Capital Requirements of Health Insurers Under Different Risk-Adjusted Capitation Payments

Medicare Risk-Adjusted Capitation Payments: From Research to Implementation

Mandatory pooling as a supplement to risk-adjusted capitation payments in a competitive health insurance market.

Risk-adjusted capitation payments (RACPs) to competing health insurers are an essential element of market-oriented health care reforms in many countries. RACPs based on demographic variables only are insufficient, because they leave ample room for cream skimming. However, the implementation of improved RACPs does not appear to be straightforward. A solution might be to supplement imperfect RACP...

Health-Based Risk Assessment: Risk-Adjusted Payments and Beyond

AcademyHealth is the national program office for HCFO, an initiative of The Robert Wood Johnson Foundation. A number of payers across the country, including Medicaid managed care programs, the Medicare+Choice program, some state employee programs, and a few private purchasing cooperatives, have adjusted their payments based on health status. Researchers generally agree that most health-based ri...

Using chronic disease risk factors to adjust Medicare capitation payments

This study evaluates the use of risk factors for chronic disease as health status adjusters for Medicare's capitation formula, the average adjusted per capita costs (AAPCC). Risk factor data for the surviving members of the Framingham Study cohort who were examined in 1982-83 were merged with 100 percent Medicare payment data for 1984 and 1985, matching on Social Security number and sex. Seven ...

Diagnosis-Based Risk Adjustment for Medicare Capitation Payments

Using 1991-92 data for a 5-percent Medicare sample, we develop, estimate, and evaluate risk-adjustment models that utilize diagnostic information from both inpatient and ambulatory claims to adjust payments for aged and disabled Medicare enrollees. Hierarchical coexisting conditions (HCC) models achieve greater explanatory power than diagnostic cost group (DCG) models by taking account of multi...