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Risk Selection, Risk Adjustment and Choice: Concepts and Lessons from the Americas

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  • Randall P. Ellis

    (Departement of Economics, Boston University, 270 Bay State Road, Boston, MA 02215, USA)

  • Juan Gabriel Fernandez

    (Ministry of Fiscal Property, Av. Bdo O'Higgins 720, Santiago, Chile)

Abstract

Interest has grown worldwide in risk adjustment and risk sharing due to their potential to contain costs, improve fairness, and reduce selection problems in health care markets. Significant steps have been made in the empirical development of risk adjustment models, and in the theoretical foundations of risk adjustment and risk sharing. This literature has often modeled the effects of risk adjustment without highlighting the institutional setting, regulations, and diverse selection problems that risk adjustment is intended to fix. Perhaps because of this, the existing literature and their recommendations for optimal risk adjustment or optimal payment systems are sometimes confusing. In this paper, we present a unified way of thinking about the organizational structure of health care systems, which enables us to focus on two key dimensions of markets that have received less attention: what choices are available that may lead to selection problems, and what financial or regulatory tools other than risk adjustment are used to influence these choices. We specifically examine the health care systems, choices, and problems in four countries: the US, Canada, Chile, and Colombia, and examine the relationship between selection-related efficiency and fairness problems and the choices that are allowed in each country, and discuss recent regulatory reforms that affect choices and selection problems. In this sample, countries and insurance programs with more choices have more selection problems.

Suggested Citation

  • Randall P. Ellis & Juan Gabriel Fernandez, 2013. "Risk Selection, Risk Adjustment and Choice: Concepts and Lessons from the Americas," IJERPH, MDPI, vol. 10(11), pages 1-34, October.
  • Handle: RePEc:gam:jijerp:v:10:y:2013:i:11:p:5299-5332:d:29862
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    1. Thomas Buchmueller & John Dinardo, 2002. "Did Community Rating Induce an Adverse Selection Death Spiral? Evidence from New York, Pennsylvania, and Connecticut," American Economic Review, American Economic Association, vol. 92(1), pages 280-294, March.
    2. Shen, Yujing & Ellis, Randall P., 2002. "Cost-minimizing risk adjustment," Journal of Health Economics, Elsevier, vol. 21(3), pages 515-530, May.
    3. Antonio Trujillo & Jorge Portillo & John Vernon, 2005. "The Impact of Subsidized Health Insurance for the Poor: Evaluating the Colombian Experience Using Propensity Score Matching," International Journal of Health Economics and Management, Springer, vol. 5(3), pages 211-239, September.
    4. Dranove, David & Spier, Kathryn E. & Baker, Laurence, 2000. "'Competition' among employers offering health insurance," Journal of Health Economics, Elsevier, vol. 19(1), pages 121-140, January.
    5. Thomas G. McGuire & Jacob Glazer, 2000. "Optimal Risk Adjustment in Markets with Adverse Selection: An Application to Managed Care," American Economic Review, American Economic Association, vol. 90(4), pages 1055-1071, September.
    6. Steven D. Pizer & Austin B. Frakt & Roger Feldman, 2008. "Predicting risk selection following major changes in medicare," Health Economics, John Wiley & Sons, Ltd., vol. 17(4), pages 453-468, April.
    7. Pauly, Mark V. & Herring, Bradley J., 2000. "An efficient employer strategy for dealing with adverse selection in multiple-plan offerings: an MSA example," Journal of Health Economics, Elsevier, vol. 19(4), pages 513-528, July.
    8. Frank, Richard G. & Glazer, Jacob & McGuire, Thomas G., 2000. "Measuring adverse selection in managed health care," Journal of Health Economics, Elsevier, vol. 19(6), pages 829-854, November.
    9. Cutler, David M. & Zeckhauser, Richard J., 2000. "The anatomy of health insurance," Handbook of Health Economics, in: A. J. Culyer & J. P. Newhouse (ed.), Handbook of Health Economics, edition 1, volume 1, chapter 11, pages 563-643, Elsevier.
    10. Fernando Ruiz & Liliana Amaya & Stella Venegas, 2007. "Progressive segmented health insurance: Colombian health reform and access to health services," Health Economics, John Wiley & Sons, Ltd., vol. 16(1), pages 3-18, January.
    11. Gary Biglaiser & Ching-to Albert Ma, 2007. "Moonlighting: public service and private practice," RAND Journal of Economics, RAND Corporation, vol. 38(4), pages 1113-1133, December.
    12. Marchand, Maurice & Sato, Motohiro & Schokkaert, Erik, 2003. "Prior Health Expenditures and Risk Sharing with Insurers Competing on Quality," RAND Journal of Economics, The RAND Corporation, vol. 34(4), pages 647-669, Winter.
    13. Randall P. Ellis & Ching‐to Albert Ma, 2011. "Health insurance, cost expectations, and adverse job turnover," Health Economics, John Wiley & Sons, Ltd., vol. 20(1), pages 27-44, January.
    14. Baker, Laurence C., 1997. "The effect of HMOs on fee-for-service health care expenditures: Evidence from Medicare," Journal of Health Economics, Elsevier, vol. 16(4), pages 453-481, August.
    15. van de Ven, Wynand P. M. M. & Beck, Konstantin & Buchner, Florian & Chernichovsky, Dov & Gardiol, Lucien & Holly, Alberto & Lamers, Leida M. & Schokkaert, Erik & Shmueli, Amir & Spycher, Stephan & Van, 2003. "Risk adjustment and risk selection on the sickness fund insurance market in five European countries," Health Policy, Elsevier, vol. 65(1), pages 75-98, July.
    16. David Dranove & Daniel Kessler & Mark McClellan & Mark Satterthwaite, 2003. "Is More Information Better? The Effects of "Report Cards" on Health Care Providers," Journal of Political Economy, University of Chicago Press, vol. 111(3), pages 555-588, June.
    17. David M. Cutler & Sarah J. Reber, 1998. "Paying for Health Insurance: The Trade-Off between Competition and Adverse Selection," The Quarterly Journal of Economics, President and Fellows of Harvard College, vol. 113(2), pages 433-466.
    18. Humberto Mora Alvarez, 2000. "Riesgo del aseguramiento en el sistema de salud en Colombia en 1997," Documentos de Investigación 3474, Cepal Naciones Unidas.
    19. Gruber, Jonathan, 2000. "Health insurance and the labor market," Handbook of Health Economics, in: A. J. Culyer & J. P. Newhouse (ed.), Handbook of Health Economics, edition 1, volume 1, chapter 12, pages 645-706, Elsevier.
    20. Devlin, Rose Anne & Sarma, Sisira, 2008. "Do physician remuneration schemes matter? The case of Canadian family physicians," Journal of Health Economics, Elsevier, vol. 27(5), pages 1168-1181, September.
    21. Cao, Zhun & McGuire, Thomas G., 2003. "Service-level selection by HMOs in Medicare," Journal of Health Economics, Elsevier, vol. 22(6), pages 915-931, November.
    22. McClellan, Mark & Newhouse, Joseph P., 1997. "The marginal cost-effectiveness of medical technology: A panel instrumental-variables approach," Journal of Econometrics, Elsevier, vol. 77(1), pages 39-64, March.
    23. Yujing Shen & Randall P. Ellis, 2002. "How profitable is risk selection? A comparison of four risk adjustment models," Health Economics, John Wiley & Sons, Ltd., vol. 11(2), pages 165-174, March.
    24. Ellis, Randall P. & McGuire, Thomas G., 2007. "Predictability and predictiveness in health care spending," Journal of Health Economics, Elsevier, vol. 26(1), pages 25-48, January.
    25. Glazer, Jacob & McGuire, Thomas G., 2002. "Setting health plan premiums to ensure efficient quality in health care: minimum variance optimal risk adjustment," Journal of Public Economics, Elsevier, vol. 84(2), pages 153-173, May.
    26. Crocker, Keith J & Moran, John R, 2003. "Contracting with Limited Commitment: Evidence from Employment-Based Health Insurance Contracts," RAND Journal of Economics, The RAND Corporation, vol. 34(4), pages 694-718, Winter.
    27. Matthew S. Dey & Christopher J. Flinn, 2005. "An Equilibrium Model of Health Insurance Provision and Wage Determination," Econometrica, Econometric Society, vol. 73(2), pages 571-627, March.
    28. Amitabh Chandra & Jonathan Gruber & Robin McKnight, 2010. "Patient Cost-Sharing and Hospitalization Offsets in the Elderly," American Economic Review, American Economic Association, vol. 100(1), pages 193-213, March.
    29. Van de ven, Wynand P.M.M. & Ellis, Randall P., 2000. "Risk adjustment in competitive health plan markets," Handbook of Health Economics, in: A. J. Culyer & J. P. Newhouse (ed.), Handbook of Health Economics, edition 1, volume 1, chapter 14, pages 755-845, Elsevier.
    30. Alejandro Gaviria & Carlos Medina & Carolina Mejia, 2006. "Assessing Health Reform in Colombia: From Theory to Practice," Economía Journal, The Latin American and Caribbean Economic Association - LACEA, vol. 0(Fall 2006), pages 29-72, August.
    31. Sapelli, Claudio & Vial, Bernardita, 2003. "Self-selection and moral hazard in Chilean health insurance," Journal of Health Economics, Elsevier, vol. 22(3), pages 459-476, May.
    32. Glazer, Jacob & McGuire, Thomas G. & Cao, Zhun & Zaslavsky, Alan, 2008. "Using global ratings of health plans to improve the quality of health care," Journal of Health Economics, Elsevier, vol. 27(5), pages 1182-1195, September.
    33. Michael Rothschild & Joseph Stiglitz, 1976. "Equilibrium in Competitive Insurance Markets: An Essay on the Economics of Imperfect Information," The Quarterly Journal of Economics, President and Fellows of Harvard College, vol. 90(4), pages 629-649.
    34. Mora Alvarez, Humberto, 2000. "Riesgo del aseguramiento en el sistema de salud en Colombia en 1997," Financiamiento para el Desarrollo 5303, Naciones Unidas Comisión Económica para América Latina y el Caribe (CEPAL).
    35. Randall P. Ellis & Shenyi Jiang & Tzu-Chun Kuo, 2013. "Does service-level spending show evidence of selection across health plan types?," Applied Economics, Taylor & Francis Journals, vol. 45(13), pages 1701-1712, May.
    36. Joseph P. Newhouse, 1996. "Reimbursing Health Plans and Health Providers: Efficiency in Production versus Selection," Journal of Economic Literature, American Economic Association, vol. 34(3), pages 1236-1263, September.
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    2. Elodie Adida & Hamed Mamani & Shima Nassiri, 2017. "Bundled Payment vs. Fee-for-Service: Impact of Payment Scheme on Performance," Management Science, INFORMS, vol. 63(5), pages 1606-1624, May.
    3. Naoki Aizawa & You Suk Kim, 2015. "Advertising and Risk Selection in Health Insurance Markets," Finance and Economics Discussion Series 2015-101, Board of Governors of the Federal Reserve System (U.S.).
    4. Marco Cornejo-Ovalle & Guillermo Paraje & Felipe Vásquez-Lavín & Glòria Pérez & Laia Palència & Carme Borrell, 2015. "Changes in Socioeconomic Inequalities in the Use of Dental Care Following Major Healthcare Reform in Chile, 2004–2009," IJERPH, MDPI, vol. 12(3), pages 1-14, March.

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