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Organizaciones académicas de atención administrada y selección adversa bajo la atención administrada de Medicaid en
J E Bailey1, D L Van Brunt, D M Mirvis
1Department of Medicine, University of Tennessee, Memphis 38103, USA. jebailey@utmem.edu
JAMA
|September 24, 1999
Resumen
Los centros médicos académicos en atención administrada son elegidos de manera desproporcionada por pacientes enfermos con enfermedades crónicas costosas. Esta selección adversa plantea riesgos financieros significativos para estas instituciones.
Área de la Ciencia:
- Servicios de salud Investigación Servicios de salud Investigación
- El cuidado administrado de la atención.
- Economía de la salud Economía de la salud
Sus antecedentes:
- Los planes de salud se enfrentan a riesgos financieros por una selección adversa por parte de los inscritos de alto costo.
- Los Centros Médicos Académicos (AMC) tradicionalmente atienden a pacientes más enfermos, aumentando su riesgo en la atención administrada.
Objetivo del estudio:
- Para determinar si las organizaciones de atención administrada (MCO) que representan a los AMC experimentan selección adversa.
- Investigue si los afiliados a la atención administrada de Medicaid (MMC) con costosas afecciones crónicas se inscriben de manera desproporcionada en MCOs afiliadas a AMC.
Principales métodos:
- Estudio observacional en el que se utilizaron datos de las reclamaciones de Tennessee Medicaid (1994-1995).
- Prevalencia comparada de 6 enfermedades crónicas especificadas por el estado y 27 enfermedades crónicas adicionales de alto costo en las OCM académicas, estatales y regionales.
- Se analizaron datos de 1,2 millones de personas inscritas en Medicaid en 12 MCO con capitalización.
Principales resultados:
- Las OCM académicas mostraron una mayor prevalencia de la mayoría de las enfermedades crónicas de alto costo.
- La prevalencia del SIDA fue 14,1 veces mayor en las OCM académicas; los defectos de coagulación 6,4 veces más altos.
- 22 de 27 condiciones adicionales de alto costo fueron más frecuentes en las OCM académicas.
Conclusiones:
- Los MCO académicos son seleccionados por una mayor proporción de los pacientes más enfermos en la atención administrada de Medicaid.
- La selección adversa presenta riesgos financieros sustanciales para los AMC en entornos de atención administrada.
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