Paying for Outcomes: Clinical Risk Groups-The Swiss Army Knife for Medicaid Programs.

Abstract

CRGs are a clinically based categorical classification system that uses administrative data to identify children and adults with chronic health conditions. Claims and encounter records are used to group individuals into mutually exclusive, clinically based categories. These categories comprise specific conditions or combinations of conditions as well as the associated severity of those conditions or combinations of conditions. CRGs can also incorporate data from functional assessments and capture and use Z codes that offer insight into some characteristics of social determinants of health (SDOH).