An outlier pool for Medicare HMO payments.
Medicare pays "at-risk" health maintenance organizations a prospective capitation amount that is established by the adjusted average per capita cost (AAPCC) formula for estimating the amount enrollees would have cost had they remained in the fee-for-service sector. Because the AAPCC accounts for a very small percentage of the variation in beneficiary costs, considerable research has been devoted to improving the formula. A way to improve the explained variance is to remove the most expensive beneficiaries from the AAPCC payment system and pay for them separately. This article examines one approach to a payment system that combines the AAPCC with an outlier payment mechanism.
Beebe
J C
JC
D002204:Capitation Fee / Q000706:statistics & numerical data; D006279:Health Maintenance Organizations / Q000191:economics*; D015271:Insurance Pools / Q000191:economics*; D006278:Medicare / Q000191:economics / Q000458:organization & administration*; D016311:Outliers, DRG / Q000191:economics*; D011445:Prospective Payment System / Q000191:economics*; D011907:Rate Setting and Review; D012306:Risk; D014481:United States