Institute of Health Policy and Management, Erasmus University Rotterdam, Burgemeester Oudlaan 50, 3000 DR, Rotterdam, The Netherlands.
Eur J Health Econ. 2018 Mar;19(2):203-211. doi: 10.1007/s10198-017-0874-x. Epub 2017 Feb 9.
Worldwide, risk-equalization (RE) models in competitive health insurance markets have evolved from simple demographic models to sophisticated models containing diagnosis and pharmacy-based indicators of health. However, these models still have important imperfections; adding information on (diagnoses of) physiotherapy treatment may further improve RE-models. Therefore, a new risk-adjuster based on physiotherapy costs in the prior year was introduced in the Dutch RE-model of 2016.
Physiotherapy claims-data (2012) and administrative data on costs and risk-characteristics (2013) for 94% of the Dutch population (N = 15.8 million) are used to evaluate the current risk-adjuster based on physiotherapy costs and to assess the effects of replacing it by different modalities of a risk-adjuster based on physiotherapy diagnoses. Of the 89 diagnoses in the claims-data, 62 are dropped because they relate to temporary health problems. The 27 retained diagnoses are added to the Dutch model in 4 modalities: 27 separate risk-classes, 9 diagnosis-clusters based on main pathology category, 4 diagnosis-clusters based on residual costs, and the 4 clusters of modality 3 interacted with age.
Although the cost-based risk-adjuster improves the model's predictive power and removes the average undercompensation (€919) for enrollees with physiotherapy costs in the prior year, it is outperformed by all 4 diagnosis-based modalities. Of these modalities, modality 3 is preferred based on its simplicity and comparable predictive power.
Adding information on physiotherapy can further improve the performance of sophisticated RE-models. Regarding the Dutch model, a risk-adjuster containing 4 risk-classes for clustered diagnoses based on residual costs is the preferred modality.
在全球范围内，竞争健康保险市场中的风险均衡（RE）模型已经从简单的人口统计学模型发展为包含诊断和基于药房的健康指标的复杂模型。然而，这些模型仍然存在重要的不完善之处；添加有关（理疗治疗的）诊断的信息可能会进一步改进 RE 模型。因此，在 2016 年荷兰的 RE 模型中引入了一种基于前一年理疗费用的新风险调整器。
使用 2012 年的理疗索赔数据（2012 年）和 2013 年的费用和风险特征的管理数据（94%的荷兰人口（N=1580 万））来评估当前基于理疗费用的风险调整器，并评估用基于理疗诊断的风险调整器的不同模式替代它的效果。在索赔数据中的 89 个诊断中，有 62 个因与临时健康问题有关而被剔除。保留的 27 个诊断以 4 种模式添加到荷兰模型中：27 个单独的风险类别、9 个基于主要病理类别的诊断群集、4 个基于剩余费用的诊断群集以及第 3 种模式的 4 个群集与年龄相互作用。
尽管基于成本的风险调整器提高了模型的预测能力并消除了前一年有理疗费用的参保人的平均补偿不足（919 欧元），但它还是被所有 4 种基于诊断的模式所超越。在这些模式中，模式 3 因其简单性和可比的预测能力而被优先选择。
添加有关理疗的信息可以进一步提高复杂的 RE 模型的性能。就荷兰模型而言，包含基于剩余费用的聚类诊断的 4 个风险类别的风险调整器是首选模式。
