UCSD | Medicaid Rx

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. This model was originally developed using data from 1990 to 1999 from four Medicaid programs: California, Colorado, Georgia, and Tennessee.

New models (included in Version 5.0) are based on analyses of data from 44 state Medicaid programs, 2001-2002.


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.

Download CDPS Version 5 (includes MedicaidRx) (requires Base SAS).