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Medicaid Rx is a pharmacy based risk adjustment model that may be used to adjust capitated payments to health plans that enroll Medicaid beneficiaries.  The Medicaid Rx model includes readily available demographic and pharmacy use data that are valid and accurate estimators of current and future health care costs.


 
The Medicaid Rx (MRX) Disease Categories with Summary Drug Descriptions

MRX Category

MRX Descriptions

Summary Drug Descriptions

MRX1

Alcoholism

Anti-alcoholic preparations

MRX2

Alzheimers

Cholinesterase inhibitors, NMDA receptor antagonists

MRX3

Anti-coagulants

Coumarin, Heaparin

MRX4

Asthma/COPD

Beta-adrenergic agents, glucocorticoids

MRX5

Attention Deficit

CNS stimulants

MRX6

Burns

Topical sulfonamides

MRX7

Cardiac

Ace inhibitors, beta blockers, calcium channel blockers, diuretics, vasodilators

MRX8

Cystic Fibrosis

Pancreatic enzymes, mucolytics

MRX9

Depression/Anxiety

Antidepressants, antianxiety

MRX10

Diabetes

Hypoglycemics, Insulin

MRX11

Ears, Eyes, Nose, & Throat (EENT)

Anti-inflammatory steroids, anti-infectives for EENT related conditions

MRX12

ESRD/Renal

Electrolyte depleters, hematinics

MRX13

Folate Deficiency

Folic acid

MRX14

CMV Retinitis

Eye antivirals

MRX15

Gastric Acid Disorder

Gastric acid secretion reducers

MRX16

Glaucoma

Miotics

MRX17

Gout

Purine inhibitors, colchicine

MRX18

Growth Hormone

Growth Hormones

MRX19

Hemophilia/von Willebrands

Factor IX concentrates

MRX20

Hepatitis

Hepatitis tx agents

MRX21

Herpes

Antivirals, general

MRX22

HIV

Antivirals, HIV specific

MRX23

Hyperlipidemia

Lipotropics

MRX24

Infections, High

Aminogycosides

MRX25

Infections, Medium

Macrolides

MRX26

Infections, Low

Penicillins, cephalosporins

MRX27

Inflammatory/Autoimmune

Glucocorticosteroids

MRX28

Insomnia

Sedative-hypnotics

MRX29

Iron Deficiency

Iron replacement

MRX30

Irrigating Solution

Irrigants

MRX31

Liver Disease

Ammonia inhibitors

MRX32

Malignancies

Antimetabolites

MRX33

Multiple Sclerosis/Paralysis

Skeletal muscle relaxants

MRX34

Nausea

Antimetics

MRX35

Neurogenic Bladder

Parasympathetic agents

MRX36

Osteoporosis/Pagets

Bone resorption inhibitors

MRX37

Pain

Narcotics

MRX38

Parkinsons/Tremor

Antiparkinsonism

MRX39

Prenatal Care

Prenatal vitamin preparations

MRX40

Psychotic Illness/Bipolar

Antipsychotics, anti-mania

MRX41

Replacement Solution

Calcium, potassium replacements

MRX42

Seizure Disorders

Anticonvulsants

MRX43

Thyroid Disorder

Thyroid hormones

MRX44

Transplant

Immunosuppressives

MRX45

Tuberculosis

Anti-mycobacterium agents


Prior to assessing the value associated with each of the above categories, a protocol was established classify individuals into one or more of the above Medicaid Rx categories. Only a single incidence of a drug is necessary to establish a Medicaid Rx disease category. Disease hierarchies were established in to areas where conditions were highly correlated. For example, individuals receiving antipsychotic medications for Psychotic Illness are also likely to receive mood stabilizers, which are assigned to Bipolar Disorder, as well as medications that would classify them into Depression and Anxiety categories. To avoid overstating the risk associated with these cases, these four categories were combined into two categories, and individuals with Psychotic Illness/Bipolar Disorder are not permitted to receive a Depression/Anxiety classification. Another hierarchical case relates to the Infectious categories, where an individual can only be classified into the category with the greatest intensity level (high, medium, or low). With the exception of these two hierarchical cases, the Medicaid Rx model recognizes the increased medical cost when multiple conditions are identified. For example, a person is diagnosed with Bipolar Disorder, Depression, and Cardiovascular conditions. To develop an acuity factor for this individual, they would receive the relative cost weight associated with the Psychotic Illness/Bipolar and Cardiovascular categories.