Affordable Care Act Risk Adjustment: Overview, Context, and Challenges

Kautter, John; Pope, Gregory; Keenan, Patricia S.

doi:10.5600/mmrr.004.03.a02

Cited by 24 publications

(17 citation statements)

References 5 publications

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“…Regarding outcomes, no generally valid conclusions on the effect of ACO participation could be drawn. Some of the studies reported partially positive effects for patient experience [ 51 , 52 ] and mortality [ 53 ], whereas others did not find any effects [ 49 , 50 , 54 , 55 ]. Nejati et al [ 22 ] evaluated the impact of ACOs in cancer care and reported mixed results but did find some improvements in process quality due to decreased utilization of low-value services within the Medicare Pioneer ACO.…”

Section: Resultsmentioning

confidence: 99%

Effects of Monetary Incentives in Physician Groups: A Systematic Review of Reviews

Heider

Mang

2020

Appl Health Econ Health Policy

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Background Reimbursement systems that contribute to the cooperation and integration of providers have become increasingly important within the healthcare sector. Reimbursement systems not only serve as payment mechanisms but also provide control and incentive functions. Thus, the design of reimbursement systems is extremely important. Objectives The aims of this systematic review were to describe and gain a better understanding of the effects of monetary incentives in the setting of physician groups. Methods In January 2020, we searched the MEDLINE (PubMed), Cochrane Library, CINAHL, PsycINFO, EconLit, and ISI Web of Science databases as well as the gray literature and authors' personal collections. Results We included 21 reviews containing seven different incentive schemes/initiatives. The study settings and outcome measures varied considerably, as did the results within the incentive schemes and initiatives. However, we found positive effects on process quality for two types of incentives: pay-for-performance and accountable care organizations. The main limitations of this review were the variations in study settings and outcome measures of the studies included. Conclusions Monetary incentives in healthcare are often implemented as a control measure and are supposed to increase quality of care and reduce costs. The heterogeneity of the study results indicates that this is not always successful. The results reveal a need for research into the effects of monetary incentives in healthcare.

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Section: Resultsmentioning

confidence: 99%

Effects of Monetary Incentives in Physician Groups: A Systematic Review of Reviews

Heider

Mang

2020

Appl Health Econ Health Policy

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“…In 2014, the US Department of Health and Human Services (HHS) introduced a further revised HCC system for use in redistributing funds among the competing health plans in the new Health Insurance Marketplace (originally called an Exchange) set up in each US state (Kautter et al, 2014a and2014b). That formula started with 264 HCCs and, after applying principles for simplification that drop discretionary, vague and common low-cost HCCs, ends up with 127 HHS-HCCs in the final, preferred model.…”

Section: The Us Centers For Medicare and Medicaid Services (Cms) Hierarchical Condition Category (Hcc) Modelsmentioning

confidence: 99%

Global Risk-Adjusted Payment Models

Cid¹,

Ellis²,

Vargas³

et al. 2016

World Scientific Handbook of Global Health Economics and Public Policy

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Global health care payment systems reflect enormous differences in provider characteristics, health systems, and development levels. Risk adjustment is used for payment and performance measurement to correct for demand heterogeneity and incentives for plans and providers to prefer healthy, low-cost patients, and to provide quality care. This article reviews the practical, theoretical, and statistical aspects of risk adjustment models, which use socio-demographic variables and more recently morbidity and pharmaceuticals, to predict outcomes. Diverse uses of risk adjustment include geographical budget allocations, health plan premium equalization, pay for performance, primary care provider payment, integrated provider networks, and rewards for good doctor performance. Settings in more than 30 countries are examined, which include high-, middle-and low-income countries, competitive health plans and single payer systems, integrated provider networks, clinics, and solo practice primary care doctors. Recent concepts in health economics are highlighted that hold potential for improving efficiency and equitable patient access to health care.

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“…Risk equalization (RE) models are widely used—Belgium, Germany, Israel, the Netherlands, Switzerland, and the U.S. health care exchanges—for calculating risk‐adjusted payments to health insurers in order to compensate them for predictable differences in individuals' health care expenses (Ash, Porell, Gruenberg, Sawitz, & Beiser, ; Kautter, Pope, & Keenan, ; van de Ven, van de Beck, van de Voorde, Wasem, & Zmora, ). In the presence of premium regulation, as is the case in all of the aforementioned countries, the goal of RE is to mitigate financial incentives for risk selection and thereby achieve a level playing field for health insurers.…”

Section: Introductionmentioning

confidence: 99%

Exploring the predictive power of interaction terms in a sophisticated risk equalization model using regression trees

et al. 2017

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This study explores the predictive power of interaction terms between the risk adjusters in the Dutch risk equalization (RE) model of 2014. Due to the sophistication of this RE-model and the complexity of the associations in the dataset (N = ~16.7 million), there are theoretically more than a million interaction terms. We used regression tree modelling, which has been applied rarely within the field of RE, to identify interaction terms that statistically significantly explain variation in observed expenses that is not already explained by the risk adjusters in this RE-model. The interaction terms identified were used as additional risk adjusters in the RE-model. We found evidence that interaction terms can improve the prediction of expenses overall and for specific groups in the population. However, the prediction of expenses for some other selective groups may deteriorate. Thus, interactions can reduce financial incentives for risk selection for some groups but may increase them for others. Furthermore, because regression trees are not robust, additional criteria are needed to decide which interaction terms should be used in practice. These criteria could be the right incentive structure for risk selection and efficiency or the opinion of medical experts.

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Affordable Care Act Risk Adjustment: Overview, Context, and Challenges

Cited by 24 publications

References 5 publications

Effects of Monetary Incentives in Physician Groups: A Systematic Review of Reviews

Effects of Monetary Incentives in Physician Groups: A Systematic Review of Reviews

Global Risk-Adjusted Payment Models

Exploring the predictive power of interaction terms in a sophisticated risk equalization model using regression trees

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