Capitation Adjustment for Children with Special Health Care Needs

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Although risk-adjusted capitation payments have commonly been implemented by public and private insurers, few risk adjustment models have been estimated specifically for children. Increasing reliance on cost containment mechanisms, such as managed care and capitation in both private markets and public programs targeting children, makes the need to set adequate capitation rates for children more urgent. This study addresses this need by developing risk adjustment models for children, especially children with special health care needs (CSHCN), who are particularly vulnerable in the current health insurance marketplace dominated by managed care plans. The goal of the proposed project is to inform policy-making on three important issues of health care financing for children: (1). How well can risk adjustment models estimated specifically for children perform? (2). How much are health plans? incentives for risk selection reduced under different risk adjustment models for children? and (3). How much can a mixed system of both risk-adjusted capitation and risk-sharing (i.e. reinsurance funded by the sponsor) reduce selection incentives? This study has four specific aims: Specific Aim 1: To assess the persistence of high expenditures among CSHCN and the persistence of CSHCN status. Specific Aim 2: First to estimate a risk adjustment model using information about CSHCN, and then to assess its predictive performance through comparison with the diagnosis-based models. Specific Aim 3: To simulate health plans? potential profits from risk selection under different risk adjusters. Specific Aim 4: To investigate health plans? potential profit under the mixed system that has both risk-adjusted capitation rates and risk-sharing. Two types of risk-sharing will be examined, including outliers risk-sharing for high-cost children and condition-specific risk-sharing. This study fits in the Agency of Healthcare Research and Quality's (AHRQ) priority program area of "Identifying Strategies to Improve Access, Foster Appropriate Use, and Reduce Unnecessary Expenditures." In particular, it will use the AHRQ's Medical Expenditure Panel Survey (MEPS) to assess how changes in financial arrangements affect access to care by CSHCN, a vulnerable population of special interest to the AHRQ.