Adjusting For Risk Selection In State Health Insurance Exchanges Will Be Critically Important And Feasible, But Not Easy
Adjusting For Risk Selection In State Health Insurance Exchanges Will Be Critically Important And Feasible, But Not Easy
复制标题
DOI：
10.1377/hlthaff.2011.0420
复制
发表时间：
2012-02-01
期刊：
影响因子：
9.7
通讯作者：
Lemke, Klaus
中科院分区：
文献类型：
--
作者：
Weiner, Jonathan P.;Trish, Erin;Lemke, Klaus
《平价医疗法案》要求建立州一级的医疗保险交易所。这些交流的可行性和成功将需要有效的风险调整战略，以补偿不同健康计划参加者健康状况的差异。本文介绍了为什么平价医疗法案可能会导致跨计划的有利或不利的风险选择。它回顾了法案中的条款和最近提出的旨在减轻风险选择问题的法规。我们进行了一个模拟，表明在法律的保费评级限制下，保险公司吸引更健康的投保人的巨大激励可能会持续下去，导致对非常健康的投保人的计划的大量超额支付和对重病成员的计划的支付不足。我们的结论是，基于患者诊断的风险调整（例如将从2014年开始实施）将使保险公司获得比仅根据年龄调整和该法案允许的其他评级更准确的付款。我们还描述了实施风险调整的其他挑战。
The Affordable Care Act calls for the establishment of state-level health insurance exchanges. The viability and success of these exchanges will require effective risk-adjustment strategies to compensate for differences in enrollees' health status across health plans. This article describes why the Affordable Care Act could lead to favorable or adverse risk selection across plans. It reviews provisions in the act and recent proposed regulations intended to mitigate the problem of risk selection. We performed a simulation that showed that under the premium rating restrictions in the law, large incentives for insurers to attract healthier enrollees will be likely to persist-resulting in substantial overpayment to plans with very healthy enrollees and underpayment to plans with very sick members. We conclude that risk adjustment based on patients' diagnoses, such as will be in place from 2014 on, will yield payments to insurers that will be more accurate than what will come solely from the age-adjusted and other rating allowed by the act. We also describe additional challenges of implementing risk adjustment.