+Choice organization forwards 
enrollment information to us, we, in turn, will send the 
Medicare+Choice organization the appropriate risk factor, as well as 
the resultant payment. Because the risk factor is computed for each 
individual beneficiary, the factor follows that beneficiary. In 
addition, since all beneficiaries will have risk factors, information 
will be immediately available for payment purposes as beneficiaries 
move among Medicare+Choice organizations.
    Risk adjustment factors for new Medicare beneficiaries (for whom 
health status information) is not available will be based on 
demographic information only. Examples of persons using the demographic 
model are new 65-year-olds and new Medicare disabled individuals. 
Similar to the current system, a ``demographic only'' model is being 
developed that will be used to determine the risk adjustment factors 
for these beneficiaries.
2. Risk Adjusted Payment Model
    To determine risk adjusted monthly payment amounts for each 
Medicare+Choice enrollee, individual risk factors (described above) 
will be multiplied by the appropriate payment rate for the county 
determined under section 1853(c) of the Act. Beginning with the 
implementation of risk adjustment, the separate aged and disabled rate 
books (incorporating combined Medicare Parts A and B) will be combined. 
Risk adjusted payments will be made using a single, combined 
Medicare+Choice county rate book. This change will be made because 
there is a single risk adjustment methodology for the entire Medicare 
population (excluding persons with end-stage renal disease).
    In addition to combining the current aged and disabled county rate 
books into a single combined county rate book, an adjustment to these 
rate book amounts will be required before applying the risk adjustment 
factors discussed above. This adjustment, or re-scaling factor, is 
necessary in order to account for the fact that the existing county 
rate book already accounts for demographic factors that are addressed, 
in a more precise way, in the risk adjustment factors we will be using. 
If the PIP-DCG model risk adjustment factors were applied to unadjusted 
county rate book amounts, this would create unintended distortions that 
would produce adjustments inconsistent with Congress' mandate in 
section 1853(c) of the Act. The application of the rescaling factor we 
are proposing would in effect translate the rate book amounts into the 
same language used under the risk adjustment methodology, so that we 
are not comparing ``apples to oranges.'' As a result of rescaling, 
payment for a person with the average risk score in a county would be 
the same as payment for a person with the average demographic score in 
that county. (However, a person with the average demographic score does 
not necessarily have the average risk score.) To the extent that an 
organization enrolls sicker people, the organization will receive 
higher payments.

C. Summary of HCFA's Proposed Approach for 2000

    The proposed approach we will use to meet the year 2000 mandate for 
risk adjusted payments will--
    (1) Be based on inpatient data;
    (2) Utilize a prospective PIP-DCG risk adjuster to estimate 
relative beneficiary risk scores;
    (3) Apply a re-scaling factor to address inconsistencies between 
demographic factors in the rate book and new risk adjusters;
    (4) Apply individual enrollee risk scores in determining fully 
capitated payments;
    (5) Include the auditing of medical records to validate encounter 
data;
    (6) Implement processes to collect encounter data on additional 
services; and
    (7) Continue to refine the risk adjustment system based on ongoing 
research.

[[Page 47510]]

D. Other Issues

    In addition to comments on the proposed risk adjustment approach, 
we are interested in receiving responses to the following questions: 
(1) Under one possible implementation approach we have considered, a 
Medicare+Choice organization would be paid initially based on estimates 
of the number of enrollees the organization has in a given risk factor 
category. These estimates would be based on the most recently available 
data (probably July 1998 through June 1999). Once more current data 
(from January 1999 through December 1999) became available in July 
2000, a retroactive adjustment would be made pursuant to section 
1853(a)(2) of the Act ``to take into account any difference between the 
actual number of individuals enrolled'' in a given risk category, and 
the ``number of such individuals estimated to be so enrolled when the 
advance payment was determined.'' These adjustments would be made 
retroactive to January 2000. This would be consistent with our 
longstanding practice of making retroactive adjustments to reflect the 
actual number of enrollees in a current demographic category (such as 
institutional status, end-stage renal disease status, dual eligible 
status, or working aged status) when this number differs from the 
number of enrollees estimated to be in any such category at the time 
payments were initially made.
    An alternative approach is to use data from an earlier period (for 
example, July 1, 1998 through June 30, 1999) to determine the risk 
factor for enrollees and payments to Medicare+Choice organizations for 
calendar year 2000. Using data from an earlier time period introduces 
some error into the estimates, but we do not believe it introduces any 
systematic bias. Note that implementation of this alternative model 
solves the problem of basing the payments to a plan on the estimated 
number of enrollees in a given risk factor category, which would 
require a retroactive adjustment as described above. Assuming a 
relatively large and stable population for a plan, aggregate payments 
under this approach are not likely to differ from aggregate payments 
using a method requiring this type of retroactive payment adjustment. 
However, on an individual basis, using data from an earlier time period 
lengthens the time between a hospital stay for an enrollee and 
compensation to the organization for the future predicted cost of that 
illness.
    Given these issues, what problems are Medicare+Choice organizations 
likely to encounter with retroactive payment adjustments? Conversely, 
if data from an earlier time period were used, what problems are 
organizations likely to encounter?
    (2) The Secretary is required to announce the annual 
Medicare+Choice capitation rate for each Medicare+Choice payment area 
and the risk and other factors to be used in adjusting such rates by 
March 1 of the year preceding the payment year. In addition, at least 
45 days prior to the annual announcement of capitation rates, the 
Secretary shall provide notice to Medicare+Choice organizations of 
proposed changes to be made in the methodology from the methodology and 
assumptions used in the previous announcement.
    The implementation of risk adjustment will alter the methodology 
for calculating rates for each Medicare+Choice payment area. Given the 
proposed changes, what types of information should be included in the 
45-day notice and the annual announcement to assist Medicare+Choice 
organizations in planning for risk adjusted payments?
    (3) What types of problems are Medicare+Choice organizations likely 
to encounter as capitation payments are changed from a demographic only 
basis to a health status adjusted basis? How should we address these 
problems, especially for small plans, rural plans, and start up plans? 
While we are currently processing the inpatient hospital data for 
managed care enrollees, we note that we will be unable to model the 
financial impact of the risk adjustment methodology until we have 
completed the processing of these data and have assigned risk scores to 
plans enrollees.

II. September 17, 1998, Public Meeting

    In addition to seeking written comments from the public, we will 
hold a public meeting on September 17, 1998, at HCFA, 7500 Security 
Boulevard, Baltimore, MD. The purpose of this meeting will be to 
discuss issues and concerns from potential Medicare+Choice 
organizations, organizations contracting under section 1876 of the Act, 
providers, beneficiaries, and other interested parties on the 
implementation of risk adjusted payment. The collection and auditing of 
encounter data, which was described in the Medicare+Choice interim 
final rule published on June 26, 1998, in the Federal Register, will 
also be addressed in this meeting. The agenda for the meeting is likely 
to cover the following topics:
     Background on the Principal Inpatient Diagnostic Cost 
Group (PIP-DCG) risk adjustment model.
     Changes to the payment rates.
     Application of the risk adjustment model for payment in CY 
2000.
     Description of the overall risk adjustment implementation 
process.
     Auditing of encounter data.
     Collection of additional encounter data.
    Comments on the proposed agenda are welcome. Further information on 
the meeting can be obtained from Chapin Wilson, (202) 690-7874.
    In accordance with E.O. 12866, this notice was reviewed by the 
Office of Management and Budget.

                     Table 1.--Current PIP-DCG Model
------------------------------------------------------------------------
Number of Observations..................................       1,401,274
R-Squared...............................................        0.058718
Dependent Variable Mean.................................          $5,300
Root Mean Square Error..................................          14,256
Model Parameters........................................              37
------------------------------------------------------------------------
Base Payment Categories                                          Payment
                                                               Increment
------------------------------------------------------------------------
Male: Aged 0-34.........................................           1,255
Male: 35-44.............................................           1,940
Male: 45-54.............................................           2,654
Male: 55-59.............................................           3,350
Male: 60-64.............................................           3,970
Male: 65-69.............................................           2,792

[[Page 47511]]

Male: 70-74.............................................           3,702
Male: 75-79.............................................           4,738
Male: 80-84.............................................           5,617
Male: 85-89.............................................           6,562
Male: 90-94.............................................           7,209
Male: 95+...............................................           7,189
Female: 0-34............................................           1,345
Female: 35-44...........................................           2,167
Female: 45-54...........................................           2,763
Female: 55-59...........................................           3,647
Female: 60-64...........................................           4,673
Female: 65-69...........................................           2,439
Female: 70-74...........................................           3,118
Female: 75-79...........................................           3,994
Female: 80-84...........................................           4,768
Female: 85-89...........................................           5,592
Female: 90-94...........................................           5,855
Female: 95+.............................................           5,466
------------------------------------------------------------------------
Other Demographic Factors
------------------------------------------------------------------------
Previously Disabled.....................................           2,381
Medicaid, Medicare Aged.................................           2,124
Medicaid, Medicare Disabled.............................           1,744
------------------------------------------------------------------------
PIP-DCGs
PIP-DCG 6...............................................           2,265
PIP-DCG 8...............................................           4,406
PIP-DCG 10..............................................           5,829
PIP-DCG 12..............................................           7,950
PIP-DCG 14..............................................           9,946
PIP-DCG 18..............................................          12,883
PIP-DCG 20..............................................          16,346
PIP-DCG 23..............................................          18,950
PIP-DCG 26..............................................          21,881
PIP-DCG 29..............................................         29,317
------------------------------------------------------------------------
Notes: PIP-DCG 4 is combined with the demographic factors, and includes
  those with no hospitalizations, modified or certain low-cost
  admissions. Diagnoses from hospital stays of less than two days are
  not used in assigning PIP-DCGS.


                 Table 2.--Diagnoses (DxGroups) Included in Each PIP-DCG--Current Payment Model
----------------------------------------------------------------------------------------------------------------
PIP-DCG 6:
    DxGroup..............................              18  Cancer of Prostate/Testis/Male Genital Organs.
                                                       14  Breast Cancer.
PIP-DCG 8:
    DxGroup..............................              82  Acute Myocardial Infarction.
                                                      146  Pelvic Fracture.
                                                      145  Fractures of Skull/Face.
                                                       77  Valvular and Rheumatic Heart Disease.
                                                       86  Atrial Arrhythmia.
                                                       84  Angina Pectoris.
                                                       80  Coronary Atherosclerosis.
                                                       92  Precerebral Arterial Occlusion.
                                                       16  Cancer of Uterus/Cervix/Female Genital Organs.
                                                       79  Hypertension, Complicated.
                                                       36  Peptic Ulcer.
                                                      110  Asthma.
                                                       96  Aortic and Other Arterial Aneurysm.
                                                      153  Brain Injury.
                                                        1  Central Nervous System Infections.
                                                       39  Abdominal Hernia, Complicated.
                                                       64  Alcohol/Drug Dependence.
PIP-DCG 10:
    DxGroup..............................             109  Bacterial Pneumonia.
                                                       42  Gastrointestinal Obstruction/Perforation.
                                                      143  Vertebral Fracture Without Spinal Cord Injury.
                                                       21  Other Cancers.
                                                        4  Tuberculosis.
                                                       97  Thromboembolic Vascular Disease.
                                                       59  Schizophrenic Disorders.

[[Page 47512]]

                                                       11  Colon Cancer.
                                                      116  Kidney Infection.
                                                       83  Unstable Angina.
                                                       94  Transient Cerebral Ischemia.
                                                       81  Post-Myocardia Infarction.
                                                      150  Internal Injuries/Traumatic Amputations/Third Degree
                                                            Burns.
                                                       32  Pancreatitis/Other Pancreatic Disorders.
                                                      147  Hip Fracture.
                                                      158  Artificial Opening of Gastrointestinal Tract Status.
PIP-DCG 12:
    DxGroup..............................              91  Cerebral Hemorrhage.
                                                       93  Stroke.
                                                       56  Dementia.
                                                       98  Peripheral Vascular Disease.
                                                       41  Inflammatory Bowel Disease.
                                                       22  Benign Brain/Nervous System Neoplasm.
                                                       48  Rheumatoid Arthritis and Connective Tissue Disease.
                                                       49  Bone/Joint Infections/Necrosis.
                                                       19   Cancer of Bladder, Kidney, Urinary Organs.
                                                       45  Gastrointestinal Hemorrhage.
                                                       87  Paroxysmal Ventricular Tachycardia.
                                                      133  Cellulitis and Bullous Skin Disorders.
                                                       57  Drug/Alcohol Psychoses.
PIP-DCG 14:
    DxGroup..............................              66  Personality Disorders.
                                                       29  Adrenal Gland, Metabolic Disorders.
                                                       70  Degenerative Neurologic Disorders.
                                                        2  Septicemia/Shock.
                                                      144  Spinal Cord Injury.
                                                       58  Delirium/Hallucinations.
                                                       61  Paranoia and Other Psychoses.
                                                       63  Anxiety Disorders.
                                                       73  Epilepsy and Other Seizure Disorders.
                                                       10  Stomach, Small Bowel, Other Digestive Cancer.
                                                       12  Rectal Cancer.
                                                       26  Diabetes with Acute Complications/Hypoglycemic Coma.
                                                      113  Pleural Effusion/Pneumothorax/Empyema.
                                                       60  Major Depression.
PIP-DCG 18:
    DxGroup..............................              34  Cirrhosis, Other Liver Disorders.
                                                       72  Paralytic and Other Neurologic Disorders.
                                                      108  Gram-Negative/Staphylococcus Pneumonia.
                                                      111  Pulmonary Fibrosis and Bronchiectasis.
                                                       89  Congestive Heart Failure.
                                                      105  Chronic Obstructive Pulmonary Disease.
                                                       95  Atherosclerosis of Major Vessel.
                                                       13  Lung Cancer.
                                                        8  Mouth/Pharynx/Larynx/Other Respiratory Cancer.
PIP-DCG 20:
    DxGroup..............................             112  Aspiration Pneumonia.
                                                       76  Coma and Encephalopathy.
                                                       75  Polyneuropathy.
                                                       17  Cancer of Placenta/Ovary/Uterine Adnexa.
                                                       55  Blood/Immune Disorders.
PIP-DCG 23:
    DxGroup..............................             134  Decubitus and Chronic Skin Ulcers.
                                                       33  End-stage Liver Disorders.
                                                        9  Liver/Pancreas/Esophagus Cancer.
                                                       88  Cardio-Respiratory Failure and Shock.
                                                       27  Diabetes with Chronic Complications.
                                                      115  Renal Failure/Nephritis.
PIP-DCG 26:
    DxGroup..............................               7  Metastatic Cancer.
PIP-DCG 29:
    DxGroup..............................               3  HIV/AIDS.
                                                       15  Blood, Lymphatic Cancers/Neoplasms.
                                                       20  Brain/Nervous System Cancers.
----------------------------------------------------------------------------------------------------------------


[[Page 47513]]


                              Table 3.--Estimating Prospective Beneficiary Expenditures Mean Predicted Expenditures = $5300
--------------------------------------------------------------------------------------------------------------------------------------------------------
 Demographic factors base PIP-                 +             PIP-DCG                          +                 Other factors
--------------DCG---------------------------------------------------------------------------------------------------------------------------------------
                                                                     Aged Population
--------------------------------------------------------------------------------------------------------------------------------------------------------
Male 65-69.....................        $2792      PIP-DCG 6                           $2265      Previously Disabled.......................        $2381
Male 70-74.....................         3702      PIP-DCG 8                            4406      Medicaid, Medicare Aged...................         2124
Male 75-79.....................         4738      PIP-DCG 10                           5829
Male 80-84.....................         5617      PIP-DCG 12                           7950
Male 85-89.....................         6562      PIP-DCG 14                           9946
Male 90-94.....................         7209      PIP-DCG 18                         12,883
Male 95+.......................         7189      PIP-DCG 20                         16,346
Female 65-69...................         2439      PIP-DCG 23                         18,950
Female 70-74...................         3118      PIP-DCG 26                         21,881
Female 75-79...................         3944      PIP-DCG 29                         29,317
Female 80-84...................         4768
Female 85-89...................         5592
Female 90-94...................         5855
Female 95+.....................         5466
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                   Disabled Population
--------------------------------------------------------------------------------------------------------------------------------------------------------
Male 0-34......................         1255      PIP-DCG 6                            2265      Medicaid, Medicare Disabled...............         1744
Male 34-44.....................         1940      PIP-DCG 8                            4406
Male 45-54.....................         2654      PIP-DCG 10                           5829
Male 55-59.....................         3350      PIP-DCG12                            7950
Male 60-64.....................         3970      PIP-DCG 14                           9946
Female 0-34....................         1345      PIP-DCG 18                         12,883
Female 34-44...................         2167      PIP-DCG 20                         16,346
Female 45-54...................         2763      PIP-DCG 23                         18,950
Female 55-59...................         3647      PIP-DCG 26                         21,881
Female 60-64...................         4673      PIP-DCG 29                         29,317
--------------------------------------------------------------------------------------------------------------------------------------------------------

(Sec. 4002 of the Balanced Budget Act of 1997 (Public Law 105-33)

    Dated: August 26, 1998.
Nancy-Ann Min DeParle,
Administrator, Health Care Financing Administration.

    Dated: September 1, 1998.
Donna E. Shalala,
Secretary.
[FR Doc. 98-24085 Filed 9-2-98; 4:10 pm]
BILLING CODE 4120-01-P