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Medicare Advantage (MA) plans increase their risk-adjusted payments through intensive coding in health risk assessments (HRAs) and chart reviews. Whether the additional diagnoses from HRAs and chart reviews are associated with increased resource use is not known. Using national MA encounter data (2016–2019), we examine the relative contributions of three health risk scores to MA resource use: the base risk score that excludes diagnoses from HRAs and chart reviews; the incremental score added to the base score from diagnoses in HRAs; and the incremental score added from diagnoses in chart reviews. We find that the incremental risk scores explain 53.4%-63.9% of resource use relative to the base risk score effect—that is, 36.1% to 46.6% of the incremental risk scores are not accompanied by increased resource use. While HRAs and chart reviews contribute to more complete coding of diagnoses, they are sources of intensive coding not accompanied by resource use.

Analysts interested in physician market concentration often have access to tax identification numbers (TINs), but not the number of truly independent negotiating units (NUs). Health plans do know the true number of NUs, and, using 2014 claims data for Minnesota physicians from a large midwestern health plan, we compare Herfindahl-Hirschman Index (HHI) measures of physician market concentration using TINs versus NUs at the county and metropolitan statistical area (MSA) levels for thirteen specialties. We found that HHIs computed using TINs versus NUs were similar across Minnesota. Two MSAs in Minnesota met the Department of Justice's definition of highly concentrated markets. There is reason to believe that the discrepancy between TIN and NU HHIs may vary by insurance product and region of the country, and so we encourage other researchers to work with health plans to replicate our study.

This study examines all 81 health maintenance organization (HMO) mergers that occurred in the United States from 1985 to 1992. The primary emphasis is on describing organizational factors that are associated with mergers, identifying market environments in which mergers are more likely to occur, and analyzing the financial status of merging HMOs. Overall, the study presents an up-to-date portrait of mergers in this important health care industry. We found that HMO mergers are relatively rare, but, over time, a substantial proportion of HMOs and their enrollees are affected by mergers. Ouranalys is suggests that some financially weak HMOs might have failed if they had not merged into stronger plans. This finding gives qualified support to the failing-company antitrust defense for HMO mergers. However, mergers between large, financially sound HMOs may have anticompetitive effects on consumers of HMO services.

Employers' willingness to control costs is a critical aspect of pro‐competition strategies for the health‐care market. Here, we present some of the first quantitative evidence of what employers do to control health‐care costs. Our sample is 44 large private and public employers in Minnesota.We develop a theoretical model in which the employer chooses cost‐control "innovations"—along with wages, fringe benefits, and labor‐force size—to maximize profits. The role of innovations is to reduce unit costs of offering fringe benefits.Our data are from a 1982 survey. Eighty percent of the surveyed employers, representing nearly 200,000 employees, responded. Most respondents offer both indemnity insurance plans and health‐maintenance organizations (HMOs). Many firms and individual health‐insurance plans conduct cost‐control activities, but less than half of the firms which offer HMOs have adopted level‐dollar premium contributions for their family health‐insurance policies. Few plans have increased their coinsurance and deductible requirements in the past five years.We use probit equations to estimate the probability that a firm or a health plan will adopt cost‐control activities. Our analysis suggests that many firms may soon make major plan‐design changes to control health‐care costs, although they have not yet done so.