PSO ACTUARIAL RATE MODEL FOR MEDICARE RISK CONTRACTS

医疗保险风险合同的 PSO 精算率模型

• 批准号: 2002245
• 负责人: GORDON R TRAPNELL
• 金额: $ 10万
• 依托单位: ACTUARIAL RESEARCH CORPORATION
• 依托单位国家: 美国
• 财政年份: 1997
• 资助国家: 美国
• 起止时间: 1997-09-30 至 1998-09-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/2002245
• 关键词: Medicare /Medicaid; behavioral /social science research tag; health care cost /financing; human data; mathematical model; model design /development

Expected liberalizations in the Medicare requirements for risk contracting will permit Provider Service Organizations (PSOs) to contract with Medicare without prior experience, while relying on complex risk sharing arrangements with providers in lieu of meeting capital and surplus requirements. Hundreds of new PSO plans are expected to be organized to take advantage of the new opportunities. Many of these new plans will involve a large number of interlocking subcapitation and risk sharing arrangements with hospitals, primary care physicians and specialists that can not be modeled with existing commercial products. To fill this need, and provide a sound basis for designing PSO based risk contracts for Medicare, a comprehensive actuarial rate model will be developed from actual Medicare data, with the capacities needed to determine the cost impact of specific subcapitation and risk sharing arrangements. Unique features of the new rate structure include: (1) derived from actual Medicare FFS and HMO claims data, (2) provide capacity to model capitation and other risk sharing arrangements, (4) model the effect of carving out specific professional procedures or hospital discharge diagnoses, (4) capacity to model managed care savings and substitution effects explicitly by type of provider, and (5) incorporate multiple stop loss reinsurance arrangements that affect limited sets of providers and services. PROPOSED COMMERCIAL APPLICATION: Hundreds of Provider Service Organization (PSO) health plans are expected to be formed in response to liberalizations in qualifications of health plans that offer risk contracts in Medicare. The reduced requirements-esp, the reliance on complex capitation and other risk sharing arrangements among providers, the limited capitalization requirements, the absence of prior experience and sole reliance on Medicare contracts-will require very different actuarial tools than are currently available. In addition to PSOs, HMOs and other insurers provide potential markets for the kind of detail and analytical capacities planned for the models.

医疗保险对风险合同要求的预期自由化 将允许提供商服务组织（PSOs）与 医疗保险没有先前的经验，同时依赖于复杂的风险分担 与供应商的安排，以代替满足资本和盈余 要求. 预计将组织数百个新的PSO计划， 利用新的机会。 这些新计划中的许多将 涉及大量环环相扣的分额和风险共担 与医院、初级保健医生和专家的安排， 不能用现有的商业产品来模拟。 为了满足这一需求， 并为设计基于PSO的风险契约提供了良好的基础， 医疗保险，一个全面的精算率模型将开发从 实际的医疗保险数据，以及确定成本所需的能力 具体的分额支付和风险分担安排的影响。 独特 新税率结构的特点包括：（1）由实际税率 Medicare FFS和HMO索赔数据，（2）提供按人头计算的建模能力 以及其他风险分担安排;（4）示范创业的效果 具体的专业程序或出院诊断，（4） 明确模拟管理式护理储蓄和替代效应的能力 按提供商类型，以及（5）纳入多个停止损失再保险 影响有限的供应商和服务的安排。 建议的商业应用：数百家提供商服务 组织（PSO）的健康计划预计将形成，以应对 放宽对提供风险的保健计划的资格限制 医疗合同。 减少的需求，特别是对 提供者之间复杂的按人头收费和其他风险分担安排， 有限的资本要求，缺乏经验， 和对医疗保险合同的唯一依赖-将需要非常不同的 比目前可用的精算工具。 除了PSO，HMO 和其他保险公司提供了潜在的市场， 为模型规划的分析能力。