Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands.
Health Econ. 2022 May;31(5):784-805. doi: 10.1002/hec.4477. Epub 2022 Feb 8.
Health insurance markets with community-rated premiums typically include risk adjustment (RA) to mitigate selection problems. Over the past decades, RA systems have evolved from simple demographic models to sophisticated morbidity-based models. Even the most sophisticated models, however, tend to overcompensate people with persistently low spending and undercompensate those with persistently high spending. This paper compares three methods that exploit spending-level persistence for improving health plan payment systems: (1) implementation of spending-based risk adjustors, (2) implementation of high-risk pooling for people with multiple-year high spending, and (3) indirect use of spending persistence via constrained regression. Based on incentive measures for risk selection and cost control, we conclude that a combination of the last two options can substantially outperform the first, which is currently used in the health plan payment system in the Netherlands.
医疗保险市场通常采用按人头计费的保费，以减轻选择问题。在过去的几十年中，风险调整（RA）系统已经从简单的人口统计学模型发展到复杂的基于发病率的模型。然而，即使是最复杂的模型也往往会过度补偿持续低支出的人群，而对持续高支出的人群补偿不足。本文比较了三种利用支出水平持续性来改善医疗保险支付系统的方法：（1）实施基于支出的风险调整器，（2）对多年高支出人群实施高风险池，（3）通过约束回归间接利用支出持续性。基于风险选择和成本控制的激励措施，我们得出结论，最后两种选择的结合可以大大优于目前在荷兰医疗保险支付系统中使用的第一种选择。
