New Evidence on the Persistence of High Health Spending

描述(由投保人提供)：如果高额的医疗保健支出随着时间的推移持续存在，基于年度合同的私人保险市场的逆向选择问题将会加剧，从而加剧人们对可负担得起的保险覆盖范围的担忧。尽管了解医疗支出的持续性很重要，但令人惊讶的是，人们对此知之甚少。一些研究是基于联邦医疗保险的数据，将推广范围限制在65岁以下的人群。代表年轻人的研究有局限性，包括缺乏最新数据，跟踪时间短，单一雇主或保险公司样本，以及缺乏对雇主保险的自然减员的关注。关于支出持久性的新知识可以改善覆盖未参保者的许多政策选项的证据基础，包括补贴再保险市场、联邦医疗保险买入和 鼓励扩大个人保险合同和以消费者为导向的健康计划的作用。我们将使用2002-2007年的Thomson Healthcare MarketScan数据库来评估医疗成本的持续性，该数据库包括通过100多家大公司投保的个人的索赔数据，以及2001-2006年的欧洲议会议员浪潮。支出类别将基于年度支出的削减点 分布(例如，前5%)。初步分析将集中在65岁以下的个人。子分析将按年龄/性别组进行，并针对选定的临床条件和符合联邦医疗保险条件的退休人员。费用模式的预测因素将包括人口统计数据、健康计划设计和共病情况。由于欧洲议会议员的样本量有限，而且只对家庭进行了两年的跟踪调查，因此初步分析将使用MarketScan数据，在大样本上提供更长的面板。超过300万人可以被跟踪至少5年。欧洲议会议员将被用来评估MarketScan调查结果的概括性，以及雇主保险的自然减员对基于私营保险公司索赔的支出持续性估计的影响。分析方法是通过1)描述成本分布、转移概率和随着时间的推移(例如，从最高的50%到最高的5%)跨类别的支出相关性，以及2)将分配类别之间的转换预测因素建模为员工和家庭特征的函数，以及MarketScan数据库中的自然减员预测因素，来表征高支出时期的前期和高支出随时间的持续性。 由此产生的估计可以为处理再保险成本等问题的保单模拟提供信息 在不同的止损阈值下，以及扩大的个人保险市场或联邦医疗保险买入中逆向选择的潜在规模。我们将提供一个例子，说明这种估计如何为风险调整和再保险的评价提供信息，以此作为改善小群体健康保险市场运作的机制。

DESCRIPTION (provided by the applicant): To the extent that high health care spending persists over time, problems of adverse selection would be accentuated in private insurance markets based on annual contracts, exacerbating concerns about the availability of affordable coverage. Despite the importance of understanding the persistence of medical spending, surprisingly little is known. Several studies are based on Medicare data, limiting generalizability to the under 65 population. Studies representing younger persons have limitations, including the lack of recent data, short follow-up, single employer or insurer samples, and lack of attention to attrition from employer-based coverage. New knowledge regarding spending persistence can improve the evidence base underlying many policy options for covering the uninsured, including subsidized reinsurance markets, Medicare buy-ins, and incentives to expand the role of individual insurance contracts and consumer-driven health plans. We will assess the persistence of health care costs using the 2002-2007 Thomson Healthcare MarketScan Database, which includes claims data for individuals insured through over 100 large firms, and the 2001-2006 waves of the MEPS. Spending categories will be based on cut points in the annual spending distribution (e.g., top 5%). The primary analyses will focus on individuals under age 65. Subanalyses will be done by age/gender group and for selected clinical conditions and Medicare-eligible retirees. Predictors of cost patterns will include demographics, health plan design, and comorbid conditions. Because the MEPS has a limited sample size and follows households for only two years, the primary analyses will use MarketScan data to provide a longer panel on a large sample. Over 3 million people can be followed for at least 5 years. The MEPS will be used to assess the generalizability of the MarketScan findings and the effects of attrition from employer coverage on estimates of spending persistence based on private insurer claims. The analytic approach is to characterize the run-up to high spending periods and the persistence of high spending over time by 1) describing the cost distribution, transition probabilities, and spending correlations across categories over time (e.g., from top 50% to top 5%), and 2) modeling the predictors of transitioning between distributional categories as a function of employee and household characteristics, and the predictors of attrition from the MarketScan database. The resulting estimates can inform policy simulations addressing issues such as the cost of reinsurance under different stop-loss thresholds, and the potential magnitude of adverse selection in expanded individual insurance markets or Medicare buy-ins. We will provide an example of how such estimates can inform the evaluation of risk-adjustment and reinsurance as mechanisms to improve the functioning of small group health insurance markets.