Department of Medicine, Massachusetts General Hospital, Boston.
Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.
JAMA Health Forum. 2022 Sep 2;3(9):e223073. doi: 10.1001/jamahealthforum.2022.3073.
More than 70% of Medicare beneficiaries in Puerto Rico are enrolled in a Medicare Advantage (MA) plan. Evidence of MA plan payments and quality in Puerto Rico compared with the 50 US states and Washington, DC (hereafter referred to as US mainland), is lacking, notably after implementation of the Patient Protection and Affordable Care Act (ACA).
To compare MA plan payments and quality in Puerto Rico with those in the US mainland and to evaluate how differences between MA plans in Puerto Rico and the US mainland changed after ACA implementation.
DESIGN, SETTING, AND PARTICIPANTS: This cohort study used publicly available data on MA plans from January 1, 2006, to December 31, 2019, from the Centers for Medicare & Medicaid Services. Data analysis was performed from October 2019 to February 2022.
Medicare Advantage plans in Puerto Rico and implementation of the ACA.
Primary outcomes were risk-standardized federal benchmark payments (the amount offered by the federal government for insuring a beneficiary of average risk), risk-standardized plan bids (a plan's asking price for a beneficiary of average risk), and rebates received by plans. Additional outcomes included risk-adjusted benchmarks, risk-adjusted bids, actual plan payment, and aggregate plan quality ratings (star ratings). A difference-in-differences analysis examined differential changes in plan payments in Puerto Rico vs the US mainland after ACA implementation.
Before ACA implementation, 211 MA plans in Puerto Rico and 13 899 plans in the US mainland were included. After ACA implementation, 433 MA plans in Puerto Rico and 29 515 plans in the US mainland were included. Before ACA implementation, risk-standardized benchmarks were 33% lower for MA plans in Puerto Rico than plans in the US mainland ($556.73 [95% CI, $551.82-$561.64] vs $831.15 [95% CI, $828.55-$833.75] per beneficiary per month [PBPM]). This gap increased to 38% after ACA implementation ($540.58 [95% CI, $536.86-$544.32] vs $869.31 [95% CI, $868.21-$870.42] PBPM). Risk-standardized plan bids in Puerto Rico were 46% lower before ACA implementation and 43% lower after ACA implementation compared with those in the US mainland. Rebates in Puerto Rico decreased from $168.50 (95% CI, $163.57-$173.42) PBPM before ACA implementation to $93.39 (95% CI, $89.51-$97.27) PBPM after ACA implementation, a decrease of $75.11 PMPM compared with a decrease of $2.05 PMPM in the US mainland. Plans in Puerto Rico received increased quality bonus payments, and the mean (SD) risk score for plans in Puerto Rico increased to 1.55 (0.31) after ACA implementation, which increased risk-adjusted benchmarks and actual plan payments, offsetting the widening payment disparity.
This cohort study found that after implementation of the ACA, federal benchmark payment amounts decreased in Puerto Rico compared with the US mainland. Responses by MA plans in Puerto Rico, including increased quality bonus payments and risk scores, offset this payment reduction, although actual plan payments in Puerto Rico were lower than those in the US mainland.
波多黎各超过 70%的医疗保险受益人参加了医疗保险优势（MA）计划。缺乏波多黎各 MA 计划支付情况和质量与美国 50 个州和华盛顿特区（以下简称美国大陆）的证据，尤其是在《患者保护与平价医疗法案》（ACA）实施后。
比较波多黎各的 MA 计划支付情况和质量与美国大陆的情况，并评估波多黎各和美国大陆之间 MA 计划之间的差异在 ACA 实施后如何变化。
设计、设置和参与者：本队列研究使用了 2006 年 1 月 1 日至 2019 年 12 月 31 日来自医疗保险和医疗补助服务中心（Centers for Medicare & Medicaid Services）的 MA 计划的公开可用数据。数据分析于 2019 年 10 月至 2022 年 2 月进行。
波多黎各的医疗保险优势计划和 ACA 的实施。
主要结果是风险标准化联邦基准支付（联邦政府为平均风险的受益人提供的金额）、风险标准化计划投标（计划为平均风险的受益人提出的要价）和计划收到的回扣。其他结果包括风险调整基准、风险调整投标、实际计划支付和综合计划质量评级（星级评级）。差异分析检查了 ACA 实施后波多黎各与美国大陆之间计划支付的差异变化。
在 ACA 实施之前，波多黎各有 211 个 MA 计划，美国大陆有 13899 个计划。在 ACA 实施之后，波多黎各有 433 个 MA 计划，美国大陆有 29515 个计划。在 ACA 实施之前，波多黎各的风险标准化基准比美国大陆的计划低 33%（每月每位受益人 556.73 美元[95%置信区间，551.82-561.64]与 831.15 美元[95%置信区间，828.55-833.75]）。ACA 实施后，这一差距扩大到 38%（每月每位受益人 540.58 美元[95%置信区间，536.86-544.32]与 869.31 美元[95%置信区间，868.21-870.42]）。波多黎各的风险标准化计划投标在 ACA 实施前低 46%，在 ACA 实施后低 43%，与美国大陆相比。波多黎各的回扣从 ACA 实施前的 168.50 美元（95%置信区间，163.57-173.42）降至 93.39 美元（95%置信区间，89.51-97.27），与美国大陆相比，每 PMPM 减少 75.11 美元。波多黎各的计划获得了更高的质量奖金支付，波多黎各计划的平均（SD）风险评分从 ACA 实施前的 1.55（0.31）增加到 1.55（0.31），这增加了风险调整后的基准和实际计划支付，抵消了支付差距的扩大。
这项队列研究发现，ACA 实施后，波多黎各的联邦基准支付金额与美国大陆相比有所下降。波多黎各的 MA 计划做出了回应，包括增加质量奖金支付和风险评分，抵消了这一支付减少，尽管波多黎各的实际计划支付仍低于美国大陆。
