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Performance Pay in Insurance Markets: Evidence from Medicare

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  • Michele Fioretti

    (ECON - Département d'économie (Sciences Po) - Sciences Po - Sciences Po - CNRS - Centre National de la Recherche Scientifique)

  • Hongming Wang

    (Hitotsubashi University)

Abstract

Public procurement bodies increasingly resort to pay-for-performance contracts to promote efficient spending. We show that firm responses to pay-for-performance can widen the inequality in accessing social services. Focusing on the quality bonus payment initiative in Medicare Advantage, we find that higher quality-rated insurers responded to bonus payments by selecting healthier enrollees with premium differences across counties. Selection is profitable because the quality rating fails to adjust for differences in enrollee health. Selection inflated the bonus payments and shifted the supply of high-rated insurance to the healthiest counties, reducing access to lower-priced, higher-rated insurance in the riskiest counties.

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  • Michele Fioretti & Hongming Wang, 2021. "Performance Pay in Insurance Markets: Evidence from Medicare," SciencePo Working papers hal-03386584, HAL.
    • Handle: RePEc:hal:wpspec:hal-03386584
    Note: View the original document on HAL open archive server: https://sciencespo.hal.science/hal-03386584
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    1. repec:mpr:mprres:7375 is not listed on IDEAS
    2. Jason Brown & Mark Duggan & Ilyana Kuziemko & William Woolston, 2014. "How Does Risk Selection Respond to Risk Adjustment? New Evidence from the Medicare Advantage Program," American Economic Review, American Economic Association, vol. 104(10), pages 3335-3364, October.
    3. Francesco Decarolis, 2015. "Medicare Part D: Are Insurers Gaming the Low Income Subsidy Design?," American Economic Review, American Economic Association, vol. 105(4), pages 1547-1580, April.
    4. Jason Abaluck & Jonathan Gruber, 2011. "Choice Inconsistencies among the Elderly: Evidence from Plan Choice in the Medicare Part D Program," American Economic Review, American Economic Association, vol. 101(4), pages 1180-1210, June.
    5. Claudio Lucarelli & Jeffrey Prince & Kosali Simon, 2012. "The Welfare Impact Of Reducing Choice In Medicare Part D: A Comparison Of Two Regulation Strategies," International Economic Review, Department of Economics, University of Pennsylvania and Osaka University Institute of Social and Economic Research Association, vol. 53(4), pages 1155-1177, November.
    6. Kurt Lavetti & Kosali Simon, 2018. "Strategic Formulary Design in Medicare Part D Plans," American Economic Journal: Economic Policy, American Economic Association, vol. 10(3), pages 154-192, August.
    7. Breyer, Friedrich & Bundorf, M. Kate & Pauly, Mark V., 2011. "Health Care Spending Risk, Health Insurance, and Payment to Health Plans," Handbook of Health Economics, in: Mark V. Pauly & Thomas G. Mcguire & Pedro P. Barros (ed.), Handbook of Health Economics, volume 2, chapter 0, pages 691-762, Elsevier.
    8. Simon Burgess & Carol Propper & Marisa Ratto & Emma Tominey, 2017. "Incentives in the Public Sector: Evidence from a Government Agency," Economic Journal, Royal Economic Society, vol. 127(605), pages 117-141, October.
    9. Layton, Timothy J., 2017. "Imperfect risk adjustment, risk preferences, and sorting in competitive health insurance markets," Journal of Health Economics, Elsevier, vol. 56(C), pages 259-280.
    10. Jeffrey R. Kling & Sendhil Mullainathan & Eldar Shafir & Lee C. Vermeulen & Marian V. Wrobel, 2012. "Comparison Friction: Experimental Evidence from Medicare Drug Plans," The Quarterly Journal of Economics, President and Fellows of Harvard College, vol. 127(1), pages 199-235.
    11. Jason Abaluck & Jonathan Gruber, 2011. "Heterogeneity in Choice Inconsistencies among the Elderly: Evidence from Prescription Drug Plan Choice," American Economic Review, American Economic Association, vol. 101(3), pages 377-381, May.
    12. Thomas G. McGuire & Jacob Glazer, 2000. "Optimal Risk Adjustment in Markets with Adverse Selection: An Application to Managed Care," American Economic Review, American Economic Association, vol. 90(4), pages 1055-1071, September.
    13. Vilsa Curto & Liran Einav & Jonathan Levin & Jay Bhattacharya, 2021. "Can Health Insurance Competition Work? Evidence from Medicare Advantage," Journal of Political Economy, University of Chicago Press, vol. 129(2), pages 570-606.
    14. Hanming Fang & Michael P. Keane & Dan Silverman, 2008. "Sources of Advantageous Selection: Evidence from the Medigap Insurance Market," Journal of Political Economy, University of Chicago Press, vol. 116(2), pages 303-350, April.
    15. Amanda Starc & Robert J Town, 2020. "Externalities and Benefit Design in Health Insurance," The Review of Economic Studies, Review of Economic Studies Ltd, vol. 87(6), pages 2827-2858.
    16. Simon Burgess & Carol Propper & Marisa Ratto & Emma Tominey, 2017. "Incentives in the Public Sector: Evidence from a Government Agency," Economic Journal, Royal Economic Society, vol. 127(605), pages 117-141.
    17. Michael Geruso & Timothy Layton & Daniel Prinz, 2019. "Screening in Contract Design: Evidence from the ACA Health Insurance Exchanges," American Economic Journal: Economic Policy, American Economic Association, vol. 11(2), pages 64-107, May.
    18. Tatyana Deryugina & David Molitor, 2020. "Does When You Die Depend on Where You Live? Evidence from Hurricane Katrina," American Economic Review, American Economic Association, vol. 110(11), pages 3602-3633, November.
    19. Amy Finkelstein & Matthew Gentzkow & Heidi Williams, 2016. "Sources of Geographic Variation in Health Care: Evidence From PatientMigration," The Quarterly Journal of Economics, President and Fellows of Harvard College, vol. 131(4), pages 1681-1726.
    20. Neale Mahoney & E. Glen Weyl, 2017. "Imperfect Competition in Selection Markets," The Review of Economics and Statistics, MIT Press, vol. 99(4), pages 637-651, July.
    21. Baker, George P, 1992. "Incentive Contracts and Performance Measurement," Journal of Political Economy, University of Chicago Press, vol. 100(3), pages 598-614, June.
    22. Janet Currie & Hannes Schwandt, 2016. "Mortality Inequality: The Good News from a County-Level Approach," Journal of Economic Perspectives, American Economic Association, vol. 30(2), pages 29-52, Spring.
    23. Joseph P. Newhouse & Mary Price & John Hsu & J. Michael McWilliams & Thomas G. McGuire, 2015. "How Much Favorable Selection Is Left in Medicare Advantage?," American Journal of Health Economics, University of Chicago Press, vol. 1(1), pages 1-26, Winter.
    24. Liran Einav & Amy Finkelstein & Raymond Kluender & Paul Schrimpf, 2016. "Beyond Statistics: The Economic Content of Risk Scores," American Economic Journal: Applied Economics, American Economic Association, vol. 8(2), pages 195-224, April.
    25. Denis Chetverikov & Bradley Larsen & Christopher Palmer, 2016. "IV Quantile Regression for Group‐Level Treatments, With an Application to the Distributional Effects of Trade," Econometrica, Econometric Society, vol. 84, pages 809-833, March.
    26. Atul Gupta, 2021. "Impacts of Performance Pay for Hospitals: The Readmissions Reduction Program," American Economic Review, American Economic Association, vol. 111(4), pages 1241-1283, April.
    27. Duggan, Mark & Starc, Amanda & Vabson, Boris, 2016. "Who benefits when the government pays more? Pass-through in the Medicare Advantage program," Journal of Public Economics, Elsevier, vol. 141(C), pages 50-67.
    28. Jason Abaluck & Mauricio Caceres Bravo & Peter Hull: & Amanda Starc, 2021. "Mortality Effects and Choice Across Private Health Insurance Plans," The Quarterly Journal of Economics, President and Fellows of Harvard College, vol. 136(3), pages 1557-1610.
    29. Susan Athey & Guido W. Imbens, 2006. "Identification and Inference in Nonlinear Difference-in-Differences Models," Econometrica, Econometric Society, vol. 74(2), pages 431-497, March.
    30. Office of Health Economics, 2007. "The Economics of Health Care," For School 001490, Office of Health Economics.
    31. Barbara Biasi, 2018. "The Labor Market for Teachers Under Different Pay Schemes," NBER Working Papers 24813, National Bureau of Economic Research, Inc.
    32. André Veiga & E. Glen Weyl, 2016. "Product Design in Selection Markets," The Quarterly Journal of Economics, President and Fellows of Harvard College, vol. 131(2), pages 1007-1056.
    33. Abadie, Alberto & Diamond, Alexis & Hainmueller, Jens, 2010. "Synthetic Control Methods for Comparative Case Studies: Estimating the Effect of California’s Tobacco Control Program," Journal of the American Statistical Association, American Statistical Association, vol. 105(490), pages 493-505.
    34. Tisamarie B. Sherry, 2016. "A Note on the Comparative Statics of Pay‐for‐Performance in Health Care," Health Economics, John Wiley & Sons, Ltd., vol. 25(5), pages 637-644, May.
    35. Ben Handel & Igal Hendel & Michael D. Whinston, 2015. "Equilibria in Health Exchanges: Adverse Selection versus Reclassification Risk," Econometrica, Econometric Society, vol. 83(4), pages 1261-1313, July.
    36. Michael Darden & Ian M. McCarthy, 2015. "The Star Treatment: Estimating the Impact of Star Ratings on Medicare Advantage Enrollments," Journal of Human Resources, University of Wisconsin Press, vol. 50(4), pages 980-1008.
    37. Kathleen J. Mullen & Richard G. Frank & Meredith B. Rosenthal, 2010. "Can you get what you pay for? Pay‐for‐performance and the quality of healthcare providers," RAND Journal of Economics, RAND Corporation, vol. 41(1), pages 64-91, March.
    38. Holmstrom, Bengt & Milgrom, Paul, 1991. "Multitask Principal-Agent Analyses: Incentive Contracts, Asset Ownership, and Job Design," The Journal of Law, Economics, and Organization, Oxford University Press, vol. 7(0), pages 24-52, Special I.
    39. Amy Finkelstein & Matthew Gentzkow & Heidi Williams, 2021. "Place-Based Drivers of Mortality: Evidence from Migration," American Economic Review, American Economic Association, vol. 111(8), pages 2697-2735, August.
    40. Ellis, Randall P. & McGuire, Thomas G., 2007. "Predictability and predictiveness in health care spending," Journal of Health Economics, Elsevier, vol. 26(1), pages 25-48, January.
    41. Eggleston, Karen, 2005. "Multitasking and mixed systems for provider payment," Journal of Health Economics, Elsevier, vol. 24(1), pages 211-223, January.
    42. Francesco Decarolis & Maria Polyakova & Stephen P. Ryan, 2020. "Subsidy Design in Privately Provided Social Insurance: Lessons from Medicare Part D," Journal of Political Economy, University of Chicago Press, vol. 128(5), pages 1712-1752.
    43. Jonathan Gruber & Benjamin R. Handel & Samuel H. Kina & Jonathan T. Kolstad, 2020. "Managing Intelligence: Skilled Experts and AI in Markets for Complex Products," NBER Working Papers 27038, National Bureau of Economic Research, Inc.
    44. Van de ven, Wynand P.M.M. & Ellis, Randall P., 2000. "Risk adjustment in competitive health plan markets," Handbook of Health Economics, in: A. J. Culyer & J. P. Newhouse (ed.), Handbook of Health Economics, edition 1, volume 1, chapter 14, pages 755-845, Elsevier.
    45. Marika Cabral & Michael Geruso & Neale Mahoney, 2018. "Do Larger Health Insurance Subsidies Benefit Patients or Producers? Evidence from Medicare Advantage," American Economic Review, American Economic Association, vol. 108(8), pages 2048-2087, August.
    46. Decarolis, Francesco & Guglielmo, Andrea, 2017. "Insurers’ response to selection risk: Evidence from Medicare enrollment reforms," Journal of Health Economics, Elsevier, vol. 56(C), pages 383-396.
    47. Colleen Carey, 2017. "Technological Change and Risk Adjustment: Benefit Design Incentives in Medicare Part D," American Economic Journal: Economic Policy, American Economic Association, vol. 9(1), pages 38-73, February.
    48. Hugh Gravelle & Matt Sutton & Ada Ma, 2010. "Doctor Behaviour under a Pay for Performance Contract: Treating, Cheating and Case Finding?," Economic Journal, Royal Economic Society, vol. 120(542), pages 129-156, February.
    49. Bauhoff, Sebastian, 2012. "Do health plans risk-select? An audit study on Germany's Social Health Insurance," Journal of Public Economics, Elsevier, vol. 96(9-10), pages 750-759.
    50. Skinner, Jonathan, 2011. "Causes and Consequences of Regional Variations in Health Care," Handbook of Health Economics, in: Mark V. Pauly & Thomas G. Mcguire & Pedro P. Barros (ed.), Handbook of Health Economics, volume 2, chapter 0, pages 45-93, Elsevier.
    51. Han, Tony & Lavetti, Kurt, 2017. "Does Part D abet advantageous selection in Medicare Advantage?," Journal of Health Economics, Elsevier, vol. 56(C), pages 368-382.
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    More about this item

    Keywords

    Pay-for-Performance; Medicare Advantage; Risk Selection; Quality Ratings; Health Insurance Access;
    All these keywords.

    JEL classification:

    • I13 - Health, Education, and Welfare - - Health - - - Health Insurance, Public and Private
    • I14 - Health, Education, and Welfare - - Health - - - Health and Inequality
    • L15 - Industrial Organization - - Market Structure, Firm Strategy, and Market Performance - - - Information and Product Quality

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