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Improving risk equalization using information on physiotherapy diagnoses

BACKGROUND: Worldwide, risk-equalization (RE) models in competitive health insurance markets have evolved from simple demographic models to sophisticated models containing diagnosis and pharmacy-based indicators of health. However, these models still have important imperfections; adding information...

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Autores principales: Eijkenaar, Frank, van Vliet, René C. J. A.
Formato: Online Artículo Texto
Lenguaje:English
Publicado: Springer Berlin Heidelberg 2017
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5813071/
https://www.ncbi.nlm.nih.gov/pubmed/28185028
http://dx.doi.org/10.1007/s10198-017-0874-x
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author Eijkenaar, Frank
van Vliet, René C. J. A.
author_facet Eijkenaar, Frank
van Vliet, René C. J. A.
author_sort Eijkenaar, Frank
collection PubMed
description BACKGROUND: Worldwide, risk-equalization (RE) models in competitive health insurance markets have evolved from simple demographic models to sophisticated models containing diagnosis and pharmacy-based indicators of health. However, these models still have important imperfections; adding information on (diagnoses of) physiotherapy treatment may further improve RE-models. Therefore, a new risk-adjuster based on physiotherapy costs in the prior year was introduced in the Dutch RE-model of 2016. METHODS: Physiotherapy claims-data (2012) and administrative data on costs and risk-characteristics (2013) for 94% of the Dutch population (N = 15.8 million) are used to evaluate the current risk-adjuster based on physiotherapy costs and to assess the effects of replacing it by different modalities of a risk-adjuster based on physiotherapy diagnoses. Of the 89 diagnoses in the claims-data, 62 are dropped because they relate to temporary health problems. The 27 retained diagnoses are added to the Dutch model in 4 modalities: 27 separate risk-classes, 9 diagnosis-clusters based on main pathology category, 4 diagnosis-clusters based on residual costs, and the 4 clusters of modality 3 interacted with age. RESULTS: Although the cost-based risk-adjuster improves the model’s predictive power and removes the average undercompensation (€919) for enrollees with physiotherapy costs in the prior year, it is outperformed by all 4 diagnosis-based modalities. Of these modalities, modality 3 is preferred based on its simplicity and comparable predictive power. CONCLUSIONS: Adding information on physiotherapy can further improve the performance of sophisticated RE-models. Regarding the Dutch model, a risk-adjuster containing 4 risk-classes for clustered diagnoses based on residual costs is the preferred modality. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (doi:10.1007/s10198-017-0874-x) contains supplementary material, which is available to authorized users.
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spelling pubmed-58130712018-02-26 Improving risk equalization using information on physiotherapy diagnoses Eijkenaar, Frank van Vliet, René C. J. A. Eur J Health Econ Original Paper BACKGROUND: Worldwide, risk-equalization (RE) models in competitive health insurance markets have evolved from simple demographic models to sophisticated models containing diagnosis and pharmacy-based indicators of health. However, these models still have important imperfections; adding information on (diagnoses of) physiotherapy treatment may further improve RE-models. Therefore, a new risk-adjuster based on physiotherapy costs in the prior year was introduced in the Dutch RE-model of 2016. METHODS: Physiotherapy claims-data (2012) and administrative data on costs and risk-characteristics (2013) for 94% of the Dutch population (N = 15.8 million) are used to evaluate the current risk-adjuster based on physiotherapy costs and to assess the effects of replacing it by different modalities of a risk-adjuster based on physiotherapy diagnoses. Of the 89 diagnoses in the claims-data, 62 are dropped because they relate to temporary health problems. The 27 retained diagnoses are added to the Dutch model in 4 modalities: 27 separate risk-classes, 9 diagnosis-clusters based on main pathology category, 4 diagnosis-clusters based on residual costs, and the 4 clusters of modality 3 interacted with age. RESULTS: Although the cost-based risk-adjuster improves the model’s predictive power and removes the average undercompensation (€919) for enrollees with physiotherapy costs in the prior year, it is outperformed by all 4 diagnosis-based modalities. Of these modalities, modality 3 is preferred based on its simplicity and comparable predictive power. CONCLUSIONS: Adding information on physiotherapy can further improve the performance of sophisticated RE-models. Regarding the Dutch model, a risk-adjuster containing 4 risk-classes for clustered diagnoses based on residual costs is the preferred modality. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (doi:10.1007/s10198-017-0874-x) contains supplementary material, which is available to authorized users. Springer Berlin Heidelberg 2017-02-09 2018 /pmc/articles/PMC5813071/ /pubmed/28185028 http://dx.doi.org/10.1007/s10198-017-0874-x Text en © The Author(s) 2017 Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.
spellingShingle Original Paper
Eijkenaar, Frank
van Vliet, René C. J. A.
Improving risk equalization using information on physiotherapy diagnoses
title Improving risk equalization using information on physiotherapy diagnoses
title_full Improving risk equalization using information on physiotherapy diagnoses
title_fullStr Improving risk equalization using information on physiotherapy diagnoses
title_full_unstemmed Improving risk equalization using information on physiotherapy diagnoses
title_short Improving risk equalization using information on physiotherapy diagnoses
title_sort improving risk equalization using information on physiotherapy diagnoses
topic Original Paper
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5813071/
https://www.ncbi.nlm.nih.gov/pubmed/28185028
http://dx.doi.org/10.1007/s10198-017-0874-x
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