1 Oregon Health and Science University, Portland, OR, USA.
2 Health Systems Division, Oregon Health Authority, Salem, OR, USA.
Med Care Res Rev. 2019 Oct;76(5):661-677. doi: 10.1177/1077558717740206. Epub 2017 Nov 15.
Dual-eligible beneficiaries or "duals" are individuals enrolled in both the Medicare and Medicaid programs. For both Medicare and Medicaid, they may be enrolled in fee-for-service or managed care, creating a mix of possible coverage models. Understanding these different models is essential to improving care for duals. Using All-Payer All-Claims data, we empirically described health service use and quality of care for Oregon duals across five coverage models with different combinations of fee-for-service, managed care, and plan alignment status across Medicare and Medicaid. We found substantial heterogeneity in care across these five coverage models. We also found that duals in plans with aligned financial incentives for Medicare and Medicaid experienced more improvement in their care relative to those with nonaligned Medicare Advantage and Medicaid managed care plans. These results highlight the importance of developing policies that account for the heterogeneity of the dual population and their coverage options.
双重资格受益人或“双重”是同时参加医疗保险和医疗补助计划的个人。对于医疗保险和医疗补助，他们可以参加按服务收费或管理式医疗，从而形成各种可能的覆盖模式。了解这些不同的模式对于改善双重受益人的护理至关重要。我们使用全民医保所有索赔数据，通过实证描述了俄勒冈州五种不同覆盖模式下的双重受益人的医疗服务使用情况和护理质量，这些覆盖模式在医疗保险和医疗补助方面具有不同的按服务收费、管理式医疗和计划调整状况组合。我们发现，在这五种覆盖模式下，护理存在很大的异质性。我们还发现，在医疗保险和医疗补助方面具有财务激励措施相协调的计划中的双重受益人的护理质量相对于那些医疗保险优势计划和医疗补助管理式医疗计划中不具有协调财务激励措施的双重受益人的护理质量有更多的改善。这些结果突出了制定政策的重要性，这些政策需要考虑双重受益人群及其覆盖范围的异质性。
