Eric T. Roberts (
Xinwei Chen, University of Pennsylvania.
Health Aff (Millwood). 2024 Sep;43(9):1296-1305. doi: 10.1377/hlthaff.2023.01579.
Dual-eligible beneficiaries have insurance through two distinct and uncoordinated programs: Medicaid, which pays for long-term care; and Medicare, which pays for medical care, including hospital stays. Concern that this system leads to poor quality and inefficient care, particularly for dual-eligible nursing home residents, has led policy makers to test managed care plans that provide incentives for coordinating care across Medicare and Medicaid. We examined enrollment in three such plans among dual-eligible beneficiaries receiving long-term nursing home care. Two of those plans, Medicare-Medicaid plans and Fully Integrated Dual Eligible Special Needs Plans, are integrated care plans that establish a global budget including Medicare and Medicaid spending. The third, Institutional Special Needs Plans, puts insurers and nursing homes at risk for Medicare spending but not Medicaid spending. Among dual-eligible nursing home residents, enrollment in these plans increased from 6.5 percent of residents per month in 2013 to 16.9 percent in 2020. Enrollment varied across counties but did not vary appreciably with respect to nursing home characteristics, including the share of residents with Medicaid. As policy makers pursue strategies to coordinate medical and long-term care for dual-eligible beneficiaries, it remains critical to evaluate how these plans influence the care of dual-eligible nursing home residents.
医疗保险，支付长期护理费用；和医疗保险，支付医疗费用，包括住院费用。人们担心这种制度会导致护理质量差和效率低下，特别是对于双重资格的疗养院居民，这导致政策制定者测试管理式医疗保健计划，为协调医疗保险和医疗补助的护理提供激励措施。我们研究了接受长期疗养院护理的双重资格受益人中的三种此类计划的参与情况。其中两项计划，医疗保险-医疗补助计划和完全整合的双重资格特殊需求计划，是整合护理计划，为包括医疗保险和医疗补助支出在内的全球预算制定了规定。第三项，机构特殊需求计划，使保险公司和疗养院面临医疗保险支出的风险，但不承担医疗补助支出的风险。在双重资格的疗养院居民中，这些计划的参与率从 2013 年每月 6.5%增加到 2020 年的 16.9%。参与率在各县之间有所不同，但与疗养院的特点，包括有医疗补助的居民比例，没有明显差异。随着政策制定者为双重资格受益人寻求协调医疗和长期护理的策略，评估这些计划如何影响双重资格疗养院居民的护理仍然至关重要。
