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Risk Selection (risk + selection)
Selected AbstractsEvaluation of 280 000 cases in Dutch midwifery practices: a descriptive studyBJOG : AN INTERNATIONAL JOURNAL OF OBSTETRICS & GYNAECOLOGY, Issue 5 2008MP Amelink-Verburg Objective, To assess the nature and outcome of intrapartum referrals from primary to secondary care within the Dutch obstetric system. Design, Descriptive study. Setting, Dutch midwifery database (LVR1), covering 95% of all midwifery care and 80% of all Dutch pregnancies (2001,03). Population, Low-risk women (280 097) under exclusive care of a primary level midwife at the start of labour either with intention to deliver at home or with a personal preference to deliver in hospital under care of a primary level midwife. Methods, Women were classified into three categories (no referral, urgent referral and referral without urgency) and were related to maternal characteristics and to neonatal outcomes. Main outcome measures, Distribution of referral categories, main reasons for urgent referral, Apgar score at 5 minutes, perinatal death within 24 hours and referral to a paediatrician within 24 hours. Results, In our study, 68.1% of the women completed childbirth under exclusive care of a midwife, 3.6% were referred on an urgency basis and 28.3% were referred without urgency. Of all referrals, 11.2% were on an urgency basis. The main reasons for urgent referrals were fetal distress and postpartum haemorrhage. The nonurgent referrals predominantly took place during the first stage of labour (73.6% of all referrals). Women who had planned a home delivery were referred less frequently than women who had planned a hospital delivery: 29.3 and 37.2%, respectively (P < 0.001). On average, the mean Apgar score at 5 minutes was high (9.72%) and the peripartum neonatal mortality was low (0.05%) in the total study group. No maternal deaths occurred. Adverse neonatal outcomes occurred most frequently in the urgent referral group, followed by the group of referrals without urgency and the nonreferred group. Conclusions, Risk selection is a crucial element of the Dutch obstetric system and continues into the postpartum period. The system results in a relatively small percentage of intrapartum urgent referrals and in overall satisfactory neonatal outcomes in deliveries led by primary level midwives. [source] Predicting risk selection following major changes in medicareHEALTH ECONOMICS, Issue 4 2008Steven D. Pizer Abstract The Medicare Modernization Act of 2003 created several new types of private insurance plans within Medicare, starting in 2006. Some of these plan types previously did not exist in the commercial market and there was great uncertainty about their prospects. In this paper, we show that statistical models and historical data from the Medicare Current Beneficiary Survey can be used to predict the experience of new plan types with reasonable accuracy. This lays the foundation for the analysis of program modifications currently under consideration. We predict market share, risk selection, and stability for the most prominent new plan type, the stand-alone Medicare prescription drug plan (PDP). First, we estimate a model of consumer choice across Medicare insurance plans available in the data. Next, we modify the data to include PDPs and use the model to predict the probability of enrollment for each beneficiary in each plan type. Finally, we calculate mean-adjusted actual spending by plan type. We predict that adverse selection into PDPs will be substantial, but that enrollment and premiums will be stable. Our predictions correspond well to actual experience in 2006. Copyright © 2007 John Wiley & Sons, Ltd. [source] The Costs of Decedents in the Medicare Program: Implications for Payments to Medicare+Choice PlansHEALTH SERVICES RESEARCH, Issue 1 2004Melinda Beeuwkes Buntin Objective. To discuss and quantify the incentives that Medicare managed care plans have to avoid (through selective enrollment or disenrollment) people who are at risk for very high costs, focusing on Medicare beneficiaries in the last year of life,a group that accounts for more than one-quarter of Medicare's annual expenditures. Data Source. Medicare administrative claims for 1994 and 1995. Study Design. We calculated the payment a plan would have received under three risk-adjustment systems for each beneficiary in our 1995 sample based on his or her age, gender, county of residence, original reason for Medicare entitlement, and principal inpatient diagnoses received during any hospital stays in 1994. We compared these amounts to the actual costs incurred by those beneficiaries. We then looked for clinical categories that were predictive of costs, including costs in a beneficiary's last year of life, not accounted for by the risk adjusters. Data Extraction Methods. The analyses were conducted using claims for a 5 percent random sample of Medicare beneficiaries who died in 1995 and a matched group of survivors. Principal Findings. Medicare is currently implementing the Principal Inpatient Diagnostic Cost Groups (PIP-DCG) risk adjustment payment system to address the problem of risk selection in the Medicare+Choice program. We quantify the strong financial disincentives to enroll terminally ill beneficiaries that plans still have under this risk adjustment system. We also show that up to one-third of the selection observed between Medicare HMOs and the traditional fee-for-service system could be due to differential enrollment of decedents. A risk adjustment system that incorporated more of the available diagnostic information would attenuate this disincentive; however, plans could still use clinical information (not included in the risk adjustment scheme) to identify beneficiaries whose expected costs exceed expected payments. Conclusions. More disaggregated prospective risk adjustment methods and alternative payment systems that compensate plans for delivering care to certain classes of patients should be considered to ensure access to high-quality managed care for all beneficiaries. [source] Regulated Competition in Social Health Insurance: A Three-Country ComparisonINTERNATIONAL SOCIAL SECURITY REVIEW, Issue 3 2006Stefan Gre The objectives guiding healthcare reforms in Germany, Switzerland and the Netherlands were to increase efficiency and consumer satisfaction in the provision of healthcare services. This paper reviews the incentives for and instruments of competition for consumers, sickness funds and healthcare providers in these three countries which are necessary to fulfil these objectives. Incentives for risk selection of sickness funds are high in Germany and Switzerland while they are low in the Netherlands. Incentives for consumer choice are also highest in Germany and Switzerland. In all three countries sickness funds have only a few instruments of competition. The effects of competition have been disappointing so far. The objectives of competitive healthcare reforms can be achieved only if incentives for and instruments of competition consistently support competitive behaviour on the part of market actors. [source] | ||||||||||