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PubMed2001

Health plans and selection: formal risk adjustment vs. market design and contracts.

In this paper, we explore the demand for risk adjustment by health plans that contract with private employers by considering the conditions under which plans might value risk adjustment. Three factors reduce the value of risk adjustment from the plans' point of view. First, only a relatively small segment of privately insured Americans face a choice of competing health plans. Second, health plans share much of their insurance risk with payers, providers, and reinsurers. Third, de facto experience rating that occurs during the premium negotiation process and management of coverage appear to substitute for risk adjustment. While the current environment has not generated much demand for risk adjustment, we reflect on its future potential.

Community Participation↗
PubMed2001

Formal risk adjustment by private employers.

This paper explores explanations for why few private employers have adopted formal risk adjustment. The lack of data, challenges of using highly imperfect signals, and absence of market power are not compelling explanations. Alternative strategies that reduce selection problems are clearly important. The central argument is that U.S. health markets are not in equilibrium, but rather are changing rapidly. Since many agents-consumers, employers, health plans, and providers--do not currently demand formal risk adjustment, it is not surprising that adoption has been slow. Recent changes in health plan markets may change the demand and accelerate future adoption.

Actuarial Analysis↗
PubMedDate not supplied

Effects of "second generation" small group health insurance market reforms, 1993 to 1997.

In the mid-1990s, several state legislatures enacted a "second generation" of small group health insurance reforms that required guaranteed issue of all products and prohibited the use of health as a rating factor. We use data from two large employer surveys to compare the behavior of small business in nine states that adopted these reforms between 1993 and 1997 to the behavior of small business in 11 states and the District of Columbia, where neither of these small group health insurance market reforms existed prior to 1997 (N = 8,465 in 1993; N = 12,219 in 1997). Our analyses focus on several outcomes: health insurance offer and enrollment rates in any employer plan, and in an HMO plan; turnover in offer decisions; and premiums, variability in premiums, and the rate of change in premiums. Overall, we find no effect of small group reform on any of the outcomes; the sign of the effect is not consistent across reform states, the estimates rarely attain statistical significance, and they show no consistent pattern across the outcomes within each state. Therefore, predictions of the harm these regulations might cause to the market have not come to pass. On the other hand, proponents' hopes for a solution to low coverage rates among small businesses have not materialized either.

Fees and Charges↗
PubMedDate not supplied

Health-based risk adjustment: is inpatient and outpatient diagnostic information sufficient?

Adequate risk adjustment is critical to the success of market-oriented health care reforms in many countries. Currently used risk adjusters based on demographic and diagnostic cost groups (DCGs) do not reflect expected costs accurately. This study examines the simultaneous predictive accuracy of inpatient and outpatient morbidity measures and prior costs. DCGs, pharmacy cost groups (PCGs), and prior year's costs improve the predictive accuracy of the demographic model substantially. DCGs and PCGs seem complementary in their ability to predict future costs. However, this study shows that the combination of DCGs and PCGs still leaves room for cream skimming.

Capitation Fee↗
PubMed2002

Do welfare caseload declines make the Medicaid risk pool sicker?

Declining welfare caseloads may lead to a sicker population remaining in the Medicaid program, which could increase per enrollee costs and the level of adequate capitation rates. Using data from the 1997 National Survey of America's Families for adults and children, we examine differences in health status and utilization among welfare recipients and welfare leavers who did and did not retain Medicaid. We adjust utilization differences for insurance status and factors often used to adjust capitation rates. We conclude that declining welfare caseloads likely will result in a sicker and more expensive adult Medicaid risk pool.

Adult↗
PubMed2002

Using survey measures to assess risk selection among Medicare managed care plans.

This paper quantifies risk selection among competing Medicare managed care plans, using beneficiary survey data from the Consumer Assessments of Health Plans Survey. Selection, measured by variation in plan-level prevalence of health conditions and predicted costs, was substantial. A plan with moderate (one standard deviation) adverse selection would have predicted costs 11.6% above an average plan. Only a small part of this variation was explained by the geographical differences in the prevalence of health conditions among or within Metropolitan Statistical Areas, indicating that the selection was driven by plan attributes. Plans serving members with greater health needs have the potential to establish programs to serve these sick members well, yet this places plans at financial risk. Hence, improved risk adjustment for chronic conditions may be warranted. Moreover, survey measures have the potential to measure the prevalence of such conditions reliably and consistently across plans.

Adult↗
PubMed2002

Risk selection among SSI enrollees in TennCare.

The issue of risk selection is especially important for states that enroll blind and disabled beneficiaries of Supplemental Security Income (SSI) in Medicaid managed care. SSI beneficiaries have persistent needs for care, have a wide variety of chronic conditions, and often need atypical and complex services. Risk selection occurs when the health care needs of beneficiaries enrolled in a specific plan differ systematically from the needs of the overall beneficiary population and payments do not reflect those needs. We assess the extent of risk selection among managed care plans for SSI beneficiaries over the first three years of Tennessee's Medicaid managed care program, TennCare. Using claims data containing fee-for-service expenditures prior to enrollment in managed care, we find substantial evidence of persistent risk selection among plans. Results are robust to most alternative measures of risk selection for most plans.

Aid to Families with Dependent Children↗
PubMed2002

Participation in a public insurance program: subsidies, crowd-out, and adverse selection.

This paper examines how varying the level of subsidies affects participation in a public insurance program, crowd-out of private insurance, and adverse selection. We study the experience in Washington's Basic Health program in 1997. Findings show that adverse selection is not a problem in voluntary public programs. Increasing subsidies have only modest effects on participation in subsidized programs, though the gains are not at the expense of the private market. Overall participation in the subsidized plan is also modest, even though participants benefit from it. The challenge to policymakers is to find program design characteristics, beyond subsidies, that attract the uninsured.

Adolescent↗
PubMedDate not supplied

Health plan disenrollment in a choice-based Medicaid managed care program.

Consumer decisions to switch health plans have implications for quality of care and risk selection. We examine factors related to time to disenrollment in a Medicaid managed care program where beneficiaries face a menu of plans and can change plans every month. Several findings have direct policy relevance. Families and individuals who make active choices upon entering the program are at substantially lower risk of disenrollment than those who are auto-assigned. Interactions between enrollee ethnicity and provider language proficiency suggest that enrollee satisfaction depends on the cultural competence of providers. Differential disenrollment by risk status results in adverse retention for certain types of plans.

Adult↗
PubMed1996

Diabetes in a managed care system.

Health care expenditures account for over 14% of the gross domestic product in the United States. Managed care has evolved to control these costs. Because diabetes accounts for nearly 15% of health care expenditures, the strategies used by managed care organizations are expected to have a particular effect on diabetes. Managed care organizations have two primary goals: to control costs and to provide care of sufficient quality to attract and satisfy enrollees. Managed care organizations have designed strategies to meet these goals. Four primary managed care strategies and their effects on diabetes care are discussed: 1) payment incentives rewarding desired provider practice patterns; 2) designation of providers who possess desirable practice behaviors; 3) coverage policies that control the services paid for; and 4) traditional insurance strategies that determine who is eligible for insurance and what premiums are to be paid. The few direct studies of the effects of each strategy on the care of diabetic persons are discussed. The conclusion is that although managed care organizations have the potential to provide excellent care for diabetic persons, little evidence exists that they have improved either the quality or the cost-effectiveness of diabetes care. Recommendations to guide the development of cost-effective care for diabetic persons are presented.

Cost-Benefit Analysis↗
PubMed1990

The performance of urban and public hospitals and NHCs (neighborhood health centers) under Medicaid capitation programs.

This article reports the results of a study that examined what happened to the utilization of Medicaid beneficiaries, eligible under Aid to Families with Dependent Children, who were mandatorily enrolled in several capitated alternatives in the Kansas City area. Their experience is contrasted with that of a comparison group selected from the St. Louis area. The types of plans analyzed include those sponsored by hospitals, neighborhood health centers, HMOs, and private physicians (IPAs). With the exception of emergency room use, all plans controlled utilization equally well. Results are explained in light of their management and policy implications.

Adult↗
PubMed1991

Risky business: HMOs and managed care.

Are HMOs doing all they can do to control health care costs? Or are they enjoying the best of both worlds; that is, healthy subscribers and "equal dollars"?

Cost Control↗