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How does Risk Selection Respond to Risk Adjustment? Evidence from the Medicare Advantage Program

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  • Jason Brown
  • Mark Duggan
  • Ilyana Kuziemko
  • William Woolston

Abstract

Governments often contract with private firms to provide public services such as health care and education. To decrease firms' incentives to selectively enroll low-cost individuals, governments frequently "risk-adjust" payments to firms based on enrollees' characteristics. We model how risk adjustment affects selection and differential payments---the government's payments to a firm for covering an individual minus the counterfactual cost had the government directly covered her. We show that firms reduce selection along dimensions included in the risk-adjustment formula, while increasing selection along excluded dimensions. These responses can actually increase differential payments relative to pre-risk-adjustment levels and thus risk adjustment can raise the total cost to the government of providing the public service. We confirm both selection predictions using individual-level data from Medicare, which in 2004 began risk-adjusting payments to private Medicare Advantage plans. We find that differential payments actually rise after risk adjustment and estimate that they totaled $30 billion in 2006, or nearly eight percent of total Medicare spending.

Suggested Citation

  • Jason Brown & Mark Duggan & Ilyana Kuziemko & William Woolston, 2011. "How does Risk Selection Respond to Risk Adjustment? Evidence from the Medicare Advantage Program," NBER Working Papers 16977, National Bureau of Economic Research, Inc.
  • Handle: RePEc:nbr:nberwo:16977
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    References listed on IDEAS

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    1. 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.
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    Citations

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    Cited by:

    1. Laurence Seidman, 2014. "Medicare For All: A Public Finance Analysis," Working Papers 14-02, University of Delaware, Department of Economics.
    2. Mark Stabile & Sarah Thomson, 2014. "The Changing Role of Government in Financing Health Care: An International Perspective," Journal of Economic Literature, American Economic Association, vol. 52(2), pages 480-518, June.
    3. Newhouse, Joseph P. & McWilliams, J. Michael & Price, Mary & Huang, Jie & Fireman, Bruce & Hsu, John, 2013. "Do Medicare Advantage plans select enrollees in higher margin clinical categories?," Journal of Health Economics, Elsevier, vol. 32(6), pages 1278-1288.
    4. Baicker, Katherine & Chernew, Michael E. & Robbins, Jacob A., 2013. "The spillover effects of Medicare managed care: Medicare Advantage and hospital utilization," Journal of Health Economics, Elsevier, vol. 32(6), pages 1289-1300.
    5. Laurence Seidman, 2013. "Medicare for All," Challenge, Taylor & Francis Journals, vol. 56(1), pages 88-115.
    6. Raj Chetty & Amy Finkelstein, 2012. "Social Insurance: Connecting Theory to Data," NBER Working Papers 18433, National Bureau of Economic Research, Inc.
    7. Fang, H., 2016. "Insurance Markets for the Elderly," Handbook of the Economics of Population Aging, in: Piggott, John & Woodland, Alan (ed.),Handbook of the Economics of Population Aging, edition 1, volume 1, chapter 0, pages 237-309, Elsevier.
    8. Paulina Restrepo-Echavarria & Antonella Tutino & Anton Cheremukhin, 2013. "A Theory of Targeted Search," 2013 Meeting Papers 664, Society for Economic Dynamics.
    9. Katherine Baicker & Jacob A. Robbins, 2015. "Medicare Payments and System-Level Health-Care Use: The Spillover Effects of Medicare Managed Care," American Journal of Health Economics, MIT Press, vol. 1(4), pages 399-431, Fall.
    10. Hall Anne E, 2011. "Measuring the Return on Government Spending on the Medicare Managed Care Program," The B.E. Journal of Economic Analysis & Policy, De Gruyter, vol. 11(2), pages 1-43, January.
    11. repec:hrv:faseco:34330197 is not listed on IDEAS
    12. Pieter Bakx & Frederik Schut & Eddy Doorslaer, 2015. "Can universal access and competition in long-term care insurance be combined?," International Journal of Health Economics and Management, Springer, vol. 15(2), pages 185-213, June.
    13. Lorenz, Normann, 2015. "The interaction of direct and indirect risk selection," Journal of Health Economics, Elsevier, vol. 42(C), pages 81-89.
    14. Buchmueller, Thomas C. & Fiebig, Denzil G. & Jones, Glenn & Savage, Elizabeth, 2013. "Preference heterogeneity and selection in private health insurance: The case of Australia," Journal of Health Economics, Elsevier, vol. 32(5), pages 757-767.

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    More about this item

    JEL classification:

    • H51 - Public Economics - - National Government Expenditures and Related Policies - - - Government Expenditures and Health
    • I11 - Health, Education, and Welfare - - Health - - - Analysis of Health Care Markets
    • I18 - Health, Education, and Welfare - - Health - - - Government Policy; Regulation; Public Health

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