Roberts Eric T, Nimgaonkar Alok, Aarons Joshua, Tomko Heather, Shartzer Adele, Zuckerman Stephen B, Everette James A
Department of Health Policy and Management, University of Pittsburgh Graduate Schools of Public Health, Pittsburgh, Pennsylvania.
Tufts University School of Medicine, Boston, Massachusetts.
Health Serv Res. 2020 Oct;55(5):701-709. doi: 10.1111/1475-6773.13545.
To develop the first longitudinal database of state Medicaid policies for paying the cost sharing in Medicare Part B for services provided to dual Medicare-Medicaid enrollees ("duals") and an index summarizing the impact of these policies on payments for physician office services.
Medicaid policy data collected from electronic sources and inquiries with states.
We constructed a national database of Medicaid payment policies for the period 2004-2018, consolidating information from online Medicaid policy documents, state laws, and policy data reported to us by state Medicaid programs. Using this database and state Medicaid fee schedules, we constructed a Medicaid payment index for duals. This index represented the proportion of the Medicare allowed amount that physicians would expect to be paid from Medicare and Medicaid for a subset of physician office services (evaluation and management services) based on annual state payment policies and Medicaid fee schedules.
In 2018, 42 states had policies to limit Medicaid payments of Medicare cost sharing when Medicaid's fee schedule was lower than Medicare's-an increase from 36 such states in 2004. In the preponderance of states with these policies, combined Medicare and Medicaid payments for evaluation and management services provided to duals averaged 78 percent of the Medicare allowed amount for these services, reflecting relatively low Medicaid fee schedules in these states. In 2013 and 2014, physicians who qualified for the Affordable Care Act's Medicaid "fee bump" were paid 100 percent of the Medicare allowed amount for these services.
Medicaid programs vary across states and over time in their payments of cost sharing for physician office services provided to duals. Our database and index can facilitate monitoring of these policies and research on the consequences of policy changes for duals.
建立首个纵向数据库，记录各州医疗补助计划（Medicaid）为向医疗保险和医疗补助双重参保者（“双重参保者”）提供的医疗保险B部分服务支付费用分担的政策，并编制一个索引，总结这些政策对医生门诊服务支付的影响。
从电子资源收集的医疗补助政策数据以及向各州进行的问询。
我们构建了一个2004 - 2018年期间全国性的医疗补助支付政策数据库，整合了在线医疗补助政策文件、州法律以及各州医疗补助计划向我们报告的政策数据中的信息。利用这个数据库和各州医疗补助费用表，我们构建了双重参保者的医疗补助支付指数。该指数代表了根据年度州支付政策和医疗补助费用表，医生期望从医疗保险和医疗补助中获得支付的医疗保险允许金额的比例，这些服务是医生门诊服务的一个子集（评估和管理服务）。
2018年，42个州制定了政策，在医疗补助费用表低于医疗保险费用表时限制医疗补助对医疗保险费用分担的支付，这一数字高于2004年的36个州。在实施这些政策的大多数州，向双重参保者提供的评估和管理服务的医疗保险和医疗补助支付总额平均为这些服务医疗保险允许金额的78%，这反映出这些州的医疗补助费用表相对较低。2013年和2014年，符合《平价医疗法案》医疗补助“费用提升”条件的医生获得了这些服务医疗保险允许金额的100%支付。
各州的医疗补助计划在向双重参保者提供的医生门诊服务费用分担支付方面存在差异，且随时间变化。我们的数据库和索引有助于监测这些政策以及研究政策变化对双重参保者的影响。
