Agency for Healthcare Research and Quality, Center for Financing, Access, and Cost Trends, Rockville, Maryland, USA.
Herbert Wertheim School of Public Health, University of California San Diego, La Jolla, California, USA.
Health Serv Res. 2021 Apr;56(2):178-187. doi: 10.1111/1475-6773.13591. Epub 2020 Nov 9.
To assess how beneficiary premiums, expected out-of-pocket costs, and plan finances in the Medicare Advantage (MA) market are related to coding intensity.
DATA SOURCES/STUDY SETTING: MA plan characteristics and administrative records from the Centers for Medicare and Medicaid Services (CMS) for the sample of beneficiaries enrolled in both MA and Part D between 2008 and 2015. Medicare claims and drug utilization data for Traditional Medicare (TM) beneficiaries were used to calibrate an independent measure of health risk.
Coding intensity was measured by comparing the CMS risk score for each MA contract with a contract level risk score developed using prescription drug data. We conducted regressions of plan outcomes, estimating the relationship between outcomes and coding intensity. To develop prescription drug scores, we assigned therapeutic classes to beneficiaries based on their prescription drug utilization. We then regressed nondrug spending for TM beneficiaries in 2015 on demographic and therapeutic class identifiers for 2014 and used the coefficients to predict relative risk.
We found that, for each $1 increase in potential revenue resulting from coding intensity, MA plan bid submissions declined by $0.10 to $0.19, and another $0.21 to $0.45 went toward reducing plans' medical loss ratios, an indication of higher profitability. We found only a small impact on beneficiary's projected out-of-pocket costs in a plan, which serves as a measure of the generosity of plan benefits, and a $0.11 to $0.16 reduction in premiums. As expected, coding intensity's effect on bids was substantially larger in counties with higher levels of MA competition than in less competitive counties.
While coding intensity increases taxpayers' costs of the MA program, enrollees and plans both benefit but with larger gains for plans. The adoption of policies to more completely adjust for coding intensity would likely affect both beneficiaries and plan profits.
评估医疗保险优势（MA）市场中的受益人的保费、预期自付费用和计划财务状况与编码强度之间的关系。
数据来源/研究环境：来自医疗保险和医疗补助服务中心（CMS）的 MA 计划特征和管理记录，用于 2008 年至 2015 年期间同时参加 MA 和 Part D 的受益人群样本。传统医疗保险（TM）受益人的医疗保险索赔和药物利用数据用于校准健康风险的独立衡量标准。
通过将每个 MA 合同的 CMS 风险评分与使用药物数据开发的合同级别风险评分进行比较，来衡量编码强度。我们进行了计划结果的回归分析，估计结果与编码强度之间的关系。为了开发药物评分，我们根据受益人的药物使用情况将治疗类别分配给他们。然后，我们将 2014 年的人口统计学和治疗类别标识符回归到 2015 年 TM 受益人的非药物支出，并使用系数预测相对风险。
我们发现，编码强度每增加 1 美元潜在收入，MA 计划投标提交就会减少 0.10 美元至 0.19 美元，另外 0.21 美元至 0.45 美元用于降低计划的医疗损失率，这表明盈利能力更高。我们发现编码强度对计划中受益人的预计自付费用只有很小的影响，这是衡量计划福利慷慨程度的指标，保费降低了 0.11 美元至 0.16 美元。正如预期的那样，编码强度对投标的影响在 MA 竞争水平较高的县比在竞争水平较低的县大得多。
虽然编码强度增加了 MA 计划的纳税人成本，但参保人和计划都受益，但计划的收益更大。采取政策更完全地调整编码强度可能会同时影响受益人和计划利润。
