Friedman Bernard, Jiang H Joanna
Agency for Healthcare Research and Quality, 540 Gaither Road, Rockville, MD 20850, USA.
Int J Health Care Finance Econ. 2010 Jun;10(2):171-85. doi: 10.1007/s10754-010-9076-0. Epub 2010 Feb 6.
The hospitals selected by or for Medicare beneficiaries might depend on whether the patient is enrolled in a Medicare Advantage (MA) plan. A theoretical model of profit maximization by MA plans takes into account the tradeoffs of consumer preferences for annual premium versus outcomes of care in the hospital and other attributes of the plan. Hospital discharge databases for 13 states in 2006, maintained by the Agency for Healthcare Research and Quality, are the main source of data. Risk-adjusted mortality rates are available for all non-maternity adult patients in each of 15 clinical categories in about 1,500 hospitals. All-adult postoperative safety event rates covering 9 categories of events are calculated for surgical cases in about 900 hospitals. Instrumental variables are used to address potential endogeneity of the choice of a MA plan. The key findings are these: enrollees in MA plans tend to be treated in hospitals with lower resource cost and higher risk-adjusted mortality compared to Fee-for-Service (FFS) enrollees. The risk-adjusted mortality measure is about 1.5 percentage points higher for MA plan enrollees than the overall mean of 4%. However, the rate of safety events in surgical patients favors MA plan enrollees--the rate is 1 percentage point below the average of 3.5%. These discrepant results are noteworthy and are plausibly due to greater discretion by the health plan in approving patients for elective surgery and as well as selecting hospitals for surgical patients. Emergency patients are generally excluded for the safety outcome measures. In addition, the current mortality measures may not adequately represent all surgical patients. Such caveats should be prominently highlighted when presenting comparative data. With that proviso, the study justifies informing Medicare beneficiaries about the mortality and safety outcome measures for hospitals being used by a MA plan compared to hospitals used by FFS enrollees.
医疗保险受益人选择的医院或为其选择医院的情况可能取决于患者是否参加了医疗保险优势（MA）计划。MA计划实现利润最大化的理论模型考虑了消费者对年度保费的偏好与医院护理结果及计划其他属性之间的权衡。由医疗保健研究与质量局维护的2006年13个州的医院出院数据库是主要数据来源。在约1500家医院的15个临床类别中的所有非产妇成年患者都有风险调整后的死亡率数据。在约900家医院中，针对手术病例计算了涵盖9类事件的全成年术后安全事件发生率。使用工具变量来解决MA计划选择中潜在的内生性问题。主要发现如下：与按服务收费（FFS）参保者相比，MA计划的参保者倾向于在资源成本较低且风险调整后死亡率较高的医院接受治疗。MA计划参保者的风险调整后死亡率指标比4%的总体均值高约1.5个百分点。然而，手术患者的安全事件发生率对MA计划参保者有利——该发生率比3.5%的平均水平低1个百分点。这些不同的结果值得注意，可能是由于健康计划在批准患者进行择期手术以及为手术患者选择医院方面有更大的自由裁量权。安全结果指标通常不包括急诊患者。此外，当前的死亡率指标可能无法充分代表所有手术患者。在呈现比较数据时，应突出强调此类注意事项。在有该条件的情况下，该研究证明有理由向医疗保险受益人告知MA计划使用的医院与FFS参保者使用的医院相比的死亡率和安全结果指标。
