Kenton J. Johnston (
Karen E. Joynt Maddox is an assistant professor of medicine (cardiology) at the Washington University School of Medicine, in St. Louis.
Health Aff (Millwood). 2019 Apr;38(4):569-576. doi: 10.1377/hlthaff.2018.05032.
The Centers for Medicare and Medicaid Services is increasingly focused on value-based payment programs, which tie payment to performance on quality and cost measures. In this context, there is rising concern that such programs systematically disadvantage providers that care for vulnerable populations, such as the poor, by holding the providers accountable for factors beyond their control that influence patient outcomes and utilization. In this nationally representative study of Medicare beneficiaries, we found that dually enrolled Medicare beneficiaries (those also enrolled in Medicaid) had strikingly higher levels of medical, functional, and cognitive comorbidities, as well as social needs, compared to their non-dually enrolled counterparts. Dual enrollees also had significantly higher annual costs of care. Including functional, cognitive, and social factors in cost prediction, in addition to risk factors derived from medical claims, improved risk prediction and decreased differences between dual and nondual enrollees. Medicare could consider such adjustment to improve accuracy and fairness in value-based payment programs.
医疗保险和医疗补助服务中心越来越关注基于价值的支付计划，这些计划将支付与质量和成本措施的绩效挂钩。在这种情况下，人们越来越担心，这些计划会通过让提供者对影响患者结果和利用的超出其控制范围的因素负责，从而系统地使为弱势群体（如穷人）提供护理的提供者处于不利地位。在这项针对 Medicare 受益人的全国代表性研究中，我们发现，与非双重注册的 Medicare 受益人相比，双重注册的 Medicare 受益人（同时注册 Medicaid 的人）在医疗、功能和认知合并症以及社会需求方面的水平明显更高。双重注册者的年度护理费用也明显更高。除了从医疗索赔中得出的风险因素外，在成本预测中纳入功能、认知和社会因素，可改善风险预测并减少双重和非双重注册者之间的差异。医疗保险可以考虑这种调整，以提高基于价值的支付计划的准确性和公平性。
