van Vliet R C, van de Ven W P
Department of Health Policy and Management, Erasmus University, The Netherlands.
Health Econ. 1993 Jul;2(2):177-88. doi: 10.1002/hec.4730020210.
In many countries the concept of capitating health care insurers is receiving increasing attention. In a competitive environment, capitation should induce insurers to concentrate more on cost containment instead of indulging in risk selection. The necessary premium-replacing capitation payments should account for predictable variations in annual per-person health care expenditures as far as these are related to health status. Various studies have shown that crude capitation models based on e.g. age, sex and place of residence, do not reflect expected costs accurately. This implies inefficient pricing possibly leading to risk selection and windfall profits or losses for insurers, thereby undermining the objectives of a capitation system. Using Dutch micro data on some 200,000 individuals, this article stimulates various alternative capitation models based on, among others, diagnostic information from previous hospitalizations. Results suggest that the problems of both risk selection and windfall profits/losses may be mitigated substantially by using this type of information together with data on prior costs. These results are not only relevant for situations where competing insurers are capitated, as intended in the Netherlands, but also when providers are capitated, as in the UK, or when HMOs are capitated, as in the US.
在许多国家，对医疗保健保险公司实行按人头付费的概念正受到越来越多的关注。在竞争环境中，按人头付费应促使保险公司更多地关注成本控制，而不是热衷于风险选择。必要的替代保费的按人头付费应考虑到每人每年医疗保健支出的可预测变化，只要这些变化与健康状况相关。各种研究表明，基于年龄、性别和居住地等的粗略按人头付费模型并不能准确反映预期成本。这意味着定价效率低下，可能导致保险公司出现风险选择以及意外之财或损失，从而破坏按人头付费制度的目标。本文利用约20万荷兰人的微观数据，激发了各种基于既往住院诊断信息等的替代按人头付费模型。结果表明，通过将这类信息与既往成本数据结合使用，风险选择和意外之财/损失的问题可能会大大缓解。这些结果不仅与荷兰所设想的竞争保险公司实行按人头付费的情况相关，也与英国供应商实行按人头付费或美国健康维护组织实行按人头付费的情况相关。
