RESUMEN
BACKGROUND: Risk-adjustment in resource allocation is commonly used for regional redistribution or for eliminating risk selection motives of multiple statutory health insurers. In the Czech Republic, revenue redistribution between health insurers takes place since the 1990's. Since 2018, the risk-adjustment mechanism includes an adjustment for insured with chronic diseases using Pharmacy-based Cost Group (PCG) classification. In addition, retrospective compensation for very high cost patients has been strengthened. AIM: To provide an internationally relevant overview of the Czech risk-adjustment system. To assess the implication of the 2018 reform for health insurers and for the development of chronic care. METHOD: The framework of the Health Reform Monitor is used to analyse the policy process. Data from Czech health insurers and Czech Ministry of Health are used to assess likely impact of the reform. RESULTS: The reform increases coverage of predictable individual health risks and combines prospective risk-rating with strengthened retrospective risk-sharing among insurers. The reform results in moderate changes in risk-adjusted allocations of individual insurers. CONCLUSION: The Czech experience with risk-adjustment reforms is relevant for countries with multiple health insurers as well as for countries with risk-adjusted regional redistribution mechanisms. Combining prospective risk factors of age, sex, and PCGs with retrospective compensation of expensive cases limits potential losses to a manageable level, also for small risk-pools. It reduces incentives for cream skimming based on health status, enables higher use of risk-sharing contracts, and incentivizes the development of disease management programs in the Czech Republic.
Asunto(s)
Seguro de Salud/economía , Seguro de Salud/organización & administración , Ajuste de Riesgo/legislación & jurisprudencia , Enfermedad Crónica/tratamiento farmacológico , Enfermedad Crónica/economía , República Checa , Utilización de Medicamentos/economía , Reforma de la Atención de Salud , Humanos , Aseguradoras/economía , Aseguradoras/legislación & jurisprudencia , Ajuste de Riesgo/métodos , Prorrateo de Riesgo Financiero/economía , Prorrateo de Riesgo Financiero/legislación & jurisprudenciaRESUMEN
Shards of a bipartisan effort to stabilize the individual health insurance markets emerged. They focused mostly on resurrecting the ACA cost-reduction payments and giving states flexibility to come up with their own ideas, like reinsurance, for shoring up the troubled individual market.
Asunto(s)
Intercambios de Seguro Médico/economía , Intercambios de Seguro Médico/legislación & jurisprudencia , Seguro de Salud/economía , Seguro de Salud/legislación & jurisprudencia , Política , Prorrateo de Riesgo Financiero/economía , Prorrateo de Riesgo Financiero/legislación & jurisprudencia , Deducibles y Coseguros/economía , Deducibles y Coseguros/legislación & jurisprudencia , Humanos , Patient Protection and Affordable Care Act , Gobierno Estatal , Estados UnidosRESUMEN
Subsidized reinsurance represents a potentially important tool to help stabilize individual health insurance markets. This brief describes alternative forms of subsidized reinsurance and the mechanisms by which they spread risk and reduce premiums. It summarizes specific state initiatives and Congressional proposals that include subsidized reinsurance. It compares approaches to each other and to more direct subsidies of individual market enrollment. For a given amount of funding, a particular program's efficacy will depend on how it affects insurers' risk and the risk margins built into premiums, incentives for selecting or avoiding risks, incentives for coordinating and managing care, and the costs and complexity of administration. These effects warrant careful consideration by policymakers as they consider measures to achieve stability in the individual market in the long term.
Asunto(s)
Intercambios de Seguro Médico/economía , Intercambios de Seguro Médico/legislación & jurisprudencia , Prorrateo de Riesgo Financiero/economía , Prorrateo de Riesgo Financiero/legislación & jurisprudencia , Deducibles y Coseguros/economía , Deducibles y Coseguros/legislación & jurisprudencia , Humanos , Seguro de Salud/economía , Seguro de Salud/legislación & jurisprudencia , Patient Protection and Affordable Care Act/economía , Patient Protection and Affordable Care Act/legislación & jurisprudencia , Estados UnidosRESUMEN
The Affordable Care Act (ACA) reformed the individual health insurance market. Because insurers can no longer vary their offers of coverage based on applicants' health status, the ACA established a risk adjustment program to equalize health-related cost differences across plans. The ACA also established a temporary reinsurance program to subsidize high-cost claims. To assess the impact of these programs, we compared revenues to claims costs for insurers in the individual market during the first two years of ACA implementation (2014 and 2015), before and after the inclusion of risk adjustment and reinsurance payments. Before these payments were included, for the 30 percent of insurers with the highest claims costs, claims (not including administrative expenses) exceeded premium revenues by $90-$397 per enrollee per month. The effect was reversed after these payments were included, with revenues exceeding claims costs by $0-$49 per month. The risk adjustment and reinsurance programs were relatively well targeted in the first two years. While there is ongoing discussion regarding the future of the ACA, our findings can shed light on how risk-sharing programs can address risk selection among insurers-a pervasive issue in all health insurance markets.
Asunto(s)
Aseguradoras/legislación & jurisprudencia , Patient Protection and Affordable Care Act/economía , Ajuste de Riesgo/estadística & datos numéricos , Prorrateo de Riesgo Financiero/legislación & jurisprudencia , Gastos en Salud , Humanos , Aseguradoras/economía , Seguro de Salud/economía , Patient Protection and Affordable Care Act/legislación & jurisprudencia , Método de Control de Pagos/legislación & jurisprudencia , Ajuste de Riesgo/economía , Prorrateo de Riesgo Financiero/economía , Estados UnidosRESUMEN
Accountable care organizations (ACOs) result in physician organizations' and hospitals' receiving risk-based payments tied to costs, health care quality, and patient outcomes. This article (1) describes California ACOs within Medicare, the commercial market, and Medi-Cal and the safety net; (2) discusses how ACOs are regulated by the California Department of Managed Health Care and the California Department of Insurance; and (3) analyzes the increase of ACOs in California using data from Cattaneo and Stroud. While ACOs in California are well established within Medicare and the commercial market, they are still emerging within Medi-Cal and the safety net. Notwithstanding, the state has not enacted a law or issued a regulation specific to ACOs; they are regulated under existing statutes and regulations. From August 2012 to February 2014, the number of lives covered by ACOs increased from 514,100 to 915,285, representing 2.4 percent of California's population, including 10.6 percent of California's Medicare fee-for-service beneficiaries and 2.3 percent of California's commercially insured lives. By emphasizing health care quality and patient outcomes, ACOs have the potential to build and improve on California's delegated model. If recent trends continue, ACOs will have a greater influence on health care delivery and financial risk sharing in California.
Asunto(s)
Organizaciones Responsables por la Atención/organización & administración , Programas Controlados de Atención en Salud/organización & administración , Medicaid/organización & administración , Medicare/organización & administración , Prorrateo de Riesgo Financiero/organización & administración , Organizaciones Responsables por la Atención/economía , Organizaciones Responsables por la Atención/legislación & jurisprudencia , Organizaciones Responsables por la Atención/normas , California , Centers for Medicare and Medicaid Services, U.S. , Prestación Integrada de Atención de Salud/legislación & jurisprudencia , Regulación Gubernamental , Humanos , Programas Controlados de Atención en Salud/economía , Programas Controlados de Atención en Salud/legislación & jurisprudencia , Programas Controlados de Atención en Salud/normas , Medicaid/economía , Medicare/economía , Calidad de la Atención de Salud/organización & administración , Prorrateo de Riesgo Financiero/economía , Prorrateo de Riesgo Financiero/legislación & jurisprudencia , Gobierno Estatal , Estados UnidosRESUMEN
This final rule implements standards for States related to reinsurance and risk adjustment, and for health insurance issuers related to reinsurance, risk corridors, and risk adjustment consistent with title I of the Patient Protection and Affordable Care Act as amended by the Health Care and Education Reconciliation Act of 2010, referred to collectively as the Affordable Care Act. These programs will mitigate the impact of potential adverse selection and stabilize premiums in the individual and small group markets as insurance reforms and the Affordable Insurance Exchanges ("Exchanges") are implemented, starting in 2014. The transitional State-based reinsurance program serves to reduce uncertainty by sharing risk in the individual market through making payments for high claims costs for enrollees. The temporary Federally administered risk corridors program serves to protect against uncertainty in rate setting by qualified health plans sharing risk in losses and gains with the Federal government. The permanent State-based risk adjustment program provides payments to health insurance issuers that disproportionately attract high-risk populations (such as individuals with chronic conditions).
Asunto(s)
Aseguradoras/legislación & jurisprudencia , Patient Protection and Affordable Care Act/economía , Prorrateo de Riesgo Financiero/legislación & jurisprudencia , Enfermedad Crónica/economía , Participación de la Comunidad/economía , Participación de la Comunidad/legislación & jurisprudencia , Competencia Económica/economía , Competencia Económica/legislación & jurisprudencia , Gobierno Federal , Aseguradoras/economía , Selección Tendenciosa de Seguro , Patient Protection and Affordable Care Act/legislación & jurisprudencia , Método de Control de Pagos/legislación & jurisprudencia , Prorrateo de Riesgo Financiero/economía , Prorrateo de Riesgo Financiero/normas , Gobierno EstatalRESUMEN
In this paper, we characterise the risk-sharing contracts that health authorities can design when they face a regulatory decision on drug pricing and reimbursement in a context of uncertainty. We focus on two types of contracts. On the one hand, the health authority can reimburse the firm for each treated patient regardless of health outcomes (non risk-sharing). Alternatively, the health authority can pay for the drug only when the patient is cured (risk-sharing contract). The optimal contract depends on the trade-off between the monitoring costs, the marginal production cost and the utility derived from treatment. A non-risk-sharing agreement will be preferred by the health authority, if patients who should not be treated impose a relatively low cost to the health system. When this cost is high, the health authority would prefer a risk-sharing agreement for relatively low monitoring costs.
Asunto(s)
Contratos/legislación & jurisprudencia , Industria Farmacéutica/legislación & jurisprudencia , Costos de la Atención en Salud/estadística & datos numéricos , Política de Salud/legislación & jurisprudencia , Accesibilidad a los Servicios de Salud/economía , Prorrateo de Riesgo Financiero/métodos , Costos de la Atención en Salud/legislación & jurisprudencia , Accesibilidad a los Servicios de Salud/legislación & jurisprudencia , Accesibilidad a los Servicios de Salud/estadística & datos numéricos , Humanos , Reembolso de Seguro de Salud/economía , Reembolso de Seguro de Salud/legislación & jurisprudencia , Reembolso de Seguro de Salud/estadística & datos numéricos , Modelos Teóricos , Médicos/legislación & jurisprudencia , Pautas de la Práctica en Medicina/legislación & jurisprudencia , Pautas de la Práctica en Medicina/estadística & datos numéricos , Prorrateo de Riesgo Financiero/legislación & jurisprudenciaRESUMEN
From bedside to boardroom, nurses deal with the consequences of health care provider insurance risk assumption. Professional caregiver insurance risk refers to insurance risks assumed through contracts with third parties, federal and state Medicare and Medicaid program mandates, and the diagnosis-related groups and Prospective Payment Systems. This article analyzes the financial, legal, and ethical implications of provider insurance risk assumption by focusing on the degree to which patient benefits are reduced.
Asunto(s)
Seguro de Salud , Gestión de Riesgos , Prorrateo de Riesgo Financiero , Análisis Actuarial/economía , Análisis Actuarial/ética , Análisis Actuarial/métodos , Planificación en Salud Comunitaria/ética , Planificación en Salud Comunitaria/legislación & jurisprudencia , Control de Costos , Eficiencia Organizacional , Regulación Gubernamental , Adhesión a Directriz/ética , Adhesión a Directriz/legislación & jurisprudencia , Guías como Asunto , Necesidades y Demandas de Servicios de Salud/ética , Necesidades y Demandas de Servicios de Salud/legislación & jurisprudencia , Humanos , Seguro de Salud/ética , Seguro de Salud/legislación & jurisprudencia , Medicaid/ética , Medicaid/legislación & jurisprudencia , Medicare/ética , Medicare/legislación & jurisprudencia , Modelos Económicos , Investigación Operativa , Probabilidad , Sistema de Pago Prospectivo/ética , Sistema de Pago Prospectivo/legislación & jurisprudencia , Gestión de Riesgos/ética , Gestión de Riesgos/legislación & jurisprudencia , Prorrateo de Riesgo Financiero/ética , Prorrateo de Riesgo Financiero/legislación & jurisprudencia , Estados UnidosRESUMEN
The Patient Protection and Affordable Care Act depends on new, state-based exchanges to make health insurance readily available to certain segments of the population. One such segment is the lower-income uninsured, who can qualify for subsidized coverage only through an exchange. Other segments are unsubsidized individuals and small employers, who may choose to buy coverage inside or outside of an exchange. Although the law provides some guidance in structuring these new exchanges, it leaves many key decisions to the states. Successfully implementing exchanges will require public-private partnerships, expertise in insurance operations and marketing, and a series of strategic decisions. We review the half-dozen most important design issues.
Asunto(s)
Reforma de la Atención de Salud/legislación & jurisprudencia , Seguro de Salud/legislación & jurisprudencia , Gobierno Estatal , Propuestas de Licitación/legislación & jurisprudencia , Propuestas de Licitación/organización & administración , Honorarios Médicos/legislación & jurisprudencia , Reforma de la Atención de Salud/organización & administración , Sector de Atención de Salud/legislación & jurisprudencia , Sector de Atención de Salud/organización & administración , Beneficios del Seguro/legislación & jurisprudencia , Seguro de Salud/organización & administración , Pacientes no Asegurados/legislación & jurisprudencia , Asociación entre el Sector Público-Privado/legislación & jurisprudencia , Prorrateo de Riesgo Financiero/legislación & jurisprudencia , Prorrateo de Riesgo Financiero/organización & administración , Estados UnidosRESUMEN
An individual mandate is an important feature of many recent plans to achieve universal health insurance coverage in the United States, without radically changing the way most Americans get health care and coverage. Using national public opinion data, we find that on its own, an individual mandate does not have broad support across partisan and sociodemographic groups. Policymakers who choose to pursue an individual mandate for policy reasons may expand the base of supporters by incorporating it into a "shared-responsibility" plan that includes requirements for employers, government, and insurers.
Asunto(s)
Reforma de la Atención de Salud/legislación & jurisprudencia , Política de Salud/legislación & jurisprudencia , Programas Obligatorios/legislación & jurisprudencia , Política , Opinión Pública , Cobertura Universal del Seguro de Salud/legislación & jurisprudencia , Adolescente , Adulto , Anciano , Niño , Conducta Cooperativa , Femenino , Financiación Gubernamental/legislación & jurisprudencia , Financiación Personal/legislación & jurisprudencia , Planes de Asistencia Médica para Empleados/legislación & jurisprudencia , Humanos , Cobertura del Seguro/legislación & jurisprudencia , Fondos de Seguro/legislación & jurisprudencia , Masculino , Persona de Mediana Edad , Prorrateo de Riesgo Financiero/legislación & jurisprudencia , Atención no Remunerada/legislación & jurisprudencia , Estados Unidos , Adulto JovenRESUMEN
Moving toward universal participation in health insurance using a "shared responsibility" approach requires new, more accessible, and more efficient ways for people who are not offered employer coverage to obtain coverage. California's recent health reform plan-which failed to pass-incorporated individual market reform and choice-pool constructs to achieve critically important risk spreading, assure solvency, and reduce cost shifts. These measures, as well as the considerations that led to their design, offer important insights for health reform at the federal level.
Asunto(s)
Seguro de Costos Compartidos/legislación & jurisprudencia , Reforma de la Atención de Salud/legislación & jurisprudencia , Política de Salud/legislación & jurisprudencia , Atención no Remunerada/legislación & jurisprudencia , Cobertura Universal del Seguro de Salud/legislación & jurisprudencia , California , Análisis Costo-Beneficio/economía , Análisis Costo-Beneficio/legislación & jurisprudencia , Financiación Gubernamental/economía , Financiación Gubernamental/legislación & jurisprudencia , Financiación Personal/legislación & jurisprudencia , Planes de Asistencia Médica para Empleados/economía , Planes de Asistencia Médica para Empleados/legislación & jurisprudencia , Reforma de la Atención de Salud/economía , Política de Salud/economía , Humanos , Renta , Fondos de Seguro/economía , Fondos de Seguro/legislación & jurisprudencia , National Health Insurance, United States/economía , National Health Insurance, United States/legislación & jurisprudencia , Política , Prorrateo de Riesgo Financiero/economía , Prorrateo de Riesgo Financiero/legislación & jurisprudencia , Atención no Remunerada/economía , Estados Unidos , Cobertura Universal del Seguro de Salud/economíaRESUMEN
California's recent failed attempt to expand health coverage broadly offers lessons for future coverage expansion efforts. Policy efforts are most likely to advance if they are bipartisan; address the needs of both insured and uninsured residents; deliver short-term progress within the context of long-term goals; rely on broad and sustainable financing; strike a balance between specificity and flexibility; and occur within a clearer framework of state and federal responsibilities.
Asunto(s)
Seguro de Costos Compartidos/legislación & jurisprudencia , Reforma de la Atención de Salud/legislación & jurisprudencia , Política de Salud/legislación & jurisprudencia , Atención no Remunerada/legislación & jurisprudencia , Cobertura Universal del Seguro de Salud/legislación & jurisprudencia , Adulto , California , Niño , Financiación Gubernamental/economía , Financiación Gubernamental/legislación & jurisprudencia , Financiación Personal/legislación & jurisprudencia , Planes de Asistencia Médica para Empleados/economía , Planes de Asistencia Médica para Empleados/legislación & jurisprudencia , Reforma de la Atención de Salud/economía , Política de Salud/economía , Humanos , Renta , Cobertura del Seguro/economía , Cobertura del Seguro/legislación & jurisprudencia , Fondos de Seguro/economía , Fondos de Seguro/legislación & jurisprudencia , Medicaid/economía , Medicaid/legislación & jurisprudencia , Política , Prorrateo de Riesgo Financiero/economía , Prorrateo de Riesgo Financiero/legislación & jurisprudencia , Atención no Remunerada/economía , Estados Unidos , Cobertura Universal del Seguro de Salud/economíaAsunto(s)
Servicios Contratados/legislación & jurisprudencia , Conducta Cooperativa , Cirugía General/legislación & jurisprudencia , Asociaciones de Práctica Independiente/legislación & jurisprudencia , Comunicación Interdisciplinaria , Programas Nacionales de Salud/legislación & jurisprudencia , Alemania , Humanos , Inversiones en Salud/legislación & jurisprudencia , Administración de la Práctica Médica/legislación & jurisprudencia , Autonomía Profesional , Prorrateo de Riesgo Financiero/legislación & jurisprudenciaRESUMEN
This final rule is the third phase (Phase III) of a final rulemaking amending our regulations regarding the physician self-referral prohibition in section 1877 of the Social Security Act (the Act). Specifically, this rule finalizes, and responds to public comments regarding, the Phase II interim final rule with comment period published on March 26, 2004, which set forth the self-referral prohibition and applicable definitions, interpreted various statutory exceptions to the prohibition, and created additional regulatory exceptions for arrangements that do not pose a risk of program or patient abuse (69 FR 16054). In general, in response to public comments, in this Phase III final rule, we have reduced the regulatory burden on the health care industry through the interpretation of statutory exceptions and modification of the exceptions that were created using the Secretary's discretionary authority under section 1877(b)(4) of the Act to promulgate exceptions for financial relationships that pose no risk of program or patient abuse.
Asunto(s)
Conflicto de Intereses/legislación & jurisprudencia , Medicare/legislación & jurisprudencia , Auto Remisión del Médico/legislación & jurisprudencia , Práctica de Grupo/legislación & jurisprudencia , Humanos , Medicare/ética , Propiedad/legislación & jurisprudencia , Auto Remisión del Médico/ética , Prorrateo de Riesgo Financiero/legislación & jurisprudencia , Estados UnidosAsunto(s)
Planificación en Desastres/economía , Administración Financiera de Hospitales/legislación & jurisprudencia , Fondos de Seguro/legislación & jurisprudencia , Propiedad/economía , Honorarios y Precios/tendencias , Administración Financiera de Hospitales/tendencias , Florida , Prorrateo de Riesgo Financiero/legislación & jurisprudenciaRESUMEN
This final rule clarifies our interpretation of the meaning of "entity" in the final rule titled "Medicare Program; Establishment of the Medicare Advantage Program" published in the Federal Register on January 28, 2005 (70 FR 4588). Subsequent to the publication of the Medicare Advantage (MA) final rule on January 28, 2005, we have received inquiries from parties interested in offering an MA Regional Plan concerning whether they could jointly enter into a contract with us to offer a single MA Regional Plan in a multistate region. The participating health plans wish to contract with each other to create a single "joint enterprise." They have asked us whether such a joint enterprise could be considered an "entity" under sections 1859(a)(1)and 1855(a)(1) of the Social Security Act, for purposes of offering an MA Regional Plan. The MA final rule is scheduled to take effect on March 22, 2005. Our interpretation of the word "entity" that follows in the "Supplementary Information" section of this final rule is deemed to be included in that final rule.
Asunto(s)
Medicare/legislación & jurisprudencia , Regionalización/legislación & jurisprudencia , Servicios Contratados/legislación & jurisprudencia , Humanos , Prorrateo de Riesgo Financiero/legislación & jurisprudencia , Estados UnidosRESUMEN
The Stark law, first passed in 1989 and repeatedly expanded and clarified since then, has long created questions for group practices. Its primary intent is to prohibit physician referrals to entities in which the physician has a financial interest, but the details have proven confusing. The Stark law's Phase II regulations, as put forth by the Centers for Medicare and Medicaid Services, went into effect in July and attempt to offer further clarification. In this article the authors explain some of the complexities of this most recent set of Stark law regulations, especially as they apply to smaller, multi-specialty practices.
Asunto(s)
Práctica de Grupo/legislación & jurisprudencia , Auto Remisión del Médico/legislación & jurisprudencia , Administración de la Práctica Médica/legislación & jurisprudencia , Centers for Medicare and Medicaid Services, U.S. , Documentación , Adhesión a Directriz/legislación & jurisprudencia , Legislación Médica , Planes de Incentivos para los Médicos/legislación & jurisprudencia , Prorrateo de Riesgo Financiero/legislación & jurisprudencia , Especialización , Estados UnidosAsunto(s)
Medicare/legislación & jurisprudencia , Anciano , Prescripciones de Medicamentos/economía , Humanos , Beneficios del Seguro/economía , Beneficios del Seguro/legislación & jurisprudencia , Cobertura del Seguro/economía , Cobertura del Seguro/legislación & jurisprudencia , Medicare/economía , Rol de la Enfermera , Política , Privatización/economía , Privatización/legislación & jurisprudencia , Prorrateo de Riesgo Financiero/economía , Prorrateo de Riesgo Financiero/legislación & jurisprudencia , Estados UnidosRESUMEN
In order to facilitate a better understanding of the complex issues raised by the current Senate and House proposals to establish a prescription drug benefit for Medicare beneficiaries, this paper briefly addresses some fundamentals of the health insurance market, defines key risk-sharing mechanisms, including risk corridors and reinsurance, and identifies the relevant risk provisions in the bills. Other issues related to cost management strategies and program design, which may have an impact on cost and adverse selection, are briefly discussed.