Department of Health Care Policy at Harvard Medical School, Boston, Massachusetts, USA.
Health Aff (Millwood). 2012 Dec;31(12):2630-40. doi: 10.1377/hlthaff.2011.1344.
Health plans participating in the Medicare managed care program, called Medicare Advantage since 2003, have historically attracted healthier enrollees than has the traditional fee-for-service program. Medicare Advantage plans have gained financially from this favorable risk selection since their payments have traditionally been adjusted only minimally for clinical characteristics of enrollees, causing overpayment for healthier enrollees and underpayment for sicker ones. As a result, a new risk-adjustment system was phased in from 2004 to 2007, and a lock-in provision instituted to limit midyear disenrollment by enrollees experiencing health declines whose exodus could benefit plans financially. To determine whether these reforms were associated with intended reductions in risk selection, we compared differences in self-reported health care use and health between Medicare Advantage and traditional Medicare beneficiaries before versus after these reforms were implemented. We similarly compared differences between those who switched into or out of Medicare Advantage and nonswitchers. Most differences in 2001-03 were substantially narrowed by 2006-07, suggesting reduced selection. Similar risk-adjustment methods may help reduce incentives for plans competing in health insurance exchanges and accountable care organizations to select patients with favorable clinical risks.
自 2003 年以来，参与医疗保险管理式医疗计划（即医疗保险优势计划）的健康计划吸引了比传统按服务收费计划更健康的参保者。由于医疗保险优势计划的支付仅对参保者的临床特征进行最小程度的调整，导致对更健康的参保者过度支付，对病情较重的参保者支付不足，因此从 2004 年到 2007 年逐步实施了新的风险调整系统，并制定了锁定规定，以限制因健康状况下降而中途退出的参保者退保，因为他们的离开可能对计划的财务状况有利。为了确定这些改革是否与预期减少风险选择有关，我们比较了这些改革实施前后医疗保险优势计划和传统医疗保险受益人的自我报告的医疗保健使用情况和健康状况差异。我们还比较了那些转换或不转换医疗保险优势计划的受益人的差异。到 2006-07 年，2001-03 年的大多数差异大大缩小，表明选择减少。类似的风险调整方法可能有助于减少参与医疗保险交易所和问责制医疗组织的计划选择具有有利临床风险的患者的激励措施。
