Levy Jesse M, Robst John, Ingber Melvin J
Centers for Medicare & Medicaid Services, Baltimore, MD 21244-1850, USA.
Health Care Financ Rev. 2006 Summer;27(4):53-69.
Medicare is the principal payer for medical services for those in the U.S. population suffering from end-stage renal disease (ESRD). By law, beneficiaries diagnosed with ESRD may not subsequently enroll in Medicare Advantage (MA) plans, however, the potential benefits of managed care for this population have stimulated interest in changing the law and developing demonstration plans. We describe a new risk-adjustment system developed for Medicare to pay for ESRD beneficiaries in managed care plans. The model improves on current payment methodology by adjusting payments for treatment status and comorbidities.
医疗保险是美国患有终末期肾病（ESRD）人群医疗服务的主要支付方。根据法律规定，被诊断患有ESRD的受益人随后不得加入医疗保险优势（MA）计划，然而，针对这一人群的管理式医疗潜在益处激发了人们对修改法律和制定示范计划的兴趣。我们描述了一种为医疗保险开发的新风险调整系统，用于支付管理式医疗计划中ESRD受益人的费用。该模型通过调整治疗状态和合并症的支付来改进当前的支付方法。
