Harvard University, 180 Longwood Ave, Boston, MA 02115, USA.
Am J Manag Care. 2011 Jun 1;17(6 Spec No.):e231-40.
Medicare bases its risk adjustment method for Medicare Advantage plan payment on the relative costs of treating various diagnoses in traditional Medicare. However, there are many reasons to doubt that the relative cost of treating different diagnoses is similar between Medicare Advantage plans and traditional Medicare, including the varying applicability of care management methods to different diagnoses and the varying degrees of market power among suppliers of services to plans. We use internal cost data from a large health plan to compare its cost of treating various diagnoses with Medicare's reimbursement. We find substantial variability across diagnoses, implying that the current risk adjustment system creates incentives for Medicare Advantage plans to favor beneficiaries with certain diagnoses, but find no consistent relationship between the costliness of the diagnosis and the difference between reimbursement and cost.
医疗保险的医疗保险优势计划支付的风险调整方法是基于传统医疗保险中治疗各种诊断的相对成本。然而，有许多原因怀疑医疗保险优势计划和传统医疗保险之间治疗不同诊断的相对成本是相似的，包括不同的护理管理方法对不同诊断的适用性以及向计划提供服务的供应商之间的市场力量的不同程度。我们使用来自大型健康计划的内部成本数据来比较其治疗各种诊断的成本与医疗保险的报销。我们发现诊断之间存在很大的可变性，这意味着当前的风险调整系统为医疗保险优势计划创造了偏向某些诊断的受益人的激励，但没有发现诊断的昂贵程度与报销和成本之间的差异之间存在一致的关系。
