Objective of Risk Structure Compensation (RSA):
- Reduce incentives for risk selection by health insurance providers.
- Ensure adequate funding allocation for healthcare needs.
- Foster competition based on quality and efficiency.
- Equitably distribute financial resources among health insurance providers.
Calculation of Contribution Requirements:
- Normative costs (standardized service expenditures) determine the contribution requirements for each health insurance provider.
Independent Variables:
- Assignment of Insured Individuals to Risk Groups:
- Assignments for an insured individual depend on:
- Age
- Gender
- Receipt of a disability pension
- Use of cost reimbursement instead of benefits in kind
- Entitlement to sickness benefits
- Morbidity
- There are five types of risk groups:
- Age-Gender Groups (AGGs, a total of 40)
- Disability Groups (EMGs)
- Hierarchical Morbidity Groups (HMGs)
- Cost Reimbursement Groups (KEGs)
- Overseas Age-Gender Groups (AusAGGs)
- Assignments for an insured individual depend on:
- Assignment of Insured Individuals to Risk Groups:
Regression Methodology for Standardized Service Expenditures:
- Regression analysis is employed to determine standardized service expenditures, excluding sickness benefits and expenditures for overseas insurers.
- Initial data preparation involves collating reported data and creating a regression dataset for analysis.
- Data from individuals who switch health insurance providers within the fiscal year are merged into a single dataset using a predefined classification algorithm to assign risk groups.
- Overseas-insured individuals (those residing abroad for 183 days or more in the previous year) are excluded from the analysis to maintain data consistency.
- The regression model considers individual service expenditures reported in category 700 and excludes health insurance providers with significantly deviating expenditures, minimizing calculation biases.
- Total service expenditures (excluding sickness benefits) are divided by the reported insured days to derive a per-day expenditure value.
- A weighted least squares regression, without a regression constant, is performed using insured days as regression weights and risk group classifications (AGGs, EMGs, HMGs, KEGs, AusAGGs) as independent variables.
- Regression refinement occurs when negative cost estimations or hierarchy violations are identified. Negative estimations are adjusted to zero, and hierarchy violations are rectified to maintain model integrity.
- Regression coefficients represent standardized service expenditures for each risk group, indicating the average additional costs per day incurred by individuals with specific risk attributes.
- Prospective risk groups (EMGs, HMGs, KEGs) reflect expected additional costs per day for the fiscal year, considering information from the previous year.
- Regression coefficients account for the absence of allocations via the basic lump sum. Weighting factors are derived from cost estimations to calculate risk-adjusted additions or deductions to the lump sum in subsequent allocation processes.
This comprehensive regression methodology ensures accurate determination of standardized service expenditures, supporting equitable resource distribution and risk adjustment within the Risk Structure Compensation framework.