Hill Steven C, Thornton Craig, Trenholm Christopher, Wooldridge Judith
Center for Cost and Financing Studies, Agency for Healthcare Research and Quality, Rockville, MD 20852, USA.
Inquiry. 2002 Summer;39(2):152-67. doi: 10.5034/inquiryjrnl_39.2.152.
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.
对于那些将补充保障收入（SSI）的失明和残疾受益人纳入医疗补助管理式医疗的州来说，风险选择问题尤为重要。SSI受益人长期需要护理，患有多种慢性病，且常常需要非典型和复杂的服务。当参加特定计划的受益人的医疗需求与总体受益人群的需求存在系统性差异，且支付未能反映这些需求时，就会出现风险选择。我们评估了田纳西州医疗补助管理式医疗计划TennCare头三年中针对SSI受益人的管理式医疗计划的风险选择程度。利用包含参保人加入管理式医疗之前按服务付费支出的理赔数据，我们发现有大量证据表明各计划中存在持续的风险选择。对于大多数计划而言，结果对于风险选择的大多数替代衡量指标都具有稳健性。
