Scope and Incentives for Risk Selection in Health Insurance Markets With Regulated Competition: A Conceptual Framework and International Comparison.

In health insurance markets with regulated competition, regulators face the challenge of preventing risk selection. This paper provides a framework for analyzing the scope (i.e.

Coding-Driven Changes In Measured Risk In Accountable Care Organizations.

Claims data, which form the foundation of risk adjustment in payment for health care services, may reflect efforts to capture more-or more severe-clinical conditions rather than true changes in health status. This can distort payments. We quantify this in the context of Medicare's accountable care organization (ACO) program by comparing risk scores derived from two different measurement approaches.

Improving the Performance of Risk Adjustment Systems: Constrained Regressions, Reinsurance, and Variable Selection.

Modifications of risk-adjustment systems used to pay health plans in individual health insurance markets typically seek to reduce selection incentives at the individual and group levels by adding variables to the payment formula. Adding variables can be costly and lead to unintended incentives for upcoding or service utilization. While these drawbacks are recognized, they are hard to quantify and difficult to balance against the concrete, measurable improvements in fit that may be achieved by adding variables to the formula.

The Evolution of Supply and Demand in Markets for Generic Drugs.

Unlabelled: Policy Points Much concern about generic drug markets has emerged in recent policy debates. Important changes in regulations, the structure of purchasing, and the length of the drug supply chain have affected generic drug markets. Effective price competition remains the rule in generic markets for large-selling drugs.

Accuracy of US College Football Players' Estimates of Their Risk of Concussion or Injury.

Importance: Despite increased concern about the health consequences of contact sports, little is known about athletes' understanding of their own risk of sports-related injury.

Objective: To assess whether college football players accurately estimate their risk of concussion and nonconcussion injury and to identify characteristics of athletes who misestimate their injury risk.

Design, Setting, And Participants: In this survey study, questionnaires were given to 296 current college football players on 4 teams from the 3 of the 5 most competitive conferences of the US National Collegiate Athletic Association.

Medicaid Expansion's Spillover to the Criminal Justice System: Evidence from Six Urban Counties.

Spillovers from the Affordable Care Act Medicaid expansion to other social-sector outcomes have received little attention. One that may be especially salient for public policy is the impact of expanded eligibility on jail-related outcomes. This study compares recidivism outcomes in three non-expansion counties to nearby expansion counties before and after Medicaid expansion.

The vexing relationship between socioeconomic status and health.

In a recent issue of this Journal, Politzer, Shmueli, and Avni estimate the economic costs of health disparities due to socioeconomic status (SES) in Israel (Politzer et al., Isr J Health Policy Res 8: 46, 2019). Using three measures of SES, the socioeconomic ranking of localities, individual income, and individual education, Politzer and colleagues estimate welfare loss due to higher mortality, productivity loss due to poorer health, excess health care treatment costs, and excess disability payments for individuals with below median SES relative to those with above median SES.

Improving risk-equalization in Switzerland: Effects of alternative reform proposals on reallocating public subsidies for hospitals.

The Swiss healthcare financing system is on the verge of one of its largest reforms. The Swiss parliament is currently debating how to reallocate about 20 % of total health expenditures. Swiss cantons make substantial tax-funded contributions to health expenditures by paying 55 % of hospital inpatient costs.

Very high and low residual spenders in private health insurance markets: Germany, The Netherlands and the U.S. Marketplaces.

We study the extremely high and low residual spenders in individual health insurance markets in three countries. A high (low) residual spender is someone for whom the residual-spending less payment (from premiums and risk adjustment)-is high (low), indicating that the person is highly underpaid (overpaid). We begin with descriptive analysis of the top and bottom 1% and 0.

Staffing, Financial, and Administrative Oversight Models and Rates of Injury in Collegiate Athletes.

Context: Structural features of health care environments are associated with patient health outcomes, but these relationships are not well understood in sports medicine.

Objective: To evaluate the association between athlete injury outcomes and structural measures of health care at universities: (1) clinicians per athlete, (2) financial model of the sports medicine department, and (3) administrative reporting structure of the sports medicine department.

Design: Descriptive epidemiology study.

Extreme under and overcompensation in morbidity-based health plan payments: The case of Switzerland.

In 2020, the Swiss insurer payment model will include a set of sophisticated morbidity indicators in the form of Pharmaceutical Cost Groups (PCGs), added to a payment model currently largely based on age, gender, and a crude morbidity indicator. Adding powerful risk adjustors reduces underpayment for previously highly underpaid groups but creates a new group of the highly overpaid. We characterize the diseases and patterns of health care spending in most extremely under and overpaid in the new Swiss payment model.

Association between High Proportions of Seriously Mentally Ill Nursing Home Residents and the Quality of Resident Care.

Objectives: To examine the association between the quality of care delivered to nursing home residents with and without a serious mental illness (SMI) and the proportion of nursing home residents with SMI.

Design: Instrumental variable study. Relative distance to the nearest nursing home with a high proportion of SMI residents was used to account for potential selection of patients between high- and low-SMI facilities.

Limitations of P-Values and R-squared for Stepwise Regression Building: A Fairness Demonstration in Health Policy Risk Adjustment.

Stepwise regression building procedures are commonly used applied statistical tools, despite their well-known drawbacks. While many of their limitations have been widely discussed in the literature, other aspects of the use of individual statistical fit measures, especially in high-dimensional stepwise regression settings, have not. Giving primacy to individual fit, as is done with p-values and R, when group fit may be the larger concern, can lead to misguided decision making.

Data transformations to improve the performance of health plan payment methods.

The conventional method for developing health care plan payment systems uses observed data to study alternative algorithms and set incentives for the health care system. In this paper, we take a different approach and transform the input data rather than the algorithm, so that the data used reflect the desired spending levels rather than the observed spending levels. We present a general economic model that incorporates the previously overlooked two-way relationship between health plan payment and insurer actions.

The Comparative Advantage of Medicare Advantage.

We ascertain the degree of service-level selection in Medicare Advantage (MA) using individual level data on the 100 most frequent HCC's or combination of HCC's from two national insurers in 2012-2013. We find differences in the distribution of beneficiaries across HCC's between TM and MA, principally in the smaller share of MA enrollees with no coded HCC, consistent with greater coding intensity in MA. Among those with an HCC code, absolute differences between MA and TM shares of beneficiaries are small, consistent with little service-level selection.

Market Concentration and Potential Competition in Medicare Advantage.

Issue: Medicare Advantage (MA), the private option to traditional Medicare, now serves roughly 37 percent of beneficiaries. Congress intended MA plans to achieve efficiencies in the provision of health care that lead to savings for Medicare through managed competition among private health plans.

Goal: Two elements are needed for savings to accrue: a sound payment policy and effective competition among the private plans.

College Football Players Less Likely to Report Concussions and Other Injuries with Increased Injury Accumulation.

Athletes sometimes choose not to report suspected concussions, risking delays in treatment and health consequences. How and why do athletes make these reporting decisions? Using original survey data from a cohort of college football players, we evaluate two assumptions of the current literature on injury reporting: first, that the probability of reporting a concussion or injury is constant over time; second, that athletes make reasoned deliberative decisions about whether to report their concussion or other injury. We find that athletes are much less likely to report a concussion to a medical professional than they are to report another injury (47% vs.

Sample Selection for Medicare Risk Adjustment Due to Systematically Missing Data.

Objective: To assess the issue of nonrepresentative sampling in Medicare Advantage (MA) risk adjustment.

Data Sources: Medicare enrollment and claims data from 2008 to 2011.

Data Extraction: Risk adjustment predictor variables were created from 2008 to 2010 Part A and B claims and the Medicare Beneficiary Summary File.

Deriving risk adjustment payment weights to maximize efficiency of health insurance markets.

Risk-adjustment is critical to the functioning of regulated health insurance markets. To date, estimation and evaluation of a risk-adjustment model has been based on statistical rather than economic objective functions. We develop a framework where the objective of risk-adjustment is to minimize the efficiency loss from service-level distortions due to adverse selection, and we use the framework to develop a welfare-grounded method for estimating risk-adjustment weights.

The Impact of Dementia Special Care Units on Quality of Care: An Instrumental Variables Analysis.

Objective: To compare the quality of care following admission to a nursing home (NH) with and without a dementia special care unit (SCU) for residents with dementia.

Data Sources/study Setting: National resident-level minimum dataset assessments (MDS) 2005-2010 merged with Medicare claims and provider-level data from the Online Survey, Certification, and Reporting database.

Study Design: We employ an instrumental variable approach to address the endogeneity of selection into an SCU facility controlling for a range of individual-level covariates.

Matching and Imputation Methods for Risk Adjustment in the Health Insurance Marketplaces.

New state-level health insurance markets, denoted , created under the Affordable Care Act, use risk-adjusted plan payment formulas derived from a population to participate in the Marketplaces. We develop methodology to derive a sample from the target population and to assemble information to generate improved risk-adjusted payment formulas using data from the Medical Expenditure Panel Survey and Truven MarketScan databases. Our approach requires multi-stage data selection and imputation procedures because both data sources have systemic missing data on crucial variables and arise from different populations.

Implications of family risk pooling for individual health insurance markets.

While family purchase of health insurance may benefit insurance markets by pooling individual risk into family groups, the correlation across illness types in families could exacerbate adverse selection. We analyze the impact of family pooling on risk for health insurers to inform policy about family-level insurance plans. Using data on 8,927,918 enrollees in fee-for-service commercial health plans in the 2013 Truven MarketScan database, we compare the distribution of annual individual health spending across four pooling scenarios: (1) "Individual" where there is no pooling into families; (2) "real families" where costs are pooled within families; (3) "random groups" where costs are pooled within randomly generated small groups that mimic families in group size; and (4) "the Sims" where costs are pooled within random small groups which match families in demographics and size.

Measuring efficiency of health plan payment systems in managed competition health insurance markets.

Adverse selection in health insurance markets leads to two types of inefficiency. On the demand side, adverse selection leads to plan price distortions resulting in inefficient sorting of consumers across health plans. On the supply side, adverse selection creates incentives for plans to inefficiently distort benefits to attract profitable enrollees.