George Mason University, Fairfax, VA, USA.
University of Minnesota, Minneapolis, USA.
Med Care Res Rev. 2023 Dec;80(6):641-647. doi: 10.1177/10775587231191169. Epub 2023 Aug 4.
Medicare Advantage (MA) plans increase their risk-adjusted payments through intensive coding in health risk assessments (HRAs) and chart reviews. Whether the additional diagnoses from HRAs and chart reviews are associated with increased resource use is not known. Using national MA encounter data (2016-2019), we examine the relative contributions of three health risk scores to MA resource use: the risk score that excludes diagnoses from HRAs and chart reviews; the score added to the base score from diagnoses in HRAs; and the score added from diagnoses in chart reviews. We find that the incremental risk scores explain 53.5% to 64.5% of resource use relative to the base risk score effect-that is, 35.5% to 46.5% of the incremental risk scores are not accompanied by increased resource use. While HRAs and chart reviews contribute to more complete coding of diagnoses, they are sources of intensive coding not accompanied by resource use.
医疗保险优势（MA）计划通过在健康风险评估（HRA）和图表审查中进行密集编码来增加其风险调整后的支付。HRA 和图表审查中额外的诊断是否与资源使用的增加有关尚不清楚。使用全国 MA 遭遇数据（2016-2019 年），我们研究了三种健康风险评分对 MA 资源使用的相对贡献：排除 HRA 和图表审查中诊断的风险评分；从 HRA 中的诊断添加到基础评分的评分；以及从图表审查中的诊断添加的评分。我们发现，相对于基础风险评分效应，增量风险评分解释了 53.5%至 64.5%的资源使用情况，即增量风险评分的 35.5%至 46.5%没有伴随着资源使用的增加。虽然 HRA 和图表审查有助于更完整地编码诊断，但它们是密集编码的来源，没有伴随着资源使用。
