Integrating risk adjustment and enrollee premiums in health plan payment


Thomas G McGuire, Jacob Glazer, Joseph P Newhouse, Sharon-Lise Normand, Julie Shi, Anna D Sinaiko, and Samuel H Zuvekas. 2013. “Integrating risk adjustment and enrollee premiums in health plan payment.” J Health Econ, 32, 6, Pp. 1263-77.


In two important health policy contexts - private plans in Medicare and the new state-run "Exchanges" created as part of the Affordable Care Act (ACA) - plan payments come from two sources: risk-adjusted payments from a Regulator and premiums charged to individual enrollees. This paper derives principles for integrating risk-adjusted payments and premium policy in individual health insurance markets based on fitting total plan payments to health plan costs per person as closely as possible. A least squares regression including both health status and variables used in premiums reveals the weights a Regulator should put on risk adjusters when markets determine premiums. We apply the methods to an Exchange-eligible population drawn from the Medical Expenditure Panel Survey (MEPS).