Rahman Momotazur, Keohane Laura, Trivedi Amal N, Mor Vincent
Momotazur Rahman (
Laura Keohane is an assistant professor in the Department of Health Policy at the Vanderbilt University School of Medicine, in Nashville, Tennessee.
Health Aff (Millwood). 2015 Oct;34(10):1675-81. doi: 10.1377/hlthaff.2015.0272.
Medicare Advantage payment regulations include risk-adjusted capitated reimbursement, which was implemented to discourage favorable risk selection and encourage the retention of members who incur high costs. However, the extent to which risk-adjusted capitation has succeeded is not clear, especially for members using high-cost services not previously considered in assessments of risk selection. We examined the rates at which participants who used three high-cost services switched between Medicare Advantage and traditional Medicare. We found that the switching rate from 2010 to 2011 away from Medicare Advantage and to traditional Medicare exceeded the switching rate in the opposite direction for participants who used long-term nursing home care (17 percent versus 3 percent), short-term nursing home care (9 percent versus 4 percent), and home health care (8 percent versus 3 percent). These results were magnified among people who were enrolled in both Medicare and Medicaid. Our findings raise questions about the role of Medicare Advantage plans in serving high-cost patients with complex care needs, who account for a disproportionately high amount of total health care spending.
医疗保险优势计划支付规定包括风险调整后的按人头付费报销，实施该规定是为了抑制有利的风险选择行为，并鼓励留住高成本参保人员。然而，风险调整后的按人头付费取得成功的程度尚不清楚，尤其是对于那些使用高成本服务的参保人员而言，而这些服务在风险选择评估中以前并未被考虑在内。我们研究了使用三种高成本服务的参保人员在医疗保险优势计划和传统医疗保险之间转换的比率。我们发现，对于使用长期疗养院护理服务（转换率为17% 对3%）、短期疗养院护理服务（9% 对4%）和家庭保健服务（8% 对3%）的参保人员，从2010年到2011年，从医疗保险优势计划转向传统医疗保险的转换率超过了相反方向的转换率。在同时参加医疗保险和医疗补助计划的人群中，这些结果更为明显。我们的研究结果引发了关于医疗保险优势计划在为有复杂护理需求的高成本患者提供服务方面所起作用的疑问，这些患者在医疗保健总支出中所占比例过高。
