Shirk Joseph D, Kwan Lorna, Laviana Aaron A, Chu Stephanie, Huen Kathy H, Bergman Jonathan
Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, California.
Department of Family Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California.
Urol Pract. 2017 Jul;4(4):302-307. doi: 10.1016/j.urpr.2016.08.006. Epub 2016 Oct 27.
We examined provider and regional variation in services provided and payments made to urologists by CMS (Centers for Medicare & Medicaid Services) by linking payments to individual beneficiaries and examining the proportion of submitted charges resulting in payments.
We analyzed Medicare Part B Provider Utilization and Payment Data released by CMS for 2012, the last year of the purely fee-for-service reimbursement model. For each provider we determined the ratio of number of services provided to individual beneficiaries as well as the ratio of total submitted charges-to-total Medicare payments. Each provider was stratified into deciles of total Medicare payments and the mean per decile of total Medicare payment was calculated. Finally, to elucidate the potential association between the ratio of services-to-beneficiaries, we conducted multivariate linear regressions.
The 20th, 40th, 60th and 80th percentiles for the ratio of number of services per individual beneficiary ratios to total Medicare Part B payments are 2.8, 4.0, 5.2 and 7.4, respectively. Urologists with greater payments received provided more services to individual beneficiaries. Submitted charges exceeded payments by 3:1. Finally, female providers had lower ratios (p <0.01) and there was significant regional variation in the ratio of services per unique beneficiary (p <0.001 for each of the 10 Standard Federal Regions).
We found significant variation in services and payment in CMS. Reimbursement models replacing fee-for-service should be tailored to ensure appropriate health care resource utilization.
我们通过将支付与个体受益人相联系，并检查提交费用中获得支付的比例，研究了医疗保险和医疗补助服务中心（CMS）向泌尿科医生提供的服务及支付方面的提供者差异和地区差异。
我们分析了CMS发布的2012年医疗保险B部分提供者利用和支付数据，这是纯按服务收费报销模式的最后一年。对于每个提供者，我们确定了向个体受益人提供的服务数量之比以及提交的总费用与医疗保险总支付之比。每个提供者按医疗保险总支付的十分位数进行分层，并计算每个十分位数的医疗保险总支付平均值。最后，为了阐明服务与受益人之比之间的潜在关联，我们进行了多元线性回归。
每位个体受益人服务数量与医疗保险B部分总支付之比的第20、40、60和80百分位数分别为2.8、4.0、5.2和7.4。获得更高支付的泌尿科医生向个体受益人提供了更多服务。提交的费用超出支付比例为3:1。最后，女性提供者的比例较低（p<0.01），且每个独特受益人的服务比例存在显著的地区差异（10个标准联邦区域中的每个区域p<0.001）。
我们发现CMS在服务和支付方面存在显著差异。取代按服务收费的报销模式应进行调整，以确保适当利用医疗保健资源。
