McCue Michael J, Palazzolo Jennifer R
Virginia Commonwealth University, Richmond, USA
Virginia Commonwealth University, Richmond, USA.
Inquiry. 2016 Nov 17;53. doi: 10.1177/0046958016673252. Print 2016.
For the individual market, 2014 was the first year Affordable Care Act medical claims experience data were available to set 2016 rates. Accessing Centers for Medicare and Medicaid Services rate data for 175 state insurers, this study compares projected medical claims with actual medical claims of 2014, as well as the cost and utilization of benefit categories for inpatient, outpatient, professional, and prescription drug spending. Actual costs per member per month (pmpm) were greater than projected in 2014 for inpatient, outpatient, and prescription spending but not for professional care. Overall, actual median medical cost was $443 pmpm, which was significantly higher by $41 than projected cost. Greater utilization of health care was primarily responsible for higher realized medical claims. In terms of the specific benefit categories-inpatient, outpatient, and prescription-actual costs pmpm were significantly higher than projected values. In terms of the drivers of inpatient costs, on an admission basis, higher costs and greater utilization of admissions resulted in higher inpatient costs. For outpatient costs pmpm, higher utilization rather than unit cost per visit drove increased costs. Higher than expected prescription drug costs were driven by both greater utilization and cost per prescription.
对于个人市场而言，2014年是可获取《平价医疗法案》医疗理赔经验数据以设定2016年费率的第一年。本研究获取了175家州保险公司的医疗保险和医疗补助服务中心费率数据，将2014年预计医疗理赔与实际医疗理赔进行了比较，还比较了住院、门诊、专业医疗及处方药支出等福利类别的成本和使用情况。2014年，住院、门诊和处方药支出的人均每月实际成本（pmpm）高于预期，但专业医疗护理成本并非如此。总体而言，实际医疗成本中位数为每人每月443美元，比预计成本显著高出41美元。医疗保健利用率提高是已实现医疗理赔增加的主要原因。就具体福利类别（住院、门诊和处方药）而言，人均每月实际成本显著高于预计值。就住院成本的驱动因素而言，按入院情况计算，较高的成本和更多的入院次数导致住院成本增加。对于门诊人均每月成本，成本增加是由利用率提高而非每次就诊的单位成本推动的。高于预期的处方药成本是由利用率提高和每张处方成本上升共同导致的。
