Department of Health Care Policy, Harvard Medical School, Boston, USA.
Institute for Health Care Management and Research, CINCH, University of Duisburg-Essen, Duisburg, Germany.
Eur J Health Econ. 2021 Feb;22(1):35-50. doi: 10.1007/s10198-020-01227-3. Epub 2020 Aug 29.
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 0.1% of residuals building to address the question of the degree of persistence in membership at the extremes. Common findings emerge among the countries. First, the diseases found among those with the highest residual spending are also disproportionately found among those with the lowest residual spending. Second, those at the top of the residual spending distribution (where spending exceeds payments the most) account for a massively high share of the unexplained variance in the predictions from the risk adjustment model. Third, in terms of persistence, we find that membership in the extremes of the residual spending distribution is highly persistent, raising concerns about selection-related incentives targeting these individuals. As our results show, the one-in-a-thousand people (on both sides of the residual distribution) play an outsized role in creating adverse incentives associated with health plan payment systems. In response to the observed importance of the extremes of the residual spending distribution, we propose an innovative combination of risk-pooling and reinsurance targeting the predictively undercompensated group. In all three countries, this form of risk sharing substantially improves the overall fit of payments to spending. Perhaps surprisingly, by reducing the burden on diagnostic indicators to predict high payments, our proposed risk sharing policy reduces the gap between payments and spending not only for the most undercompensated individuals but also for the most overcompensated people.
我们研究了三个国家的个人医疗保险市场中极高和极低的剩余支出者。高（低）剩余支出者是指剩余支出（保费和风险调整后）较高（低）的人，这表明该人被严重低估（高估）了。我们首先对前 1%和 0.1%的剩余部分进行描述性分析，以解决在极端情况下会员资格持续存在的程度问题。这三个国家有一些共同的发现。首先，在剩余支出最高的人群中发现的疾病，在剩余支出最低的人群中也不成比例地存在。其次，在剩余支出分布的顶端（支出超过支付最多的地方），占风险调整模型预测中无法解释的方差的比例非常高。第三，就持续性而言，我们发现，在剩余支出分布的极端情况下，会员资格高度持久，这引发了对针对这些个体的与选择相关的激励措施的关注。正如我们的研究结果所表明的那样，千分之一的人（在剩余分布的两侧）在创造与健康计划支付系统相关的不利激励方面发挥了巨大作用。针对剩余支出分布极端重要性的问题，我们提出了一种创新的风险池化和再保险组合，针对预测性补偿不足的群体。在所有三个国家，这种形式的风险分担都大大提高了支付与支出的整体匹配度。也许令人惊讶的是，通过减少预测高支付所需的诊断指标的负担，我们提出的风险分担政策不仅减少了最补偿不足的个体的支付与支出之间的差距，也减少了最补偿过度的个体的差距。
