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CEBS-GBA 2, Module 3 Exam (Controlling Risk Factors)
CEBS-GBA 2, Module 3 Exam (Controlling Risk Factors)
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CEBS-GBA 2, Module 3 Exam (Controlling RiskFactors)
Value of predicting health services' utilization - -three factors typically used
to predict the use of
health services are an:
-individual's demographic characteristics
-health status
-prior utilization
Demographic characteristics perform surprisingly poorly. Prior utilization is
the best predictor, and various measures of health status fall somewhere
in between.
-Three key points that emerge from the process of risk adjustment for the
purpose of setting health insurance premiums - -1.) Even the most complete
set of measures explains only a small proportion of the variance
in an individual's use of health services. If utilization was wholly predictable
based on readily available measures, there would be no role for insurance.
2.) Some sets of measures are better predictors of health services use than
are others. However, dismissing the predictive abilities of these other
measures would be a mistake. The ability to predict even a couple of
percentage points better than others can yield a substantial competitive
advantage, provided it can be done at relatively low cost.
3.) statistical modeling has its limits. The presumption in risk adjustment is
that
statistical methods will eliminate the least costly efforts to attract low
utilizers and
avoid high utilizers. This may be so. But it may be that other approaches
implicitly
contain more or better information on the future use of health services than
those
contained in the statistical models.
-Medicare Adjusted Average Per Capita Cost (AAPCC) - -reimburse Medicare
Advantage
(MA) plans. (Medicare Advantage plans are types of Medicare health plans
offered by private companies (e.g., HMOs) that contract with Medicare to
provide
beneficiaries with all of their Medicare Part A and Part B benefits. All plans,
except for private fee-for-service plans, must also offer an option that
includes the
Medicare Part D drug benefit.) Medicare started by essentially paying
participating HMOs a fixed dollar amount for
each beneficiary who chose to join the plan. Because HMOs were thought to
be
, more efficient than traditional care providers, the legislation prescribed that
the
capitated rate should be 95% of the average Medicare Part A (i.e., hospital)
plus Part
B (i.e., ambulatory) expenditures per beneficiary, adjusted by various factors
including age, gender and Medicaid status. This is analogous to a simple
manual
rating system. This system appears to have provided the private plans
(primarily
HMOs) with substantial incentives for enrolling people with lower-than-
average
expected claims and avoiding people with above-average claims.
-objective of the influential RAND Health Insurance Experiment study - -to
examine the effects
of insurance copayment arrangements on expenditures with the hope of
improving
the AAPCC model used by Medicare. The study
also recorded demographic and health status characteristics of the
participants at
baseline. In fact, much of the current knowledge about the measurement of
health
status has its genesis with this study. Thus, the study has been used to
examine
alternative predictive models of utilization based on demographic
characteristics,
subjective and physiological measures of health status, and prior utilization.
-Measures of potential risk factors used in the RAND Health Insurance
Experiment - -(a) Demographic measures (AAPCC variables)
• Age
• Gender
• Location (indicator for each of the six sites in the study)
• Eligible for welfare at baseline
(b) Subjective health status measures
• Physical health (based on self-reported measures of role and personal
limitations)
• Mental health (based on self-reported measures of psychological distress,
behavioral and emotional control, and positive affect)
• General health (based on self-reported measures of general well-being)
• Disease count (based on the presence of any of 32 chronic conditions)
(c) Physiological health status measures
• Dichotomous measures
• Continuous measures (based on 27 measures, including such items as
elevated cholesterol, hypertension, diabetes, electrocardiogram
abnormalities,
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