- Title
- Using prior utilization to determine payments for Medicare enrollees in health maintenance organizations.
- First Author
- Beebe, James C
- Date of Pub
- 1985 Spring
- Pages
- 27-38
- Volume
- 6
- Issue
- 3
- Other Authors
- Eggers, Paul W; Lubitz, James
- Abstract
- The Tax Equity and Fiscal Responsibility Act of 1982 is expected to make it more attractive for health maintenance organizations (HMO's) to participate in the Medicare program on an at-risk basis. Currently, payments to at-risk HMO's are based on a formula known as the adjusted average per capita cost (AAPCC). This article describes the current formula and discusses a modification, based on prior use of Medicare services, that endeavors to more accurately predict risk. Using statistical simulations, formulas incorporating prior use performed better for some types of biased groups than a formula similar to the one currently employed. Major concerns involve the ability to "game the system." The prior-use model is now being tested in an HMO demonstration. This article also outlines the limitations of a prior-use model and areas for future research.
- Abstract Continued
- N/A
- MeSH
- Forecasting/methods : Health Maintenance Organizations/economics : Medicare/utilization : Models, Theoretical : Rate Setting and Review/methods : Regression Analysis : Reimbursement Mechanisms : Tax Equity and Fiscal Responsibility Act : United States
- NTIS Number
- PB85-226165
