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PubMed1998

Risk adjustment: where are we now?

Risk adjustment is intended to minimize selection of patients or enrollees in health plans. Current efforts generally are recognized as inadequate, but improvement is difficult. The greatest short-term gain will come from introducing diagnostic information, though outpatient diagnosis data are unreliable. Initial efforts may use inpatient data, but this creates incentives to hospitalize people. Even exploiting diagnosis information leaves substantial imperfections. Partial capitation, common in behavioral health, reduces incentives to select patients and stent on services, but current policy resists it, perhaps because policymakers misinterpret the lesson of the Prospective Payment System. Theoretically, not paying plans more for providing additional services is optimal only if consumers are well informed.

Capitation Fee↗

PubMed1998

Applications of health risk adjustment: what can be learned from experience to date?

Health-based payment is a key component of any strategy for health care reform. This paper summarizes four case studies describing "real-world" applications of health status risk adjustment to determine payments to health plans and providers. For each case study, the context for risk adjustment, the data and methods employed, and the implementation experience are assessed. The experience shows that the tools and methods required for determining health-based payments are available, and in many cases, well developed. They have been applied with success in different settings for different populations. Although many operational issues need to be addressed, obstacles can be overcome and the implementation of health-based payments is a feasible objective.

Actuarial Analysis↗

PubMed1998

Risk Adjustment for the Medicare program: lessons learned from research and demonstrations.

The Balanced Budget Act (BBA) of 1997 requires numerous changes in Medicare. Medicare's managed care program has been reinvented as "Medicare + Choice," offering an expanded range of delivery system options for beneficiaries and a schedule of payment changes that will dramatically affect managed care plans. Preceding some of these BBA-legislated changes to Medicare were years of research and demonstrations. Risk-adjusted payment in the Medicare + Choice program, which is mandated for implementation in 2000, is one example of a longstanding developmental initiative. This paper provides a brief overview of risk adjustment-related research and demonstration activities carried out by the Health Care Financing Administration (HCFA) since the 1980s, and describes a possible technical approach for the implementation of risk-adjusted Medicare managed care payments in 2000.

Aged↗

PubMed1998

State-sponsored programs for the uninsured: is there adverse selection?

Risk contracting by states for coverage of previously uninsured populations has been hampered by uncertainty regarding likely claims experience. This study reports on the utilization experience of two state programs offering subsidized coverage in commercial managed care organizations to low-income and previously uninsured people. Program participants used services similarly to people enrolled through large employer benefit plans. There was no evidence of pent-up demand or an unusual level of chronic illness. Similarly, there was little evidence of underutilization, although dissatisfaction and reported barriers to service were more frequent among nonwhite enrollees.

Adolescent↗

PubMed1992

Consumer information and biased selection in the demand for coverage supplementing Medicare.

This study examines how the relationship between health insurance knowledge and the health status of health insurance consumers influences their decisions to purchase insurance coverage. Data from the federal Medicare health insurance program for the elderly in the United States are used. The basic Medicare program provides a limited amount of coverage for health care services obtained from any provider in the private fee-for-service (FFS) market. Beneficiaries of this program may choose to supplement the basic coverage which they receive by two mechanisms: either they may purchase private insurance designed to fill some of the gaps left by the federal program ('Medigap' policies), thereby remaining in the FFS market and preserving their choice of provider, or they may enroll in health maintenance organizations (HMOs), thereby leaving the FFS market and agreeing to use only those providers affiliated with the HMO, and in return receiving broader coverage at little additional out-of-pocket cost. The study was made possible by a unique data set which combines measures of beneficiary knowledge of Medicare coverage with measures of perceived health status, socio-economic characteristics, and insurance coverage choices for a sample of Medicare beneficiaries who participated in an educational workshop about their insurance coverage options. These data were used to estimate a multinomial logistic model of the determinants of insurance choices, where the options included the two listed above and a basic Medicare option. The study explicitly recognizes the interaction between insurance information and health status in health plan choice. These results show that knowledge of coverage does have a differential impact on the decision to purchase health insurance depending on health status. With a high level of knowledge, sicker beneficiaries are less likely to have basic Medicare alone, compared with HMOs or Medigap policies, while healthier beneficiaries are less likely to be enrolled in HMOs, compared with Medigap policies. This finding has important implications for the use of health status measures to adjust capitated payment formulas when knowledgable consumers have the option to enroll in HMOs or remain in the FFS environment. In the absence of health status adjusters for the HMO capitation payments, high levels of coverage knowledge may exacerbate inherent selection bias among these coverage options by healthier and sicker consumers of health insurance.

Aged↗

PubMed1985

Regression toward the mean in medical care costs. Implications for biased selection in health maintenance organizations.

As more Americans choose among insurance plans, the possibility of biased selection increases in importance. Although regression toward the mean is recognized as a common problem in evaluating social programs, it has generally been ignored in studies of biased selection. Suppose that people are included in a group simply because they had expenditures in one year $100 below the mean; that is, health status or other risk factors are not part of the selection criteria. Empirically, the expected difference in the following year is about $20 and appears to fall in each subsequent year. This pattern holds for the elderly and nonelderly. Evidence of lower pre-enrollment expenditure of prepaid group practice (PGP) enrollees can be interpreted in several ways. Under one interpretation, PGP enrollees are assumed to be a random sample conditional on pre-enrollment expenditure, such that biased selection is one fifth of estimates based on 1 year of data and one half of estimates based on 4 years of data. This article cannot resolve the issue of alternative interpretations; it only raises it.

Adolescent↗

PubMed1985

Selection and the competitive standing of health plans in a multiple-choice, multiple-insurer market.

Previous studies have determined that biased selection occurs in multiple-choice, multiple-insurer programs. To the extent that health plans are affected by biased selection, efficiency becomes less important since adverse selection may raise a particular plan's costs relative to those of its competitors. This study finds that both favorable and unfavorable selection deteriorate over time. Thus, not only may selection harm the competitive standing of individual plans, but it may also force these plans to withdraw from the market. With free entry, no plan is immune from fatal adverse selection.

Community Participation↗

PubMed2004

Anorexia nervosa: a 63-year population-based survival study.

As eating disorders attract increasing publicity, more affected individuals will seek medical attention. Many will have needs for life insurance. Due to selection bias, most of the literature on anorexia nervosa (AN) presents an unfavorable prognosis. Therefore, the impairment is considered an adverse life insurance risk. This review is from an unselected, community population. The demographics of the study population and its expected mortality are similar to a population purchasing life insurance products. Comparative experience over 63 years of follow-up reveals mortality ratios and excess death rates similar to those expected for the population. High-risk comorbid diagnoses of depression and alcoholism are discussed.

Actuarial Analysis↗

PubMedDate not supplied

[The impact of social security system reform on health services equity in Colombia].

To evaluate the impact on access to, and use of, health services in Colombia's new national health insurance system, the authors compared two cross sections of the population: before (1993) and after (1997), with the approval of Act 100, creating the General System for Social Security in Health (SGSSS). Two equity indicators were assessed: concentration curves (CC) and concentration indices (CI), summarizing the distribution of access to health care and utilization of health care services provided by the SGSSS according to income deciles. Between 1993 and 1997, the CI for access to insurance halved from 0.34 to 0.17; simultaneously, coverage increased from 23% to 57%, especially among the poorest segments of the population, where it increased from 3.7% to 43.7% as a result of subsidies provided by local governments. The CI for utilization of health care services did not vary significantly. Increased disease prevalence and utilization of services among the insured, due to biased selection of risks and moral hazards, were also documented. These findings suggest a positive impact by the Reform on inequalities in access to health care insurance; however, a similar effect on inequities in utilization of health services is not clear.

Adolescent↗

PubMed1985

Biased selection in the Federal Employees Health Benefits Program.

The existence of biased selection in health insurance markets has long been assumed by economic theorists as well as seen between classes of health plans. In this paper, we use a model of the premium rate that takes into consideration the effects of moral hazard to make empirical estimates of the extent of selection in the Federal Employees Health Benefits Program. We find that biased selection has raised the premium of the Blue Cross Plan high-option coverage by 21% and lowered the premium of the low-option coverage by 29%, both relative to premiums that would have been charged in the absence of selection.

Blue Cross Blue Shield Insurance Plans↗

PubMed1989

The triple option choice: self-selection bias in traditional coverage, HMOs, and PPOs.

Health care costs and utilization by salaried employees and their dependents at a large self-insured midwestern industrial manufacturing corporation were analyzed for the year before employees were first offered a triple option choice. Members had the option of retaining traditional Blue Cross and Blue Shield of Michigan (BCBSM) coverage or switching to either a number of health maintenance organizations (HMOs) or a number of preferred provider organizations (PPOs). Members who switched to HMOs or PPOs were generally younger and had lower average expenses and utilization rates than those who retained the traditional BCBSM plan. The results suggest that a selection bias does occur in this population, as lower cost members were more attracted to the HMOs and PPOs than were more expensive members. Implications for the corporation as well as for the drive toward managed care alternatives are discussed.

Age Factors↗

PubMed1985

Factors that affect the HMO enrollment decision: a tale of two cities.

Although there is agreement that utilization patterns in HMOs differ from those in non-HMO systems, there is less agreement on how and why these differences are achieved. Selection bias is one frequently offered explanation. In an attempt to identify those individual and site-specific factors that help determine employees' choice of coverage, we developed and tested a logistic model of the enrollment decision. We used both survey data and claims data to study the decision to enroll in either an HMO or a traditional indemnity plan among state employees in Tallahassee, Florida, and Salt Lake City, Utah. We found that many factors affected the decision--factors that could be altered by an HMO or insurance company to correct selection bias if and when it is encountered.

Adult↗

PubMed2004

Health insurance and treatment seeking behaviour: evidence from a low-income country.

This paper analyses the effect of being insured under the voluntary component of Vietnamese Health Insurance, on patterns of treatment seeking behaviour. A multinomial logit model is estimated using household survey data from three provinces in Vietnam. Decisions regarding both the type of provider sought and type of care received are analysed. Insurance status is treated as both exogenous and endogenous to account for potential selection bias. The results indicate that, overall, insured patients are more likely to use outpatient facilities, and public providers, an effect that is particularly strong at lower income levels.

Adult↗

PubMed1996

Functional restoration. Returning patients with chronic low back pain to work--revolution or fad?

STUDY DESIGN: A review was performed to assess the basis for functional restoration programs in returning patients with chronic low back pain to work. OBJECTIVE: To review and assess the effectiveness of functional restoration programs in the treatment of chronic low back pain. SUMMARY OF BACKGROUND DATA: Functional restoration programs generally use an aggressive program of physical exercises and psychosocial support with the focus on improving function despite the pain. METHODS: A review was conducted of significant papers presenting results of large clinical trials that used functional restoration programs. RESULTS: Several influential studies have reported statistically significant improvement in return-to-work rates of treated patients. The comparison groups consisted of treatment failures and/or patients refused entry to the programs because of insurers refusal to pay. Selection bias, incomplete follow-up, and inappropriate allocation of compared patients cast doubt on the effectiveness of these functional restoration programs. The only published prospective randomized clinical trial failed to demonstrate the efficacy of a functional restoration program. CONCLUSIONS: Further clinical trials based on sound methodology are needed.

Disability Evaluation↗

PubMed2004

Is it really worse to have public health insurance than to have no insurance at all? Health insurance and adult health in the United States.

Using prospective cohort data from the 1979 National Longitudinal Survey of Youth, this study examines the extent to which health insurance coverage and the source of that coverage affect adult health. While previous research has shown that privately insured nonelderly individuals enjoy better health outcomes than their uninsured counterparts, the same relationship does not hold for those publicly insured through programs such as Medicaid. Because it is unclear whether this finding reflects a true causal relationship or is in fact due to selection bias on socioeconomic status and health, previous estimates of the contribution of health insurance to inequities in health may have been biased. This study attempts to disentangle these competing hypotheses of causation or selection bias by using fixed effects models with sibling clusters to corroborate--or contradict--the results of a conventional OLS regression. By controlling for unobserved factors shared by siblings, such as parental genetic influences, sibling models estimate health insurance effects that are less affected by selection bias. Findings suggest that, among the US. birth cohorts of 1957 to 1961, the negative relationship between public health insurance and health is not causal, but rather due to prior health and socioeconomic status. Conversely, the lack of health insurance coverage has a strong cumulative negative impact on adult health.

Adult↗

PubMed2003

Health status and heterogeneity of cost-sharing responsiveness: how do sick people respond to cost-sharing?

This paper examines whether the responsiveness of health care utilization to cost-sharing varies by health status and the implications of such heterogeneity. First, we show theoretically that if health care utilization of those in poor health is less responsive to cost sharing, this, combined with the skewness of health expenditures in health status, leads to overestimates of the effect of cost sharing. This bias is exacerbated when elasticities are generalized to populations with greater expenditure skewness. Second, we show empirically that cost-sharing responsiveness does differ by health status using data from the Medicare Current Beneficiary Survey. Medicare beneficiaries are stratified into health status groups based on activity of daily living (ADL) impairments and self-reported health status. Separately, for each of the health status groups, we estimate the effect of Medigap insurance on Part B utilization using a two-part expenditure model. We find that the change in expenditures associated with Medigap is smaller for those in poorer health. For example, when stratified using ADLs, Medigap insurance increases expenditures for 'healthy' groups by 36.4%, while the increase for the 'sick' group is 12.7%. Results are qualitatively the same for different forms of supplemental insurance and different methods of health status stratification. We develop a test to demonstrate that adjusting our results for selection bias would result in estimates of greater heterogeneity. Our results imply that a lowerbound estimate of the bias from neglecting heterogeneity is about 2-7%.

Activities of Daily Living↗

PubMed2000

A retrospective evaluation of the causes of death of 448 insured French horses in 1995.

Epidemiological studies should allow comparisons to be made of the prevalence of disease in populations from different countries, but the population characteristics and health problems in French horses are not well established. We have conducted a retrospective evaluation of the causes of death and vital characteristics of insured horses in France for the year 1995, with a view to comparison with published data from other countries. Files on 448 deceased horses were provided by nine insurance companies. Most of the animals were used for breeding (60%), followed by leisure (20%), eventing and racing (10% each). Physical characteristics were associated significantly with occupational categories. The overall mortality rate was 2.47%, and was due, in decreasing order, to foaling (24%), colic (21%) or locomotor (21%), cardiovascular (9%), neurological (8%), respiratory (5%) or infectious (4%) disease. Infectious disease was more frequent in younger animals (p < 0.05) and locomotor disease in racehorses (p < 0.01). Horses aged over 15 years had a lower incidence of colic (p <0.05). The cause of death was not significantly linked to breed, insurance value or season. Despite some selection bias, the study provides useful information about mortality in the French equine population.

Animals↗

PubMed2005

Insurance and other socioeconomic determinants of elderly longevity in a Costa Rican panel.

Official figures show that life expectancy in Costa Rica is longer than in the United States (US), in spite of the fact that per capita health expenditure is only one-tenth that of the US. To check whether this is for real and to explore some of its determinants, 900 Costa Ricans aged 60+ were followed from 1984 to 2001. Follow-up household visits were made, deaths were tracked in the national death registry, and survival status in the voting registry was double-checked. In addition, the survivors were contacted in 2002. Two-thirds of the panel had died by December 2001. Kaplan-Meier curves, life tables and Cox regression were used to analyse the panel's survival. Mortality in the panel was slightly higher than the Costa Rican average and similar to that in the US, confirming the exceptional longevity of Costa Ricans. Survival was substantially lower among unmarried men and individuals with limited autonomy at the beginning of the study. The effect of socioeconomic status is weak. Insurance effects seem to be confounded by selection biases.

Aged↗