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Using risk assessment to evaluate adverse selection under capitated contracts.

J B Trauner¹, C Thilgen

¹PM Squared, Inc., San Francisco, CA, USA.

The Journal of Ambulatory Care Management

|December 8, 1997

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Provider organizations often misinterpret performance data due to enrollee mix variations. This study explores adverse selection, offering risk adjustment methods for fairer health plan contract negotiations.

Area of Science:

Health Economics
Actuarial Science
Healthcare Management

Background:

Provider organizations commonly use health plan data for performance benchmarking.
Existing benchmarks like capitation rates and per member per month costs can be misleading.
Differences in enrollee mix and contracting terms across organizations create performance disparities.

Purpose of the Study:

To identify the limitations of health plan contract provisions in mitigating adverse selection.
To explore actuarial and statistical data sources for evaluating adverse selection.
To present risk adjustment approaches for quantifying adverse selection in contract negotiations.

Main Methods:

Review of health plan contract provisions and their impact on adverse selection.

Related Experiment Videos

Analysis of actuarial and statistical data sources relevant to adverse selection.

Description of population-based risk adjustment methodologies.

Main Results:

Health plan data can be misleading due to variations in enrollee populations.
Adverse selection poses a significant challenge in provider-payer negotiations.
Risk adjustment models offer a quantitative approach to address selection bias.

Conclusions:

Relying solely on market-based data for performance benchmarking is inadequate.
Understanding and quantifying adverse selection is crucial for equitable health plan contracts.
Implementing risk adjustment strategies can lead to more accurate performance evaluations and fairer negotiations.