aca风险调整——一个有改进空间的成功案例

© Oliver WymanBACKGROUNDThe authors of the Affordable Care Act (ACA) understood that an effective risk adjustmentsystem would be essential to the success of a reformed individual health insurance market,one in which issuers would be prohibited from denying coverage or charging higherpremiums to those with pre-existing conditions or expected high claims. Absent an effectiverisk adjustment system, issuers would have had strong financial incentives to designproducts and networks that would appeal to healthy consumers, and that would not attractconsumers with high-cost health conditions or claims. An effective risk adjustment systemwould transfer funds from those issuers with low-cost claimants to those issuers with high-cost claimants, so that issuers would be competing based on the cost and quality of theinsurance policies they offer, and not on their ability to avoid high-claims individuals.EXECUTIVE SUMMARYIn this report we use publicly available data to show the following:•The current risk adjustment system does move funds from issuers with low-costclaimants to issuers with high-cost claimants, as intended•The risk adjustment system does not appear to disadvantage small issuers or issuers thatare new to the market•The current risk adjustment system does not disadvantage issuers that are new to astate•The risk adjustment system underpays for high-costclaimants•It is likely that some issuers’ financial difficulties were the result of underpricing, and notriskadjustment•Making changes to the risk adjustment system to favor new or small issuers wouldbe unworkable and would cause existing issuers to reconsider their participation inthe market1CorletteS,BlumbergL,LuciaK,TheACA’sEffectontheIndividualInsuranceMarket,HealthAffairs,Vol.39,No3.Availablefrom:Healthaffairs 1 © Oliver WymanIS THE RISK ADJUSTMENT SYSTEM MOVING FUNDS AMONGISSUERS AS INTENDED?As discussed above, for the risk adjustment system to be effective, we would expect issuerswith members with high claims to be net recipients of risk adjustment transfers, and issuerswith members with low claims to be payers into the risk adjustment system.2To test this, we compared each issuer’s risk adjustment transfer amount to its average claimlevel relative to other issuers in the state. We then fit a line to the data to see how stronglyrisk adjustment transfers correlate with claim levels. We show the results in Exhibit1, below.We think the results in Exhibit1 show that the risk adjustment system is moving fundsfrom those issuers with relatively low claims to those issuers with relatively high claims,as intended.In Exhibit1, on the x-axis, we show at the issuing entity level, how an issuer’s incurred claimsper member per month (PMPM) differ from the statewide average. Along the y-axis, we showthe issuer’s risk adjusted payment or receipt PMPM. We use the convention that negativerisk adjustment payments are receipts offsetting claims. If the risk adjustment programwere working as intended, we would expect to see risk adjustment receipts PMPM increase,that is, become more negative, as the distance from the state-wide average claims increases.If this were true, we would see a downward sloping trend line, which is what we see inExhibit1.Exhibit 1: Risk adjustment payments (receipts) versus distance from statewide averageclaims PMPM ($)RA Payment (Receipt) PMPM−600−400−2000200400−400−300−200−1000100200300400500Distance from statewide averageBest fit line shows thatRA receipts increase asclaims increaseSource:2021MLRRebateReportingData2Wenotethattherearereasonsbeyondriskthatanissuermayhavehighorlowclaimsincludingdifferencesinnetworkdiscounts,geographicfootprint,differencesintheirenrollees’demographics,andthedistributionofmembersamongmetaltiers.Availabledatadoesnotallowustocontrolforthesefactors. © Oliver WymanAgain, the strong relationship we see between an issuer’s incurred claims relative to thestatewide average and the results of the risk adjustment system, shows that the system ismoving funds from those issuers with relatively low claims to those issuers with relativelyhigh claims, as intended.ARE SMALL ISSUERS AT A DISADVANTAGE UNDER THE RISKADJUSTMENT SYSTEM?Our analysis shows that smaller issuers are more likely to receive risk adjustment paymentsand are not disadvantaged by the risk adjustment program. To illustrate the relationshipbetween an issuer’s size and its risk adjustment outcomes, we provide a graphical view ofthe relationship in Exhibit2 where the parent company’s member months are on the x-axisand that company’s risk adjustment payment or receipt PMPM is along the y-axis.3Wefind that 65 percent of small issuers (those with fewer than 5,000 enrollees) received riskadjustment payments in2021.Next, we fit a line to the data to see if larger issuers were more or less likely to receiverisk adjustment payments. If large issuers were more likely to be receivers under the riskadjustment system, we would expect the line to be downward sloping. The flat sl