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PubMed1994

Risk-adjusted capitation: recent experiences in The Netherlands.

The market-oriented health care reforms taking place in the Netherlands show a clear resemblance to the proposals for managed competition in U.S. health care. In both countries good risk adjustment mechanisms that prevent cream skimming--that is, that prevent plans from selecting the best health risks--are critical to the success of the reforms. In this paper we present an overview of the Dutch reforms and of our research concerning risk-adjusted capitation payments. Although we are optimistic about the technical possibilities for solving the problem of cream skimming, the implementation of good risk-adjusted capitation is a long-term challenge.

Capitation Fee↗
PubMed1994

Small employers and the health insurance market.

In 1993 half of all small businesses (fewer than fifty workers) sponsored a health plan for their employees, up from 41 percent in 1989. While not as deep, the benefits offered by small firms are nearly as broad as benefits offered by large firms, and they have expanded since 1989. Small businesses pay more for coverage, however. Although coverage restrictions based on health status and preexisting conditions are a significant concern of small firms, actual limits of this type in the small-group market are modest. Firms not offering insurance report that they have wide access to coverage, and many would sponsor a plan if only prices were lower.

Data Collection↗
PubMed1995

The questionable value of medical screening in the small-group health insurance market.

Insurers perform medical screening to assess risk for health insurance in the small-group market. Most reform proposals eliminate screening because it denies coverage to those who need it. This DataWatch empirically analyzes the value of medical screening to insurers. We analyzed claims of two employed populations covered by a large insurer--one screened and the other not screened. We found no significant difference in the amounts claimed by these two populations over six years. This suggests that medical screening could be eliminated in the small-group market without an increase in premiums.

Data Collection↗
PubMed1995

Health care purchasing and market changes in California.

This paper analyzes the process and outcomes of collective negotiations among large private employers and health maintenance organizations (HMOs) in California. In 1994, prior to collective negotiations, differences in benefit packages, risk mix, and volume of purchasing accounted for only one-third of the variance in premiums among firms and HMOs. The 1995 collective negotiations reduced the variance by 22 percent and the enrollment-weighted mean premium by approximately 9 percent, while enriching the standard benefit package. Savings for the eleven participating firms totaled $36.5 million. Large purchasers are reducing the number of health plans offered to their employees, standardizing the benefit package, using collective negotiations to contain costs, and shifting from vendor to partner relations with HMOs.

California↗
PubMed1995

Preserving and strengthening Medicare.

Any restructuring or reform of Medicare should first and foremost preserve the integrity of the program. Contrary to current rhetoric, Medicare offers mainstream medical care for the most difficult-to-insure Americans, and over the past ten years its record of holding down costs has been better than that of the private insurance sector. For the very long term, when demographic changes place even greater pressures on Medicare, all dimensions of the program need to be considered in the search for a long-range solution, including asking beneficiaries and/or taxpayers to contribute more to the program. Expansion of managed care choices should certainly be part of any restructuring, but careful attention to improving the basic fee-for-service Medicare program--which will continue to serve a majority of beneficiaries for many years to come--also is needed.

Cost Control↗
PubMedDate not supplied

Managed competition in California's small-group insurance market.

This paper describes the early experience of the Health Insurance Plan of California (the HIPC), a small-employer purchasing cooperative established in 1993. The plan's experience is consistent with the predictions of advocates of market-oriented health care reform: The program's design has encouraged cost-conscious choice by enrollees, which in turn has generated price competition among plans. Differences across the HIPC's six rating regions conform with the notion that health care competition is less viable is sparsely populated areas. Evidence on risk selection suggests that while the HIPC as a whole has not experienced adverse selection, certain plans within the program have received a disproportionate share of high-cost enrollees.

California↗
PubMedDate not supplied

Risk adjustment and Medicare: taking a closer look.

Medicare's method for reimbursing at-risk managed care plans causes potential problems with selection (when beneficiaries with higher-than-expected costs stay in traditional plans) and stinting (the tendency to underprovide health services). Adjusting payment by diagnosis offers substantial improvement. We favor large-scale demonstrations of diagnosis-based reimbursement. Reducing payment, a Clinton administration proposal, would recoup excess payments in the short run but not address the selection problem, which could reemerge. Selection makes current payments vulnerable to upward spirals. We propose not using traditional Medicare to update reimbursement. Basing some payment on enrollees' actual use addresses selection and stinting. Rather than reinsurance, we propose blending traditional Medicare and risk-adjusted capitation. Ceding some cases to traditional Medicare in advance appears to be useful for terminally ill patients.

Aged↗
PubMedDate not supplied

Federal regulation of managed care: an impulse in search of a theory?

Although there is growing demand for regulation of the managed care industry, regulatory proponents have yet to articulate a clear theory of regulation. Most observers acknowledge consumer information problems that regulation could address, but there is no consensus regarding regulation of the broader public concern about restrictive medical-necessity determinations by health plans. Concerns about these issues--which fall within the gray areas of divergent clinical opinion--may be difficult or impossible to address by explicit regulation. If policymakers forbear on regulation of medical-necessity determinations, private market innovation may ultimately remedy this problem.

Consumer Advocacy↗
PubMedDate not supplied

Does a fixed-dollar premium contribution lower spending?

In a multiple-option health benefits program, the employer's premium contribution determines the incentives facing employees and participating health plans. Advocates of managed contribution argue that a fixed-dollar contribution policy will result in lower health spending by encouraging cost-conscious choices by employees and price competition among plans. The University of California (UC), which adopted a fixed-dollar contribution policy in 1994, provides a useful case study for assessing this claim. This DataWatch documents the effect of this policy on health maintenance organization (HMO) premiums and per employee health spending in the UC health benefits program.

California↗
PubMedDate not supplied

Is premium support the right medicine for Medicare?

This paper assesses the desirability of transforming Medicare into a premium-support system. I focus on three areas crucial to the future of Medicare: cost savings, beneficiary choice, and the stability of traditional Medicare. Based on my analysis of the Bipartisan Commission on the Future of Medicare plan, I find substantial problems with adopting premium support for Medicare. In particular, projections of premium-support savings are based on questionable assumptions that the slowdown in health spending during 1993-1997 can be sustained and extrapolated to future Medicare performance. Consequently, premium support may inadvertently destabilize public Medicare and erode beneficiary choice without achieving substantial savings.

Actuarial Analysis↗
PubMedDate not supplied

HealthMarts, HIPCs (health insurance purchasing cooperatives), MEWAs (multiple employee welfare arrangements), and AHPs (association health plans): a guide for the perplexed.

This paper considers how pending proposals to authorize new forms of group purchasing arrangements for health insurance would fit and function within the existing, highly complex market and regulatory landscape and whether these proposals are likely to meet their stated objectives and avoid unintended consequences. Cost savings are more likely to result from increased risk segmentation than through true market efficiencies. Thus, these proposals could erode previous market reforms whose goal is increased risk pooling. On the other hand, these proposals contain important enhancements, clarifications, and simplification of state and federal regulatory oversight of group purchasing vehicles. Also, they address some of the problems that have hampered the performance of purchasing cooperatives. On balance, although these proposals should receive cautious and careful consideration, they are not likely to produce a significant overall reduction in premiums or increase in coverage.

Cost Savings↗
PubMedDate not supplied

How and why the health insurance system will collapse.

The advocates of defined-contribution health plans extol the virtues of consumer-driven health care, consumer choice, and empowered consumers as solutions to the problems--particularly the rapidly growing costs--of employer-sponsored health benefits. This paper argues that the widespread use of defined-contribution plans, with more consumer choice and more knowledgeable consumers, will lead to the erosion of the social contract on which health insurance must be based, with healthier employees subsidizing the care of older and sicker ones, and a death spiral of adverse selection. If unchecked by government intervention, these trends will lead to the collapse of employer-sponsored health insurance.

Catastrophic Illness↗
PubMedDate not supplied

Why is there state variation in employer-sponsored insurance?

Using the National Survey of America's Families in 1997 and 1999, we investigate the sources of variation in employer-sponsored health insurance across states. We find that demographics and family characteristics (such as race/ethnicity and citizenship status), individual employment characteristics (such as firm size and labor-force attachment), and local labor market characteristics (such as unionization) consistently explain the relative position of all of the states with either high or low rates of employer coverage. Income plays a smaller role in explaining the state variation but is still an important determinant, especially among states whose average income is far from the national average.

Adult↗