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Developing An Accountability-Based Payment Model for Taiwan’s National Health Insurance
financial risk,risk adjustment,capitation,preventable hospitalization,accountable care organization,
|Publication Year :||2012|
The development of an accountability-based payment model to foster the creation of accountable care organizations (ACOs), which consist of providers who are held responsible for both the quality and cost of care, has become one of the most promising payment reform strategies.
Our purpose is to develop a method for assigning National Health Insurance (NHI) enrollees and the providers who serve them to ACOs. Additionally, we will simulate the potential financial risk of the risk-adjusted capitation payment model used in setting budget targets and the potentially avoidable costs (PACs) used in the calculation of shared savings for ACOs.
We use a random sample of one million (5%) NHI enrollees from the National Health Insurance Research Database. Each NHI enrollee was assigned to a predominant ambulatory provider and an ACO based on the beneficiary's care pattern from 2006 to 2008. Demographic and health-based risk adjustment models were used to set capitation-based budgets and compare the financial risks. Financial risk is calculated as the likelihood that an ACO's actual medical costs exceed or fall short of its budget. Preventable hospitalizations were used to estimate the PACs and were calculated as potential savings for ACOs.
A total of 88 ACOs were formed, and 847,811 (98%) enrollees were assigned to a specific provider and ACO. Two-thirds of health care services were billed by the assigned ACO in 2008. Enlarging the population size of ACOs will increase the accuracy of the risk adjustment model and reduce the financial risks to the ACOs. Using a health-based risk adjustment model to set capitation-based budgets, the average financial risk for each ACO will decrease by approximately 2% of the medical costs of the demographic model. Using preventable hospitalizations to calculate the potential savings, the average expected cost savings were approximately 4% of the medical costs for each ACO.
The development an accountability-based payment model for NHI is practical and feasible. This model would use claims data to assign virtually all enrollees to empirically defined ACOs that can be held accountable for their cost and quality of care. Adopting a health-based risk adjustment model for setting budgets and using PACs to calculate shared savings were critical to improving the equity of budget allocations and diminishing the financial risk among the ACOs.
|Appears in Collections:||健康政策與管理研究所|
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