Richard Kronick (
Health Aff (Millwood). 2017 Feb 1;36(2):320-327. doi: 10.1377/hlthaff.2016.0768.
Over the past decade, the average risk score for Medicare Advantage (MA) enrollees has risen steadily relative to that for fee-for-service Medicare beneficiaries, by approximately 1.5 percent per year. The Centers for Medicare and Medicaid Services (CMS) uses patient demographic and diagnostic information to calculate a risk score for each beneficiary, and these risk scores are used to determine payment to MA plans. The increase in relative MA risk scores is largely the result of successful efforts by MA plans to identify additional diagnoses, also known as coding intensity, and not of changes in enrollees' true health. In this article I estimate the effects of coding intensity on Medicare spending over the next decade. Under the moderately conservative assumption that coding intensity will decelerate, Medicare expenditures are expected to increase by approximately $200 billion. CMS has implemented a variety of strategies since 2010 that lessened the impact of coding intensity on Medicare spending; it has a variety of policy responses at its disposal to mitigate the impact going forward. The problem could be largely solved if CMS adjusted for coding intensity using the principle that MA beneficiaries are no healthier and no sicker than demographically similar fee-for-service Medicare beneficiaries, returning to the budget-neutrality approach that was introduced in 2004 and later abandoned.
在过去的十年中，相对于医疗保险服务（Medicare Advantage，MA）受益人的风险评分，医疗保险收费服务（Medicare Fee-for-Service，FFS）受益人的风险评分稳步上升，每年约上升 1.5%。医疗保险和医疗补助服务中心（Centers for Medicare and Medicaid Services，CMS）使用患者人口统计学和诊断信息为每位受益人计算风险评分，这些风险评分用于确定向 MA 计划支付的款项。相对 MA 风险评分的上升在很大程度上是由于 MA 计划成功地识别了更多的诊断，也称为编码强度，而不是受益人的真实健康状况发生了变化。在本文中，我估计了编码强度对未来十年医疗保险支出的影响。在编码强度将减缓的适度保守假设下，医疗保险支出预计将增加约 2000 亿美元。自 2010 年以来，CMS 实施了各种策略，减轻了编码强度对医疗保险支出的影响；它有各种政策应对措施可供选择，以减轻未来的影响。如果 CMS 通过使用 MA 受益人与人口统计学上相似的 FFS 医疗保险受益人一样健康和患病程度相同的原则来调整编码强度，那么这个问题可能会得到很大程度的解决，这将回归到 2004 年引入、后来被放弃的预算中性方法。
