Diagnoses-Based Risk Adjusted Capitation Payments for Improving Solidarity and Efficiency in the Chilean Health Care System [Elektronische Ressource] : Evaluation and Comparison with a Demographic Model / Camilo Cid Pedraza. Gutachter: Reinhold Schnabel. Betreuer: Jürgen Wasem

Ccid

Informations

• Publié par: universitat_duisburg-essen
• Publié le: 01 janvier 2011
• Nombre de lectures: 15
• Langue: English
• Poids de l'ouvrage: 3 Mo

Extrait

Diagnoses-Based Risk Adjusted Capitation Payments for Improving Solidarity and
Efficiency in the Chilean Health Care System: Evaluation and Comparison with a
Demographic Model


Dissertation

zur Erlangung des akademischen Grades eines
Doktors der Wirtschaftswissenschaften

(Dr. rer. pol.)

durch die Fakultät für Wirtschaftswissenschaften der

Universität Duisburg-Essen
Campus Essen


















vorgelegt von
Name: Camilo Cid Pedraza
aus: Valparaíso, Chile
Essen 2011
1



Tag der mündlichen Prüfung: 12.01.2011
Erstgutachter: Prof. Dr. Jürgen Wasem
Zweitgutachter: Prof. Dr. Reinhold Schnabel


Contents
SUMMARY ................................................................................................................... IV
LIST OF TABLES ........... X
LIST OF FIGURES ........ XII
ACRONYMS ............................................................................................................... XIII
I. INTRODUCTION ...... 1
1. The Chilean health care system ................................... 1
2. The health care reform .................................................................................. 4
2.1. Values and principles that motivated the reform ................ 4
2.2. The reform proposals considered in this work ..................................................... 5
3. An overview and thesis’ structure ................................................................................................ 9
II. THEORETICAL FRAMEWORK OF RISK ADJUSTMENT AND THE CHILEAN CASE ............. 13
1. Theoretical framework ................................................................................................................ 13
2. Risk adjustment models .............. 17
2.1. Financial flows organization: “external” and “internal” systems ...................... 18
2.2. Community premium in the risk adjustment mechanism ................................................................ 20
2.2.1 Income-related contribution .................................... 20
2.2.2 Flat rate community premium 21
2.3. Premium subsidy and risk adjusters .. 22
2.3.1 Demographic risk adjustment ................................................................. 22
2.3.2 Socioeconomic risk adjusters ................................... 23
2.3.3 Health status risk adjustment . 23
2.3.4 Normative and empirical variables ......................................................... 25
2.3.5 Ex-ante and ex-post risk adjustment models .......................................... 28
2.3.6 Cell models and regression models .......................................................... 29
2.3.7 Conventional and optimal risk adjustment ............................................ 31
2.4. Acceptable costs ................................................................... 34
2.5. Benefits package .................................. 34
2.6. Extreme or catastrophic costs ............. 35
III. MAIN PROBLEMS IN THE CHILEAN HEALTH CARE SYSTEM ....................................... 40
1. Inequity in the financing and expenditures ............................................... 40
1.1. Health national accounts .................................................... 40
1.2. Financial implications of the regulatory framework of ISAPREs ..................... 42
1.3. Expenditures per capita ...................... 43
1.4. Financial situation of ISAPREs and FONASA .................................................................................. 47
1.4.1 Income and expenditures ......................................... 48
1.5. Out-of-pocket expenditures in Chile: Inequity and impact on households ....... 50
1.6. Segmented health system ................... 57
2. Inefficiency: Risk selection .......................................................................................................... 61
2.1. Empirical evidence of risk selection in Chile ..................... 63
2.1.1 Risk selection and cost concentration ...................... 67
2.1.2 Consumer mobility and risk selection 72
IV. DEMOGRAPHIC RISK ADJUSTMENT MODELS FOR CHILE ........................................... 76
i
1. Private sector risk adjustment: Solidarity Compensation Fund between
ISAPREs. ...................................................................................................................................... 76
1.1. Age groups ........... 77
1.2. Estimating compensations .................. 79
1.2.1 The approved risk adjustment model ...................................................... 79
1.2.2 Sources of information ............................................................................. 80
1.2.3 Method and calculations of Inter-ISAPRE risk adjustment .................. 82
1.2.4 Risk factors or standardized expected costs ............................................ 87
1.2.5 Summary of results .................. 95
1.2.6 Comments about this risk adjustment model ......................................... 97
2. Demographic risk adjustment for public (FONASA) and private (ISAPREs)
health systems ........................................................................................... 100
2.1. Method for demographic risk adjustment model including FONASA ............................................ 100
2.1.1 Methodology in previous studies of relative costs by sex and age groups 100
2.1.2 Solidarity contributions to the Fund ..................................................... 101
2.1.3 Standardized expected costs and premium subsidies ........................................................... 102
2.2. Standardized expected costs ............................................. 102
2.2.1 Premium subsidies ................. 103
2.2.2 Distribution of the total amount of premium subsidies ....................... 103
V. DATA AND METHODS FOR DIAGNOSES-BASED RISK ADJUSTMENT ........................... 106
1. Data for diagnoses-based risk adjustment in Chile ................................................................ 106
1.1. Year 2001 discharges dataset and GES benefits package ............................... 106
1.2. Method for cost estimation in the discharges dataset ..... 108
1.2.1 Method for cost estimations in all diagnoses except GES diagnoses ... 108
1.2.2 Method for cost estimation for GES diagnoses ..................................................................... 110
1.3. Beneficiary populations ..................................................................................................................... 113
1.4. Getting data for diagnoses-based risk adjustment .......... 114
1.4.1 The Valid ID Data Subset ...................................... 114
1.4.2 Cost comparison ..................... 117
2. Risk adjustment methods and morbidity ................................................................................. 127
2.1. Advantages and disadvantages of inpatient information ................................ 130
2.2. The PIPDCG model for Medicare and DxCG/HCC Models ............................. 131
3. Diagnostic groups in DxCG/HCC models for Chile ................................. 134
3.1. Method of estimation for DxCG model in Chile ............................................... 138
3.2. Measures of predictive performance ................................. 141
VI. RESULTS AND ANALYSIS OF PREDICTIVE ACCURACY OF THE DIAGNOSES-BASED
MODEL FOR CHILE .......................................................................................... 143
1. Descriptive statistics ................................................. 143
2. Analysis by diagnosis ................ 146
3. Predictive performance ............. 148
3.1. Individual level predictive performance ........................................................................................... 148
3.2. Group level predictive performance .................................. 149
3.3. Variables’ statistical performance .... 151
3.4. Redistribution comparison ................................................................................................................ 156
VII. CONCLUSION AND DISCUSSION ........ 159
REFERENCES ............................................................................................................ 165
ii
LAWS AND NORMATIVE DOCUMENTATION ................................................................... 173
APPENDIX: COMPLEMENTARY INFORMATION ABOUT THE CHILEAN SOCIAL HEALTH
INSURANCE SYSTEM ....................................................... 175
iii SUMMARY
In Chile health insurance is mandatory for formal sector workers, so that they can be insured
against the risks of health care costs. Health coverage is provided by both public (National Health
Fund –FONASA) and private sector insurers (Previsional Health Care Institutions – ISAPREs).
Workers pay a mandatory contribution of seven percent of their income to ensure coverage with a
maximum mandatory monthly contribution of US$ 152. If individuals choose the public sector,
their coverage is pre-established, comprehensive and does not vary in time. If instead they choose