Risk Adjustment, Risk Sharing and Premium Regulation in Health Insurance Markets

Risk Adjustment, Risk Sharing and Premium Regulation in Health Insurance Markets

Theory and Practice

1st Edition - August 6, 2018

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  • Editors: Thomas McGuire, Richard Van Kleef
  • Paperback ISBN: 9780128113257
  • eBook ISBN: 9780128113264

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Risk Adjustment, Risk Sharing and Premium Regulation in Health Insurance Markets: Theory and Practice describes the goals, design and evaluation of health plan payment systems. Part I contains 5 chapters discussing the role of health plan payment in regulated health insurance markets, key aspects of payment design (i.e. risk adjustment, risk sharing and premium regulation), and evaluation methods using administrative data on medical spending. Part II contains 14 chapters describing the health plan payment system in 14 countries and sectors around the world, including Australia, Belgium, Chile, China, Columbia, Germany, Ireland, Israel, the Netherlands, Russia, Switzerland and the United States. Authors discuss the evolution of these payment schemes, along with ongoing reforms and key lessons on the design of health plan payment.

Key Features

  • Provides a conceptual toolkit that describes the goals, design and evaluation of health plan payment systems in the context of policy paradigms, such as efficiency, affordability, fairness and avoidance of risk selection
  • Brings together international experience from many different countries that apply regulated competition in different ways
  • Delivers a practical toolkit for the evaluation of health plan payment modalities from the standpoint of efficiency and fairness


Senior under(graduate) students interested in health policy. Policymakers responsible for health plan payment. Health insurers, policy researchers, patient organizations and other organizations involved in the design of risk equalisation schemes, those working as actuaries for insurance companies, and anyone involved in the political process of health plan payment design

Table of Contents

  • 1. Regulated Competition in Health Insurance Markets: Paradigms and Ongoing Issues
    2. Premium Regulation, Risk Equalization, Risk Sharing, and Subsidies: Effects on Affordability and Efficiency
    3. Risk Adjustment for Health Plan Payment
    4. Risk Sharing
    5. Evaluating the Performance of Health Plan Payment Systems
    6. Health Plan Payment in Australia
    7. Risk Adjustment in Belgium: Why and How to Introduce Socioeconomic Variables in Health Plan Payment
    8. Health Plan Payment in Chile
    9. Health Insurance and Payment System Reform in China
    10. Health Plan Payment in Colombia
    11. Health Plan Payment in Germany
    12. Health Plan Payment in Ireland
    13. Regulated Competition and Health Plan Payment Under the National Health Insurance Law in Israel—The Unfinished Story
    14. Health Plan Payment in the Netherlands
    15. Health Plan Payment in the Russian Federation
    16. Health Plan Payment in Switzerland
    17. Health Plan Payment in US Marketplaces: Regulated Competition With a Weak Mandate
    18. Health Plan Payment in Medicaid Managed Care: A Hybrid Model of Regulated Competition
    19. Medicare Advantage: Regulated Competition in the Shadow of a Public Option

Product details

  • No. of pages: 648
  • Language: English
  • Copyright: © Academic Press 2018
  • Published: August 6, 2018
  • Imprint: Academic Press
  • Paperback ISBN: 9780128113257
  • eBook ISBN: 9780128113264

About the Editors

Thomas McGuire

Thomas McGuire is a Professor of Health Economics in the Department of Health Care Policy at Harvard Medical School and a Research Associate at the National Bureau of Economic Research. His research focuses on the design and impact of health care payment systems, the economics of health care disparities, and the economics of mental health policy and drug regulation and payment. McGuire has contributed to the theory of physician, hospital, and health plan payment. McGuire was a co-editor of the Handbook of Health Economics Volume 2 (2012) and recently completed ten years as an editor of the Journal of Health Economics.

Affiliations and Expertise

Professor of Health Economics, Department of Health Care Policy, Harvard Medical School and Research Associate, National Bureau of Economic Research

Richard Van Kleef

Richard van Kleef works as an Associate Professor at the Erasmus School of Health Policy and Management of the Erasmus University Rotterdam. His research and teaching focus on economic aspects of health insurance and health care markets. Specific areas of expertise are health plan payment and consumer cost sharing. Van Kleef has published his research in national and international journals including the Journal of Health Economics, The European Journal of Health Economics, Medical Care, Health Affairs and Health Policy. Richard is currently chairman of the Dutch/Flemish Health Economics Association and a member of the Risk Adjustment Network (RAN).

Affiliations and Expertise

Associate Professor, Institute of Health Policy and Management, Erasmus University, Rotterdam, The Netherlands

Ratings and Reviews

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  • MariaTrottmann Sat Dec 15 2018

    Full of insights and still accessible

    This book offers a brilliant overview over risk adjustment in managed-competition type health care systems. The five chapters in part one explain the theory in an intuitive and accessible way. The 14 country specific chapters in part II provide countless practical insights into the implementation of the model, and some of the problems involved with it. I especially enjoyed the fact that societal goals and the economic rationale for risk adjustment are discussed in detail. Every regulator / adviser should own a copy!