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PubMed1998

Do uncompensated care pools change the distribution of hospital care to the uninsured?

In 1983, New York State established an uncompensated care pool using the New York Prospective Hospital Reimbursement Methodology (NYPHRM). Two policy objectives of the NYPHRM were (1) to encourage more equitable distribution of uncompensated care across hospitals and (2) to increase access to hospital care for the uninsured. This article demonstrates that the New York uncompensated care pool was only moderately successful in achieving these goals. The principal findings are that the NYPHRM did result in routine care being redistributed away from hospitals that traditionally provided care to the uninsured, while provision of highly technological care was not significantly redistributed. This article suggests that if the primary policy goal is to increase access to care for the uninsured by changing the distribution of hospitals willing to provide care, the uncompensated care pool approach is moderately effective.

Diagnosis-Related Groups↗
PubMed2000

The effect of marginal tax rate on the probability of employment-based insurance by risk group.

RESEARCH OBJECTIVE: To evaluate the effect of the tax subsidy on participation in employment-based health insurance for high- and low-risk individuals. The total exclusion of employer-paid health insurance premiums from taxable income has frequently been seen as contributing to excess insurance and hence welfare loss. However, less attention has been paid to quantifying the extent to which the tax subsidy mitigates the deleterious effects of adverse selection on the health insurance market. Adverse selection reduces pooling in an insurance market, so that high-risk individuals are either unable to obtain coverage or are forced to pay premiums that are unaffordable to all but the wealthiest. If there is an external benefit to society of an individual's purchase of medical care, then the presence of adverse selection may reduce the purchase of health care below the socially optimal level. Therefore, a mechanism for enhancing access to insurance and ultimately to medical care for high-risk individuals may be socially desirable. STUDY DESIGN: Data from the March 1996-March 1998 Current Population Survey (CPS). For each observation in the sample, state and federal income tax liability is calculated using code based on the ACIR Significant Features of Fiscal Federalism. The probability of having employment-based coverage in either one's own name or as a dependent is evaluated as a function of demographic variables such as age, education, marital status and family size, family income, type of employment, employer size, occupation, location, marginal tax rate, risk group (determined by self-assessed health status), and an interaction between risk group and tax rate. CPS data do not identify individuals who have declined offered coverage. Under alternative models of employer group decision making, the tax subsidy will have an important influence on the employer's decision to offer coverage. If offered, high-risk individuals accept coverage, while some low-risk individuals may decline coverage. PRINCIPAL FINDINGS: For all individuals, the probability of having coverage is an increasing function of the marginal tax rate. Those classified as high-risk because their own or a family member's self-assessed health status is fair or poor are less likely to have coverage than those considered low-risk. The effect of the tax subsidy on insurance coverage is greater for high-risk individuals than for individuals classified as low-risk. CONCLUSIONS: These preliminary results indicate that high-risk individuals benefit from the tax subsidy by increased access to employment-based coverage. Therefore, welfare loss from excess levels of health insurance may be mitigated by welfare gain through expanded access to health insurance and hence to health care for high-risk individuals. IMPLICATIONS FOR POLICY, DELIVERY, OR PRACTICE: Elimination or reduction of the tax exclusion of health insurance premiums may have the unintended consequences of disproportionately reducing the probability of obtaining coverage in the employment-based market for high-risk individuals.

Adolescent↗
PubMed1994

Implicit pooling of workers from large and small firms.

Risk pools for small employers have become an integral part of proposals for national health care reform and have been implemented by a number of states. These explicit attempts to pool small employers are occurring at the same time that many small-firm employees obtain health insurance through implicit pooling arrangements as the dependent of a policyholder insured by a large firm. We use data from the 1987 National Medical Expenditure Survey to document the extent of implicit pooling arrangements, to examine whether small-firm employees and their dependents are adverse health risks, and to assess the cost implications of pooling small- and large-firm employees and dependents.

Cost Control↗
PubMed1999

Risk pools: payers and providers take the plunge.

Providers considering managed care risk pool arrangements should understand thoroughly what services the pool covers, the time period covered, and how the pool is administered. Important issues related to pool administration include how credits and debits are applied; when the accounting occurs (interim, year-end, or contract termination); and provisions for reports, audit rights, and dispute resolution. Although a pool arrangement gives the health plan control over claims payment, the risk allocation made possible through a pool arrangement helps ensure that the economic incentives of the health plan and the provider are aligned.

Capitation Fee↗
PubMed1996

Voluntary purchasing pools: a market model for improving access, quality, and cost in health care. American College of Physicians.

States and small businesses have been rapidly establishing voluntary health care purchasing pools during the past few years. Purchasing pools can decrease health care costs, improve access for some small businesses and individual persons, allow greater choice among health care plans, and provide continuity of care. Purchasing pools also help to even the balance of power in the health care marketplace, which has come increasingly under the control of huge proprietary managed care corporations. This position paper of the American College of Physicians discusses how a system of well-designed voluntary purchasing pools can help protect the integrity of health care in the emerging managed care marketplace.

Continuity of Patient Care↗
PubMed1997

The potential role of risk-equalization mechanisms in health insurance: the case of South Africa.

International agencies such as the World Bank have widely advocated the use of health insurance as a way of improving health sector efficiency and equity in developing countries. However, in developing countries with well-established, multiple-player health insurance markets, such as South Africa, extension of insurance coverage is now inhibited by problems of moral hazard, and associated cost escalation and fragmentation of insurer risk-pools. Virtually no research has been done on the problem of risk selection in health insurance outside developed countries. This paper provides a brief overview of the problem of risk fragmentation as it has been studied in developed countries, and attempts to apply this to middle-income country settings, particularly that of South Africa. A number of possible remedial measures are discussed, with risk-equalization funds being given the most attention. An overview is given of the risk-equalization approach, common misconceptions regarding its working and the processes that might be required to assess its suitability in different national settings. Where there is widespread public support for social risk pooling in health care, and government is willing and able to assume a regulatory role to achieve this, risk-equalization approaches may achieve significant efficiency and equity gains without destroying the positive features of private health care financing, such as revenue generation, competition and free choice of insurer.

Actuarial Analysis↗
PubMed1996

Function-based payment model for inpatient medical rehabilitation: an evaluation.

OBJECTIVE: To describe the components of a function-based prospective payment model for inpatient medical rehabilitation that parallels diagnosis-related groups (DRGs), to evaluate this model in relation to stakeholder objectives, and to detail the components of a quality of care incentive program that, when combined with this payment model, creates an incentive for provides to maximize functional outcomes. DATA SOURCES: This article describes a conceptual model, involving no data collection or data synthesis. DATA SYNTHESIS: The basic payment model described parallels DRGs. Information on the potential impact of this model on medical rehabilitation is gleaned from the literature evaluating the impact of DRGs. The conceptual model described is evaluated against the results of a Delphi Survey of rehabilitation providers, consumers, policymakers, and researchers previously conducted by members of the research team. CONCLUSIONS: The major shortcoming of a function-based prospective payment model for inpatient medical rehabilitation is that it contains no inherent incentive to maximize functional outcomes. Linkage of reimbursement to outcomes, however, by withholding a fixed proportion of the standard FRG payment amount, placing that amount in a "quality of care" pool, and distributing that pool annually among providers whose predesignated, facility-level, case-mix-adjusted outcomes are attained, may be one strategy for maximizing outcome goals.

Activities of Daily Living↗
PubMed1997

Altruism or moral hazard: the impact of hospital uncompensated care pools.

Empirical evidence from New Jersey supports theories of hospitals altruism. From 1987 to 1992, New Jersey reimbursed hospitals for uncompensated care through the Uncompensated Care Trust Fund. The Trust Fund reduced the shadow price of charity care, inducing hospitals to increase their provision of uncompensated care. Hospitals increased inpatient uncompensated care by an average of 14.8% and statewide uncompensated care increased by $360 million during 1987-1990. Empirical evidence suggests that the state effectively addressed the moral hazard problem created by the Trust Fund by auditing uncompensated care and regulating hospital collection procedures.

Altruism↗
PubMed1992

An outlier pool for Medicare HMO payments.

Medicare pays "at-risk" health maintenance organizations a prospective capitation amount that is established by the adjusted average per capita cost (AAPCC) formula for estimating the amount enrollees would have cost had they remained in the fee-for-service sector. Because the AAPCC accounts for a very small percentage of the variation in beneficiary costs, considerable research has been devoted to improving the formula. A way to improve the explained variance is to remove the most expensive beneficiaries from the AAPCC payment system and pay for them separately. This article examines one approach to a payment system that combines the AAPCC with an outlier payment mechanism.

Capitation Fee↗
PubMed1994

Alternative volume performance standards for Medicare physicians' services.

The Omnibus Budget Reconciliation Act of 1989 (OBRA89) established volume performance standards (VPSs) as a key element in Medicare physician reform. This policy requires making choices along three dimensions: the risk pool, the scope and nature of the standard, and the application of the standard. VPSs have most effectively controlled expenditures and changed physician behavior when they use states as the risk pool, are composed entirely of Medicare Part B services, and establish per capita utilization targets. The institution of separate standards for voluntarily formed physician groups would pose substantial administrative challenges and has the potential to effect adverse outcomes. Instead, Congress should continue to encourage prepaid plans for the purpose of lowering health care use. Under current law, VPSs will be used to adjust future price increases. Congress may not wish to emulate the example of countries that have imposed expenditure ceilings to control costs unless the current method of using VPSs proves unsuccessful.

Canada↗
PubMed1997

Aligning incentives using risk-sharing arrangements.

Most managed care arrangements do not properly align provider and HMO incentives and thus unintentionally promote conflicting care management patterns. But appropriate risk-sharing arrangements encourage HMOs and providers to agree on the best methods to achieve member satisfaction; high-quality, cost-effective care; and healthy profits. Quality- and cost-based risk-sharing arrangements withhold a certain portion of providers' payments for placement in a risk pool fund. Providers are penalized financially for poor quality and unsatisfactory cost performance; providers are financially rewarded with risk pool funds for the cost-efficient delivery of high-quality health care. Percent-of-premium or capitation risk-sharing arrangements divide member premiums among the parties to the risk-sharing arrangement based on how much financial risk each party is willing to assume for providing care. The risk of controlling variations in cost is assumed by providers, thus minimizing HMOs' financial exposure. Inpatient case rate risk-sharing arrangements pay providers a flat rate for uncomplicated cases. Such arrangements can improve the relationship between HMOs and providers by giving providers primary control over case management and benefits HMOs by reducing their utilization review activities.

Capitation Fee↗
PubMed1999

Using contact capitation to align payment incentives among specialists.

Contact capitation is a means of paying specialists based on the number of patients managed rather than on the number of services provided or procedures performed. Payments to physicians are disbursed from budgets, or risk pools, which are established by specialty and product line (e.g., commercial coverage, Medicare). Each specialist is credited with managing a patient for a specified time period (usually 12 months) following the patient's initial visit. To ensure payments are equitable to all physicians, regardless of specialty or subspecialty, the system may be adjusted by using different contact weights for certain diagnoses or procedures, creating subpools for selected subspecialties and/or procedures, establishing separate capitation rates for different age segments, and setting aside certain specialties as fee-for-service carve-outs. Contact capitation has advantages over traditional specialist capitation of removing physicians' financial incentives to overutilize and allowing for a broad physician specialty panel. Challenges to implementing contact capitation include getting physicians to alter habitual practice patterns and managing the system's administrative complexity.

Capitation Fee↗
PubMed2001

The effect of income pooling within a call group on rates of obstetric intervention.

BACKGROUND: On July 1, 1997, the call group at a tertiary referral hospital in Ottawa changed its remuneration. The authors tested the hypothesis that change in an obstetric call group's remuneration from individual fee-for-service billing to equal sharing of the pooled group income would result in reduced rates of obstetric intervention. METHODS: Intervention rates were compared for the 12 months before (1678 births) and the 12 months after (1934 births) the change. Data were collected on onset of labour, indication for induction of labour, mode of delivery and neonatal outcome. Statistical analysis was performed with Wilcoxon's signed-rank test. RESULTS: The mean rate of elective induction of labour was 38.6% in the year before the change and 33.3% in the year after the change (p = 0.01). There were small but statistically significant increases in the mean duration of labour and mean length of the second stage (p = 0.03). INTERPRETATION: Billing policy may affect clinical decisions. Our findings add weight to the literature showing increased intervention rates with fee-for-service remuneration.

Decision Making↗