Stanford University School of Medicine, Palo Alto, California.
Center for Innovation to Implementation, VA Palo Alto, Menlo Park, California.
JAMA Netw Open. 2018 Dec 7;1(8):e185993. doi: 10.1001/jamanetworkopen.2018.5993.
Policymakers and consumers are eager to compare hospitals on performance metrics, such as surgical complications or unplanned readmissions, measured from administrative data. Fair comparisons depend on risk adjustment algorithms that control for differences in case mix.
To examine whether the Medicare Advantage risk adjustment system version 21 (V21) adequately risk adjusts performance metrics for Veterans Affairs (VA) hospitals.
DESIGN, SETTING, AND PARTICIPANTS: This cohort analysis of administrative data from all 5.5 million veterans who received VA care or VA-purchased care in 2012 was performed from September 8, 2015, to October 22, 2018. Data analysis was performed from January 22, 2016, to October 22, 2018.
A patient's risk as measured by the V21 model.
The main outcome was total cost, and the key independent variable was the V21 risk score.
Of the 5 472 629 VA patients (mean [SD] age, 63.0 [16.1] years; 5 118 908 [93.5%] male), the V21 model identified 694 706 as having a mental health or substance use condition. In contrast, a separate classification system for psychiatric comorbidities identified another 1 266 938 patients with a mental health condition. The V21 model missed depression not otherwise specified (396 062 [31.3%]), posttraumatic stress disorder (345 338 [27.3%]), and anxiety (129 808 [10.2%]). Overall, the V21 model underestimated the cost of care by $2314 (6.7%) for every person with a mental health diagnosis.
The findings suggest that current aspirations to engender competition by comparing hospital systems may not be appropriate or fair for safety-net hospitals, including the VA hospitals, which treat patients with complex psychiatric illness. Without better risk scores, which is technically possible, outcome comparisons may potentially mislead consumers and policymakers and possibly aggravate inequities in access for such vulnerable populations.
决策者和消费者渴望根据从行政数据中测量的手术并发症或计划外再入院等绩效指标对医院进行比较。公平比较取决于风险调整算法，该算法可控制病例组合的差异。
研究医疗保险优势风险调整系统版本 21（V21）是否充分调整了退伍军人事务部（VA）医院的绩效指标风险。
设计、设置和参与者：本队列分析使用 2012 年接受 VA 护理或 VA 购买护理的所有 550 万退伍军人的行政数据，于 2015 年 9 月 8 日至 2018 年 10 月 22 日进行，数据分析于 2016 年 1 月 22 日至 2018 年 10 月 22 日进行。
患者的风险由 V21 模型测量。
主要结果是总成本，关键的独立变量是 V21 风险评分。
在 5472629 名 VA 患者中（平均[标准差]年龄为 63.0[16.1]岁；5118908[93.5%]男性），V21 模型确定了 694706 人患有心理健康或物质使用疾病。相比之下，另一个针对精神共病的分类系统确定了另外 1266938 名患有心理健康疾病的患者。V21 模型错过了未特指的抑郁症（396062[31.3%]）、创伤后应激障碍（345338[27.3%]）和焦虑症（129808[10.2%]）。总体而言，V21 模型低估了每例精神健康诊断患者的护理费用 2314 美元（6.7%）。
这些发现表明，当前通过比较医院系统来激发竞争的愿望可能并不适合或公平，包括 VA 医院，这些医院治疗患有复杂精神疾病的患者。如果没有更好的风险评分（从技术上讲是可能的），则结果比较可能会误导消费者和决策者，并可能加剧弱势群体的获得机会不平等。
