The University of Texas Health Science Center at Houston School of Public Health, TX, USA.
University of California-San Diego, La Jolla, CA, USA.
Med Care Res Rev. 2021 Jun;78(3):260-272. doi: 10.1177/1077558719859724. Epub 2019 Jul 23.
Contracting between private health plans and hospitals has been described as "chaos behind a veil of secrecy." We develop a novel algorithm that classifies inpatient claims as one of three contract types-discounted charges, fixed rates, or per diems-and apply it to the 2009-2014 Colorado All Payer Claims Database. Of $1.1 billion in classifiable private health plan payments for inpatient care in Colorado, we find that 42.1% were fixed rates, 41.1% were discounted charges, and 16.0% were per diems. We find wide variation in contract types among private health plans and hospital types, and a pronounced shift over the study period in private plans' contract types, away from discounted charges, and toward fixed rates. To test our algorithm's validity, we apply it to Colorado Medicare and Medicaid claims-both of which are known primarily to pay using fixed rates-and find, reassuringly, that 86.3% of Medicare payments (98.6% when we exclude Medicare claims with special payment rules) and 79.7% of Medicaid payments are classified as fixed rates.
私人健康计划与医院之间的合同被描述为“隐藏在秘密面纱后的混乱”。我们开发了一种新的算法，可以将住院费用分为三种合同类型之一：折扣费用、固定费率或每日费用，并将其应用于 2009 年至 2014 年科罗拉多州所有支付者索赔数据库。在科罗拉多州可归类的私人健康计划支付的 11 亿美元住院费用中，我们发现 42.1%是固定费率，41.1%是折扣费用，16.0%是每日费用。我们发现私人健康计划和医院类型之间的合同类型存在很大差异，并且在研究期间，私人计划的合同类型明显从折扣费用转向固定费率。为了测试我们算法的有效性，我们将其应用于科罗拉多州的医疗保险和医疗补助索赔——这两者主要用于固定费率支付——并令人安心地发现，86.3%的医疗保险支付（当我们排除具有特殊支付规则的医疗保险索赔时，这一比例为 98.6%）和 79.7%的医疗补助支付被归类为固定费率。
