儿童按人头付费率的风险调整
Risk adjustment for a children's capitation rate.
作者信息
Newhouse J P, Sloss E M, Manning W G, Keeler E B
机构信息
Harvard University.
出版信息
Health Care Financ Rev. 1993 Fall;15(1):39-54.
Abstract
Few capitation arrangements vary premiums by a child's health characteristics, yielding an incentive to discriminate against children with predictably high expenditures from chronic diseases. In this article, we explore risk adjusters for the 35 percent of the variance in annual out-patient expenditure we find to be potentially predictable. Demographic factors such as age and gender only explain 5 percent of such variance; health status measures explain 25 percent, prior use and health status measures together explain 65 to 70 percent. The profit from risk selection falls less than proportionately with improved ability to adjust for risk. Partial capitation rates may be necessary to mitigate skimming and dumping.
摘要
很少有按人头付费的安排会根据孩子的健康特征来调整保费，这就产生了一种歧视慢性病患儿的动机，因为这些患儿的支出预计会很高。在本文中，我们探讨了风险调整因素，用于应对我们发现的占年度门诊支出方差35%的潜在可预测部分。年龄和性别等人口统计学因素仅解释了此类方差的5%；健康状况指标解释了25%，既往使用情况和健康状况指标共同解释了65%至70%。风险选择带来的利润下降幅度小于风险调整能力提高的比例。可能需要采用部分按人头付费率来减轻撇脂和倾销行为。
相似文献
1
Risk adjustment for a children's capitation rate.儿童按人头付费率的风险调整
Health Care Financ Rev. 1993 Fall;15(1):39-54.
2
Adjusting capitation rates using objective health measures and prior utilization.使用客观健康指标和既往医疗利用率来调整按人头付费率。
Health Care Financ Rev. 1989 Spring;10(3):41-54.
3
Rate adjusters for Medicare under capitation.按人头付费的医疗保险费率调整器。
Health Care Financ Rev. 1986;1986(Spec No):45-55.
4
Using chronic disease risk factors to adjust Medicare capitation payments.利用慢性病风险因素调整医疗保险按人头付费。
Health Care Financ Rev. 1992 Fall;14(1):79-90.
5
Diagnosis-based risk adjustment for Medicare capitation payments.基于诊断的医疗保险按人头付费风险调整。
Health Care Financ Rev. 1996 Spring;17(3):101-28.
6
Disability and Medicare costs of elderly persons.老年人的残疾状况与医疗保险费用
Milbank Q. 1997;75(4):461-93. doi: 10.1111/1468-0009.00066.
7
New capitation scenarios for HMO Medicare risk contracting.健康维护组织（HMO）医疗保险风险合同的新按人头付费方案。
Healthc Financ Manage. 1997 Feb;51(2):35-6, 38.
8
Modified capitation and treatment incentives for end stage renal disease.针对终末期肾病的改良人头费支付方式及治疗激励措施。
Health Care Financ Rev. 1996 Spring;17(3):129-42.
9
Biased selection and Medicare HMOs: analysis of the 1989-1994 experience.
Med Care Res Rev. 1997 Sep;54(3):259-74; discussion 275-85. doi: 10.1177/107755879705400301.
10
Congress tinkering with Medicare HMO formula.
Mod Healthc. 1995 Oct 2;25(40):42.
引用本文的文献
1
A critical review of the use of R in risk equalization research.对R在风险均等化研究中的应用的批判性综述。
Eur J Health Econ. 2025 Apr;26(3):363-375. doi: 10.1007/s10198-024-01709-8. Epub 2024 Aug 9.
2
Saving Money or Just Saving Lives? Improving the Productivity of US Health Care Spending.省钱还是拯救生命？提高美国医疗保健支出的生产率。
Annu Rev Econom. 2012 Sep;4:33-56. doi: 10.1146/annurev-economics-080511-110942. Epub 2012 Apr 5.
3
Socioeconomic Background and Commercial Health Plan Spending.社会经济背景与商业健康保险计划支出
Pediatrics. 2017 Nov;140(5). doi: 10.1542/peds.2017-1640. Epub 2017 Oct 3.
4
Anti-inflammatory medication adherence, healthcare utilization and expenditures among Medicaid and children's health insurance program enrollees with asthma.哮喘患儿的 Medicaid 和儿童健康保险计划参保者的抗炎药物治疗依从性、医疗保健利用和支出。
Pharmacoeconomics. 2012 May;30(5):397-412. doi: 10.2165/11586660-000000000-00000.
5
Risk-adjusted capitation rates for children: how useful are the survey-based measures?儿童风险调整人头付费率：基于调查的测量方法有多有用？
Health Serv Res. 2010 Dec;45(6 Pt 2):1948-62. doi: 10.1111/j.1475-6773.2010.01165.x. Epub 2010 Sep 1.
6
Health-related quality of life as a predictor of pediatric healthcare costs: a two-year prospective cohort analysis.健康相关生活质量作为儿科医疗费用的预测指标：一项为期两年的前瞻性队列分析。
Health Qual Life Outcomes. 2004 Sep 10;2:48. doi: 10.1186/1477-7525-2-48.
7
Adjusted clinical groups: predictive accuracy for Medicaid enrollees in three states.调整后的临床分组：三个州医疗补助计划参保者的预测准确性
Health Care Financ Rev. 2002 Fall;24(1):43-61.
8
Disease burden profiles: an emerging tool for managing managed care.
Health Care Manag Sci. 2002 Aug;5(3):211-9. doi: 10.1023/a:1019711617120.
9
A comparison of three methods for estimating the requirements for medical specialists: the case of otolaryngologists.三种估算医学专科医生需求方法的比较：以耳鼻喉科医生为例
Health Serv Res. 1997 Jun;32(2):139-53.
10
Chronic disease, functional health status, and demographics: a multi-dimensional approach to risk adjustment.慢性病、功能健康状况与人口统计学：一种风险调整的多维方法。
Health Serv Res. 1996 Aug;31(3):283-307.
本文引用的文献
1
Adjusting Medicare capitation payments using prior hospitalization data.利用既往住院数据调整医疗保险人头支付。
Health Care Financ Rev. 1989 Summer;10(4):17-29.
2
Adjusting capitation rates using objective health measures and prior utilization.使用客观健康指标和既往医疗利用率来调整按人头付费率。
Health Care Financ Rev. 1989 Spring;10(3):41-54.
3
Adjusting capitation using chronic disease risk factors: a preliminary study.利用慢性病风险因素调整人头费：一项初步研究。
Health Care Financ Rev. 1987 Winter;9(2):15-23.
4
Medicare enrollment in health maintenance organizations.医疗保险在健康维护组织中的参保情况。
Health Care Financ Rev. 1987 Spring;8(3):87-93.
5
Capitation pricing: adjusting for prior utilization and physician discretion.按人头定价：根据既往医疗服务利用率和医生的自由裁量权进行调整。
Health Care Financ Rev. 1986 Winter;8(2):27-34.
6
Rate adjusters for Medicare under capitation.按人头付费的医疗保险费率调整器。
Health Care Financ Rev. 1986;1986(Spec No):45-55.
7
Pricing strategies for capitated delivery systems.按人头计费的医疗服务提供系统的定价策略。
Health Care Financ Rev. 1986;1986(Spec No):35-44.
8
Medicare capitation payments to HMOs in light of regression toward the mean in health care costs.鉴于医疗保健成本的均值回归，医疗保险向健康维护组织（HMO）支付的人头费。
Adv Health Econ Health Serv Res. 1985;6:75-100.
9
Functional health measure for adjusting health maintenance organization capitation rates.用于调整健康维护组织按人头付费率的功能健康指标。
Health Care Financ Rev. 1986 Spring;7(3):85-95.
10
Using prior utilization to determine payments for Medicare enrollees in health maintenance organizations.利用既往医疗服务利用率来确定健康维护组织中医疗保险参保人的支付金额。
Health Care Financ Rev. 1985 Spring;6(3):27-38.
Zotero 插件