How profitable is risk selection? A comparison of four risk adjustment models.

To mitigate selection triggered by capitation payments, risk-adjustment models bring capitation payments closer on average to individuals' expected expenditure. We examine the maximum potential profit that plans could hypothetically gain by using their own private information to select low-cost enrollees when payments are made using four commonly used risk adjustment models. Simulations using a privately insured sample suggest that risk selection profits remain substantial. The magnitude of potential profit varies according to the risk adjustment model and the private information plans can employ to identify profitable enrollees.

[1]  Roger D. Feldman,et al.  Simulation of a Health Insurance Market with Adverse Selection , 1982, Oper. Res..

[2]  R. Lichtenstein,et al.  Selection Bias in TEFRA At-Risk HMOs , 1991, Medical care.

[3]  G. Anderson,et al.  Capitation pricing: Adjusting for prior utilization and physician discretion , 1986, Health care financing review.

[4]  J. Lubitz,et al.  Enrollee health status under Medicare risk contracts: an analysis of mortality rates. , 1991, Health services research.

[5]  Jerrold W. Hill,et al.  Biased Selection in the Tefra HMO/CMP Program , 1990 .

[6]  J. Newhouse.  Do unprofitable patients face access problems? , 1989, Health care financing review.

[7]  N. Duan.  Smearing Estimate: A Nonparametric Retransformation Method , 1983 .

[8]  D. Bates,et al.  Diagnosis-Based Risk Adjustment for Medicare Capitation Payments , 1996, Health care financing review.

[9]  E. Keeler,et al.  Health insurance and the demand for medical care: evidence from a randomized experiment. , 1987, The American economic review.

[10]  W. Manning,et al.  The logged dependent variable, heteroscedasticity, and the retransformation problem. , 1998, Journal of health economics.

[11]  Randall P. Ellis,et al.  Risk Adjustment in Competitive Health Plan Markets , 2000 .

[12]  R. Kravitz,et al.  Differences in the mix of patients among medical specialties and systems of care. Results from the medical outcomes study. , 1992, JAMA.

[13]  Thomas G. McGuire,et al.  Optimal Risk Adjustment in Markets with Adverse Selection: An Application to Managed Care , 2000 .

[14]  W. V. D. Ven,et al.  How can we prevent cream skimming in a competitive health insurance market? The great challenge for the 90's. , 1992 .

[15]  D. Bates,et al.  Using Diagnoses to Describe Populations and Predict Costs , 2000, Health care financing review.

[16]  Jonathan P. Weiner,et al.  Risk-Adjusted Medicare Capitation Rates Using Ambulatory and Inpatient Diagnoses , 1996, Health care financing review.

[17]  R. Ellis,et al.  Cost-minimizing risk adjustment. , 2002, Journal of health economics.

[18]  T. Selden.  Risk Adjustment for Health Insurance: Theory and Implications , 1998 .

[19]  J. Newhouse,et al.  Risk adjustment and Medicare: taking a closer look. , 1997, Health affairs.

[20]  J. Mullahy.  Much Ado About Two: Reconsidering Retransformation and the Two-Part Model in Health Economics , 1998, Journal of health economics.

[21]  W. van de Ven,et al.  How can we prevent cream skimming in a competitive health insurance market? The great challenge for the 90's. , 1992, Developments in health economics and public policy.

[22]  J. Kasper,et al.  Biased Selection and Regression toward the Mean in Three Medicare HMO Demonstrations: A Survival Analysis of Enrollees and Disenrollees , 1989, Medical care.

[23]  T. Mcguire,et al.  Setting capitation payments in markets for health services , 1987, Health care financing review.

[24]  W. van de Ven,et al.  Ignoring small predictable profits and losses: a new approach for measuring incentives for cream skimming , 2000, Health care management science.