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PubMed2003

Risk adjusted premium subsidies and risk sharing: key elements of the competitive sickness fund market in the Netherlands.

As part of a market-oriented health care reform, in 1991 risk adjusted premium subsidies were introduced in the Dutch social health insurance sector. Currently the premium subsidies are primarily based on demographic variables. To mitigate the obvious inadequacy of these risk adjusters, the system of risk adjustment is supplemented with a system of risk sharing. This paper describes the main characteristics of the Dutch health care system and the development of risk adjustment and risk sharing in the last decade. The effects of introducing financial risk for Dutch sickness funds on risk selection and consumer mobility are analysed. The paper concludes with a description of expected future developments.

Capitation Fee↗
PubMed2003

Risk adjustment in Switzerland.

In Switzerland the new law on Health Insurance, effective since 1996, introduced pro competitive changes in the market of sickness funds. The legislator expected high mobility between sickness funds of both healthy and sick insured as open enrolment was introduced with the new law. That is why the risk adjustment scheme, that was already introduced 1993, was limited until 2005. However, consumer mobility remained low and risk selection strategies are still profitable, since risk-adjustment is based only on demographic variables. This paper describes risk adjustment, consumer mobility, risk selection activities of sickness funds and the impact of imperfect risk adjustment on the development of HMO and PPO models. The paper concludes with a description of the current political and scientific discussion in Switzerland.

Capitation Fee↗
PubMed2003

Risk adjustment and risk selection on the sickness fund insurance market in five European countries.

From the mid-1990s citizens in Belgium, Germany, Israel, the Netherlands and Switzerland have a guaranteed periodic choice among risk-bearing sickness funds, who are responsible for purchasing their care or providing them with medical care. The rationale of this arrangement is to stimulate the sickness funds to improve efficiency in health care production and to respond to consumers' preferences. To achieve solidarity, all five countries have implemented a system of risk-adjusted premium subsidies (or risk equalization across risk groups), along with strict regulation of the consumers' direct premium contribution to their sickness fund. In this article we present a conceptual framework for understanding risk adjustment and comparing the systems in the five countries. We conclude that in the case of imperfect risk adjustment-as is the case in all five countries in the year 2001-the sickness funds have financial incentives for risk selection, which may threaten solidarity, efficiency, quality of care and consumer satisfaction. We expect that without substantial improvements in the risk adjustment formulae, risk selection will increase in all five countries. The issue is particularly serious in Germany and Switzerland. We strongly recommend therefore that policy makers in the five countries give top priority to the improvement of the system of risk adjustment. That would enhance solidarity, cost-control, efficiency and client satisfaction in a system of competing, risk-bearing sickness funds.

Capitation Fee↗
PubMed1997

Risk-adjusted capitation payments for catastrophic risks based on multi-year prior costs.

In many countries regulated competition among health insurance companies has recently been proposed or implemented. A crucial issue is whether or not the benefits package offered by competing insurers should also cover catastrophic risks (like several forms of expensive long-term care) in addition to non-catastrophic risks (like hospital care and physician services). In 1988 the Dutch government proposed compulsory national health insurance based on regulated competition among insurer as well as among providers of care. The competing insurers should offer a benefits package covering both non-catastrophic risks and catastrophic risks. The insurers would be largely financed via risk-adjusted capitation payments. The government intended to use a capitation formula that is, besides some demographic variables, based on multi-year prior costs. This paper presents the results of an explorative empirical analysis of the possible consequences of such a capitation formula for catastrophic risks. The main conclusion is that this formula would be inadequate because it would leave ample room for cream skimming.

Capitation Fee↗
PubMed2003

The social life of genes: privacy, property and the new genetics.

With the advent of the Human Genome Project and widespread fears over human cloning and medical privacy, a number of states have moved to protect genetic privacy. Oregon's unique Genetic Privacy Act of 1995, which declared that an individual had property rights to their DNA, has provoked national and international interest and controversy. This paper critically reviews the literature on genetic privacy and gene patenting from law, philosophy, science and anthropology. The debate in Oregon, from 1995 to 2001, illustrates many of the key issues in this emerging area. Both sides of the debate invoke the property metaphor, reinforcing deterministic assumptions and avoiding more fundamental questions about the integrity of the body and self-identity. The anthropological critique of the commodification of the body, and the concept of 'embodiment' are useful in analyzing the debate over DNA as property.

Anthropology↗
PubMed2004

Risk segmentation and equity in the Chilean mandatory health insurance system.

For decades, the Chilean health system has included a requirement for dependent workers to spend a certain percentage of their wages on health insurance. Since 1981, workers have been able to choose between public insurance and several private insurance providers. The reforms introduced more choice, moving away from reliance on an exclusive public provider. By 1999, about half of the country's active dependent workers had opted out of the public and into the private insurance system. The development of the private insurance system has been accompanied by controversy, however, regarding possible inequities in the utilization of medical services, the degree of risk segmentation, inefficiencies in the system's operation, and other factors. This paper discusses the issues of risk segmentation and equity. It starts by reviewing the system's design on a theoretical level, then deriving hypothesis and finally providing empirical evidence regarding these hypothesis. Particular attention is given to the issues of how individuals choose between the public and private system (to determine the reasons behind risk segmentation) and the differences in utilization among the various income groups (to clarify the issue of possible inequities).

Actuarial Analysis↗
PubMed1998

Mandatory pooling as a supplement to risk-adjusted capitation payments in a competitive health insurance market.

Risk-adjusted capitation payments (RACPs) to competing health insurers are an essential element of market-oriented health care reforms in many countries. RACPs based on demographic variables only are insufficient, because they leave ample room for cream skimming. However, the implementation of improved RACPs does not appear to be straightforward. A solution might be to supplement imperfect RACPs with a form of mandatory pooling that reduces the incentives for cream skimming. In a previous paper it was concluded that high-risk pooling (HRP), is a promising supplement to RACPs. The purpose of this paper is to compare HRP with two other main variants of mandatory pooling. These variants are called excess-of-loss (EOL) and proportional pooling (PP). Each variant includes ex post compensations to insurers for some members which depend to various degrees on actually incurred costs. Therefore, these pooling variants reduce the incentives for cream skimming which are inherent in imperfect RACPs, but they also reduce the incentives for efficiency and cost containment. As a rough measure of the latter incentives we use the percentage of total costs for which an insurer is at risk. This paper analyzes which of the three main pooling variants yields the greatest reduction of incentives for cream skimming given such a percentage. The results show that HRP is the most effective of the three pooling variants.

Capitation Fee↗
PubMed2002

Genetic testing.

Explore the source record for details and available documents.

Abortion, Legal↗
PubMed2000

Ignoring small predictable profits and losses: a new approach for measuring incentives for cream skimming.

Under inadequate capitation formulae competing health insurers have an incentive for cream skimming, i.e., the selection of enrollees whom the insurer expects to be profitable. When evaluating different capitation formulae, previous studies used various indicators of incentives for cream skimming. These conventional indicators are based on all actual profits and losses or on all predictable profits and losses. For the latter type of indicators, this paper proposes, as a new approach, to ignore the small predictable profits and losses. We assume that this new approach provides a better indication of the size of the cream skimming problem than the conventional one, because an insurer has to take into account its costs of cream skimming and the (statistical) uncertainties about the net benefits of cream skimming. Both approaches are applied in theoretical and empirical analyses. The results show that, if our assumption is right, the problem of cream skimming is overestimated by the conventional ways of measuring incentives for cream skimming, especially in the case of relatively good capitation formulae.

Adult↗
PubMed2000

Risk adjustment of capitation payments to behavioral health care carve-outs: how well do existing methodologies account for psychiatric disability?

This study used 1994-1995 administrative data from a large public employer to examine the viability of commercial risk adjustment systems for setting capitation payments to competing behavioral health care "carve-outs". The ability of Hierarchical Condition Categories and Adjusted Diagnostic Groups to predict psychiatric expenditures was improved by controlling separately for psychiatric disability. However, even the best models underpredicted expenditures of patients with psychiatric disability by 15%. Relative to full capitation, "mixed" payment systems and soft capitation reduce the ability of carve-outs to earn disproportionate profits by enrolling healthy patients and avoiding sick ones, yet also diminish incentives for cost containment.

Adult↗
PubMed2000

Growing importance of capitation in Switzerland.

Since its liberalization the Swiss health insurance market has shown risk selection activities of the insurance funds, which call for risk adjustment. Because risk selection continues to be profitable under the current risk adjustment formula, fast growing HMO and PPO plans are (mis)used to attract good risks rather than to contain costs. For fear of being replaced by one centralised fund, social health insurers are themselves proposing improvements of the risk adjustment formula, to be applied to funds. The revised formula proposed in this paper, applicable among funds for risk adjustment and to gate-keeping models to calculate fair capitation, explains 12.4% of the variance of health care expenditure, halves profits from risk selection, and uses only the (few) data that are available in Switzerland.

Adolescent↗
PubMed2000

Risk adjustment and the fear of markets: the case of Belgium.

In Belgium the management and administration of the compulsory and universal health insurance is left to a limited number of non-governmental non-profit sickness funds. Since 1995 these sickness funds are partially financed in a prospective way. The risk adjustment scheme is based on a regression model to explain medical expenditures for different social groups. Medical supply is taken out of the formula to construct risk-adjusted capitation payments. The risk-adjustment formula still leaves scope for risk selection. At the same time, the sickness funds were not given the instruments to exert a real influence on expenditures and the health insurance market has not been opened for new entrants. As a consequence, Belgium runs the danger of ending up in a situation with little incentives for efficiency and considerable profits from cream skimming.

Adult↗
PubMed2002

Government mandates and employer-sponsored health insurance: who is still not covered?

We characterize employer-sponsored health insurance offering strategies in light of benefit non-discrimination and minimum wage regulation when workers have heterogeneous earnings and partially unobservable demand for (and cost of) insurance. We then empirically examine how earnings and expected medical expenses are associated with low wage workers' ability to obtain insurance before and after enactment of federal benefit non-discrimination rules. We find no evidence that the non-discrimination rules helped low wage workers (especially those with high own or children's expected medical expenses) to obtain insurance.

Adolescent↗
PubMed2003

Evaluating Medicaid HMOs when encounter data are missing: case of developmentally delayed children.

In evaluating Medicaid Health Maintenance Organizations (HMOs), crucial information regarding severity of illness of patients is often missing--in part because encounter data are not available. If we assume that patients are either in the HMO or in fee-for-service (FFS) plans (i.e., no in or out migration); then severity of HMO patients can be deduced from encounters of FFS patients. We applied this approach to effectiveness of HMO services for developmentally delayed children. Data supported the assumption of a closed system. Data also showed that over 12 months, severity of FFS patients declined. Therefore, we inferred that the HMO was attracting sicker patients. The HMO was paid less than FFS plan, despite the fact that it attracted sicker patients.

Child↗
PubMed2003

An investigation of genetic counselors' discussion of genetic discrimination with cancer risk patients.

Twenty-five genetic counselors who see familial cancer risk patients were interviewed about their definitions of genetic discrimination, perceptions of patient risk for discrimination, frequency and type of discrimination experienced by their patients, sources of information about discrimination, and what they tell patients about genetic discrimination. There was variability in participant definitions and content of discussions of genetic discrimination. Although 82% regarded risk to be low to theoretical, 40% reported possible instances of genetic discrimination, including insurance companies requiring results to cover procedures, denial of life/health insurance, social discrimination, and employment discrimination. Ninety-six percent of the sample reported always or almost always discussing genetic discrimination, and one or more of the following: insurance discrimination risks, protective legislation, no known cases positively documenting discrimination, strategies to avoid discrimination, and uncertainty of protective measures. The majority use current literature and research as information sources. Practice, policy, and research implications are discussed.

Adult↗
PubMed2004

Multiple prior years of health expenditures and Medicare health plan choice.

This study examines the effect of multiple prior years of health expenditures on the probability of enrollment in a Medicare HMO. Beneficiaries may require more than one year of prior expenditure data to form a reliable estimate of future expenditures if health expenditures have a significant transitory component. We used a logit model to estimate the influence of 1991-1993 Part A expenditures and demographic data on the choice of health plans in 1994. The results indicate that beneficiaries use multiple years of expenditures in their choice of health plan and the effect of prior spending declined with time.

Aged↗