McCormack Grace, Trish Erin
Price School of Public Policy, Schaeffer Center, University of Southern California, Los Angeles, CA 90089, United States.
Health Aff Sch. 2024 Aug 5;2(8):qxae093. doi: 10.1093/haschl/qxae093. eCollection 2024 Aug.
As the Medicare Advantage (MA) program grows in enrollment and costs, there has been increasing concern that federal payments to MA plans exceed necessary levels. Estimates suggest that, in 2023, MA plans were paid up to 6% more per enrollee than would have been spent had that beneficiary instead enrolled in traditional Medicare (TM). We evaluated the factors driving this overpayment, characterizing trends in MA benchmarks, bids, and total payments from pre-Affordable Care Act (pre-ACA) levels through 2023. We found that, despite an overall decrease in risk-adjusted bids relative to average risk-adjusted TM enrollee costs, total payments to plans have modestly increased since 2015. Decomposing these trends into various factors in the MA payment formula, we found that divergent trends in benchmarks and bids are, in part, due to the increasing influence of payment adjustments, such as quartile spending adjustments, quality bonus payments, and risk adjustment. Our results suggest that current payment rules have contributed to overpayments and policy reform may be necessary.
随着医疗保险优势（MA）计划的参保人数和成本不断增加，人们越来越担心联邦政府向MA计划的支付超过了必要水平。估计显示，2023年，MA计划每位参保人的支付比该受益人参加传统医疗保险（TM）的支出高出6%。我们评估了导致这种超额支付的因素，描述了从《平价医疗法案》（ACA）之前到2023年MA基准、投标和总支付的趋势。我们发现，尽管相对于平均风险调整后的TM参保人成本，风险调整后的投标总体有所下降，但自2015年以来，向计划的总支付略有增加。将这些趋势分解为MA支付公式中的各种因素后，我们发现基准和投标的不同趋势部分归因于支付调整（如四分位数支出调整、质量奖金支付和风险调整）的影响不断增加。我们的结果表明，当前的支付规则导致了超额支付，可能需要进行政策改革。
