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Enrolment procedures and self-selection by patients: evidence from a Polish family practice

HEALTH POLICY AND PLANNING 1999年第3期14卷 285-290页

作者： Chawla, M Tomasik, T Kulis, M Windak, A Rogers, DA Harvard Univ Sch Publ Hlth Dept Populat & Int Hlth Int Hlth Syst Grp Boston MA 02115 USA Hlth Serv Krakow Poland Jagiellonian Univ Dept Family Med Collegium Medicum Krakow Poland Harvard Jagiellonian Consortium Hlth Krakow Poland

This paper examines the consequences of patient enrolment procedures in a capitation-based family practice in Krakow (Poland), where the local city government used two different methods for preparation of patient lists. In the first, the city gave the individuals living within the practice area the option of withdrawing from being enrolled in the practice;in the second, individuals were given the option of enrolling in the practice. These two enrolment procedures, identified as 'active-negative' and 'active-positive' respectively, provide a natural experiment for investigating the effects of an enrolment methodology on the economics of a physician's practice. An examination of the data indicates that self-selecting enrolees utilize significantly greater quantities of health care compared to others, and university educated individuals and individuals more likely to fall ill are more likely to self-select into a practice. The study suggests that in order to reduce demand-side adverse selection, either the system of active-positive enrolment should be modified, or capitation rates should be risk-adjusted by health status rather than by demographic variables only. The policy implications of this study become even more significant as more and more physicians leave their salaried jobs to start state-financed independent practice.

关键词：按人收费/组织和管理发展中国家家庭医学/经济学家庭医学/组织和管理卫生服务需求卫生服务研究病人接受卫生保健的程度病人满意度波兰利用情况审核人类

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Risk adjusting capitation: Applications in employed and disabled populations

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Health Care Management Science 2000年第2期3.0卷 101-109页

作者： Madden, Carolyn W. Mackay, Bret P. Skillman, Susan M. Ciol, Marcia Diehr, Paula K. Department of Health Services University of Washington Seattle WA 98195 United States Department of Economics University of Washington Seattle WA 98195 United States Department of Biostatistics University of Washington Seattle WA 98195 United States

Risk adjustment may be a sensible strategy to reduce selection bias because it links managed care payment directly to the costs of providing services. In this paper we compare risk adjustment models in two populations (public employees and their dependents, and publicly-insured low income individuals with disabilities) in Washington State using two statistical approaches and three health status measures. We conclude that a two-part logistic/GLM statistical model performs better in populations with large numbers of individuals who do not use health services. This model was successfully implemented in the employed population, but the managed care program for the publicly insured population was terminated before risk adjustment could be applied. The choice of the most appropriate health status measure depends on purchasers' principles and desired outcomes. © Baltzer Science Publishers BV.

关键词：按人收费/组织和管理残疾人筹资政府保健福利计划雇员/组织和管理健康状况保险选择偏倚 Logistic模型管理医疗规划/组织和管理 Medicaid/组织和管理贫困风险调节/组织和管理州卫生计划/组织和管理美国华盛顿青少年成年人老年人女(雌)性人类男(雄)性中年人

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Needs-based primary medical care capitation: Development and evaluation of alternative approaches

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Health Care Management Science 2000年第2期3卷 89-99页

作者： Hutchison, Brian Hurley, Jeremiah Birch, Stephen Lomas, Jonathan Walter, Stephen D. Eyles, John Stratford-Devai, Fawne Department of Family Medicine Centre for Health Economics and Policy Analysis McMaster University Hamilton Ont. L3N 3Z5 1200 Main Street West Canada Centre for Health Economics and Policy Analysis Department of Clinical Epidemiology and Biostatistics McMaster University Hamilton Ont. L3N 3Z5 Canada Department of Clinical Epidemiology and Biostatistics McMaster University Hamilton Ont. L3N 3Z5 Canada Institute of Environment and Health McMaster University Hamilton Ont. L3N 3Z5 Canada

Objective. To develop and evaluate alternative methods of adjusting primary medical care capitation payments for variations in relative need for health care among enrolled practice populations. Methods. We developed alternative needs-based capitation formulae and applied them to a sample of capitation-funded primary care practices to assess each formula's performance against a reference standard of capitation payments based on age, sex and self-assessed health status of the enrolled populations. The alternative formulae were based on: (1) age and sex;(2) age, sex and individually-measured socioeconomic characteristics;(3) age, sex and socioeconomic characteristics imputed from census data for enrollees' neighbourhood of residence;(4) age, sex and standardized mortality ratio for enrollees' neighbourhood of residence. Results. Age/sex-adjusted capitation payments for the six practices studied ranged from 10% higher to 18% lower than the reference standard payments. Capitation formulae based on socioeconomic and mortality data did not perform consistently better than the current age/sex-based formula. Conclusions. Primary medical care capitation payments adjusted only for age and sex do not reflect the relative health care needs of enrolled practice populations. Our alternative formulae based on socioeconomic and mortality data also failed to reflect relative needs. Methods that use other approaches to adjusting for differences in relative need among enrolled populations should be investigated. © Baltzer Science Publishers BV.

关键词：年龄因素按人收费/组织和管理数据说明统计家庭医学/组织和管理健康状况管理医疗规划/组织和管理死亡率需求估价/组织和管理安大略/流行病学初级卫生保健/组织和管理规划制订/方法方案评价/方法可重复性结果性别因素社会经济因素青少年成年人老年人老年人 80以上儿童儿童学龄前女(雌)性人类婴儿婴儿新生男(雄)性中年人

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Contract design for primary care physicians: Physician location and practice behaviour in small communities

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Health Care Management Science 2000年第2期3卷 151-157页

作者： Sørensen, Rune J. Grytten, Jostein Norwegian School of Management Sandvika Norway Institute of Community Dentistry University of Oslo Oslo Norway

Most western countries employ a combination of fee-for-service, fixed salary and per capita subsidies to finance the services of general practitioners. Based on Norwegian data, the authors demonstrate that these fianancial schemes have been used in different types of municipalities. The authors argue that the fee-for-service and per capita components should be allowed to vary between primary physicians and municipalities: (a) If the patient population per primary physician is low and patient supply is unstable, the per capita subsidy or work-free income should be differentiated to ensure recruitment of physicians, (b) Physicians in municipalities with low physician coverage should be allotted a low basic grant, whilst per capita subsidy and fee-for-service payments should be used to stimulate service production. The opposite situation exists where there is a potential of supplier inducement due to high physician coverage, (c) The responsibility for designing contracts should be assigned to local rather than national authorities. These suggestions go against important elements in the reform of primary physician services in Norway. © Baltzer Science Publishers BV.

关键词：按人收费/组织和管理职业选择合同业务/组织和管理家庭医学/组织和管理按诊疗收费计划/组织和管理模型经济计量学挪威医师诊疗模式/组织和管理人口密度专业场所/统计学和数值数据薪金和附加福利/统计学和数值数据工作负荷量人类

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Risk adjustment and the fear of markets: The case of Belgium

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Health Care Management Science 2000年第2期3卷 121-130页

作者： Schokkaert, Erik Van De Voorde, Carine Center for Economic Studies KU Leuven Leuven Belgium

In Belgium the management and administration of the compulsory and universal health insurance is left to a limited number of non-governmental non-profit sickness funds. Since 1995 these sickness funds are partially financed in a prospective way. The risk adjustment scheme is based on a regression model to explain medical expenditures for different social groups. Medical supply is taken out of the formula to construct risk-adjusted capitation payments. The risk-adjustment formula still leaves scope for risk selection. At the same time, the sickness funds were not given the instruments to exert a real influence on expenditures and the health insurance market has not been opened for new entrants. As a consequence, Belgium runs the danger of ending up in a situation with little incentives for efficiency and considerable profits from cream skimming. © Baltzer Science Publishers BV.

关键词：比利时按人收费/组织和管理效率组织筹资政府/组织和管理预测卫生经费支出/统计学和数值数据保险选择偏倚管理医疗规划/组织和管理卫生服务使用研究/组织和管理国家卫生规划/组织和管理回归分析风险调节/组织和管理成年人老年人老年人 80以上女(雌)性人类男(雄)性中年人

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Risk adjustment of capitation payments to behavioral health care carve-outs: How well do existing methodologies account for psychiatric disability?

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Health Care Management Science 2000年第2期3卷 159-169页

作者： Ettner, Susan L. Frank, Richard G. Mark, Tami Smith, Mark W. Division of General Internal Medicine and Health Services Research UCLA Department of Medicine Los Angeles CA 90095 United States Department of Health Care Policy Harvard Medical School Boston MA United States MEDSTAT Group Inc. Washington DC United States

This study used 1994-1995 administrative data from a large public employer to examine the viability of commercial risk adjustment systems for setting capitation payments to competing behavioral health care "carve-outs". The ability of Hierarchical Condition Categories and Adjusted Diagnostic Groups to predict psychiatric expenditures was improved by controlling separately for psychiatric disability. However, even the best models underpredicted expenditures of patients with psychiatric disability by 15%. Relative to full capitation, "mixed" payment systems and soft capitation reduce the ability of carve-outs to earn disproportionate profits by enrolling healthy patients and avoiding sick ones, yet also diminish incentives for cost containment. © Baltzer Science Publishers BV.

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Capitation funding in Australia: Imperatives and impediments

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Health Care Management Science 2000年第2期3.0卷 77-88页

作者： Peacock, Stuart Segal, Leonie Health Economics Unit Centre for Health Program Evaluation Monash University West Heidelberg Vic. 3081 PO Box 477 Australia

Health service funding mechanisms are pivotal in the pursuit of health system objectives, as they provide strong financial incentives for actors in the system to achieve policy goals. Underpinning funding mechanisms is a set of key economic principles, or objectives, that should guide their design and use: efficiency, equity, and accountability. The Australian health system has historically performed relatively poorly in relation to these objectives, with evidence of inefficiencies, inequities, and poor accountability in many areas of health services. The primary cause of these shortcomings may lie in the complex set of funding and delivery arrangements at the State and Federal levels of government. Potentially significant improvements in the performance of the health system would be available from the integration of the funding and delivery of services within a single tier of government, coupled with the development of a national weighted capitation approach to funding. To develop a national capitation funding model a number of unique factors require consideration, including the current fragmentation of services, the role of the private sector, the needs of indigenous populations, and the effects of rurality. The data available to develop a capitation model is of a level of detail and quality not readily found elsewhere. If policy statements promoting efficiency, accountability, and particularly equity are to be actively pursued, a national capitation model based on robust methods should become a cornerstone of Australian health system reform. © Baltzer Science Publishers BV.

关键词：澳大利亚按人收费/组织和管理卫生保健提供联合/组织和管理效率组织筹资政府/组织和管理卫生保健改革/组织和管理卫生服务易得程度/标准管理医疗规划/组织和管理模型组织管理国家卫生规划/组织和管理需求估价/组织和管理全面质量管理/组织和管理人类

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Ignoring small predictable profits and losses: A new approach for measuring incentives for cream skimming

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Health Care Management Science 2000年第2期3卷 131-140页

作者： Van Barneveld, Erik M. Lamers, Leida M. Van Vliet, René C. J. A. Van De Ven, Wynand P. M. M. Department of Health Policy and Management Erasmus University Rotterdam 3000 DR Rotterdam Netherlands

Under inadequate capitation formulae competing health insurers have an incentive for cream skimming, i.e., the selection of enrollees whom the insurer expects to be profitable. When evaluating different capitation formulae, previous studies used various indicators of incentives for cream skimming. These conventional indicators are based on all actual profits and losses or on all predictable profits and losses. For the latter type of indicators, this paper proposes, as a new approach, to ignore the small predictable profits and losses. We assume that this new approach provides a better indication of the size of the cream skimming problem than the conventional one, because an insurer has to take into account its costs of cream skimming and the (statistical) uncertainties about the net benefits of cream skimming. Both approaches are applied in theoretical and empirical analyses. The results show that, if our assumption is right, the problem of cream skimming is overestimated by the conventional ways of measuring incentives for cream skimming, especially in the case of relatively good capitation formulae. © Baltzer Science Publishers BV.

关键词：按人收费/组织和管理经济竞争/组织和管理预测保险选择偏倚管理医疗规划/组织和管理卫生服务使用研究模型经济计量学动机可重复性结果成年人女(雌)性人类男(雄)性

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