Abstract
Prospective payment schemes in health care often include supply-side insurance for cost outliers. In hospital reimbursement, prospective payments for patient discharges, based on their classification into diagnosis related group (DRGs), are complemented by outlier payments for long stay patients. The outlier scheme fixes the length of stay (LOS) threshold, constraining the profit risk of the hospitals. In most DRG systems, this threshold increases with the standard deviation of the LOS distribution. The present paper addresses the adequacy of this DRG outlier threshold rule for risk-averse hospitals with preferences depending on the expected value and the variance of profits. It first shows that the optimal threshold solves the hospital’s tradeoff between higher profit risk and lower premium loading payments. It then demonstrates for normally distributed truncated LOS that the optimal outlier threshold indeed decreases with an increase in the standard deviation.
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References
Ellis R.P., McGuire T.G. (1988) Insurance principles and the design of prospective payment systems. Journal of Health Economics, 7: 215–237. doi:10.1016/0167-6296(88)90026-4
Keeler E.B., Carter F.M., Trude S. (1988) Insurance aspects of DRG outlier payments. Journal of Health Economics, 7: 193–214. doi:10.1016/0167-6296(88)90025-2
Ma C.-T. A. (1994) Health care payment systems: cost and quality incentives. Journal of Economics & Management Strategy, 3: 93–112. doi:10.1111/j.1430-9134.1994.00093.x
Meyer J. (1987) Two-moment decision models and expected utility. The American Economic Review, 77: 421–430
Schreyögg J., Stargardt T., Tiemann O., Busse R. (2006) Methods to determine reimbursement rates for diagnosis related Groups (DRG): A comparison of nine European countries. Health Care Management Science, 9: 215–223. doi:10.1007/s10729-006-9040-1
Sinn, H. W. (1983). Economic decision under uncertainty. Second English edition. North-Holland Publishing Company: Amsterdam et al.
Zeckhauser R. (1970) Medical insurance: A case study of the tradeoff between risk spreading and appropriate incentives. Journal of Economic Theory, 2: 10–26. doi:10.1016/0022-0531(70)90010-4
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Felder, S. The variance of length of stay and the optimal DRG outlier payments. Int J Health Care Finance Econ 9, 279–289 (2009). https://doi.org/10.1007/s10754-008-9051-1
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DOI: https://doi.org/10.1007/s10754-008-9051-1