van de Ven Wynand P M M, van Kleef Richard C, van Vliet Rene C J A
Wynand P. M. M. van de Ven (
Richard C. van Kleef is an associate professor in the Institute of Health Policy and Management at Erasmus University.
Health Aff (Millwood). 2015 Oct;34(10):1713-20. doi: 10.1377/hlthaff.2014.1456.
Experience in European health insurance exchanges indicates that even with the best risk-adjustment formulas, insurers have substantial incentives to engage in risk selection. The potentially most worrisome form of risk selection is skimping on the quality of care for underpriced high-cost patients--that is, patients for whom insurers are compensated at a rate lower than the predicted health care expenses of these patients. In this article we draw lessons for the United States from twenty years of experience with health insurance exchanges in Europe, where risk selection is a serious problem. Mistakes by European legislators and inadequate evaluation criteria for risk selection incentives are discussed, as well as strategies to reduce risk selection and the complex trade-off among selection (through quality skimping), efficiency, and affordability. Recommended improvements to the risk-adjustment process in the United States include considering the adoption of risk adjusters used in Europe, investing in the collection of data, using a permanent form of risk sharing, and replacing the current premium "band" restrictions with more flexible restrictions. Policy makers need to understand the complexities of regulating competitive health insurance markets and to prevent risk selection that threatens the provision of good-quality care for underpriced high-cost patients.
欧洲健康保险交易所的经验表明，即便采用最完善的风险调整公式，保险公司仍有很大动机进行风险选择。风险选择最令人担忧的潜在形式是，保险公司会故意克扣那些保费定价偏低但成本较高患者的医疗服务质量，即保险公司获得的补偿低于这些患者预计医疗费用的患者。在本文中，我们从欧洲健康保险交易所二十年的经验中吸取教训，在欧洲，风险选择是一个严重问题。我们讨论了欧洲立法者所犯的错误以及风险选择激励措施的评估标准不足之处，还探讨了降低风险选择的策略以及在选择（通过克扣质量）、效率和可承受性之间的复杂权衡。对美国风险调整流程的改进建议包括考虑采用欧洲使用的风险调整因子、投资数据收集、采用永久性风险分担形式，并用更灵活的限制取代当前的保费“区间”限制。政策制定者需要了解监管竞争性健康保险市场的复杂性，并防止出现威胁到为保费定价偏低但成本较高患者提供优质医疗服务的风险选择行为。
