Case-mix adjustment considers variations in the health of physicians populations, often defined by age and gender. Severity is a patients degree of illness for a specific mix of conditions (e.g., cancer stages), morbidity or comorbidity. Together, case mix and severity are often called risk. Risk can be either the risk for needing a mix of medical services (utilization and associated costs) or the patients likelihood of achieving a specific level of quality-related outcome.
Risk adjustment may not apply to quality measures, particularly process measures. For quality measures, NCQA requires the organization to demonstrate that it has considered whether to risk-adjust measuresand that it has an explicit methodology if it does and an explicit rationale if it does not. If the organization determines that case-mix and severity adjustment do not apply to a quality measure, it provides documentation that supports the determination. If the organization adjusts measures for case-mix or severity, it provides documentation describing the methodology used.