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通过健康风险评估和图表审查编码强度在医疗保险的优势:它能解释资源使用吗?

Jeah Jung¹, Roger Feldman², Caroline Carlin²

¹George Mason University, Fairfax, VA, USA.

Medical care research and review : MCRR

|August 5, 2023

概括

医疗保险优势计划在健康风险评估和图表审查中使用密集编码. 然而,这些新增诊断的很大一部分与医疗保健资源使用增加无关.

科学领域:

卫生经济学卫生经济学
医疗保健政策医疗保健政策
医疗信息学医疗信息学

背景情况:

医疗保险优势 (MA) 计划使用风险调整支付.
通过健康风险评估 (HRA) 和图表审查进行密集编码,旨在捕捉患者的健康状况.
通过HRAs/图表审查识别的诊断与实际资源利用之间的关联仍然不清楚.

研究的目的:

确定MA计划中的HRA和图表审查中的额外诊断是否与医疗保健资源使用量的增加有关.
量化健康风险评分的不同组成部分对MA资源利用的贡献.

主要方法:

分析2016-2019年国家MA遭遇数据.
三个健康风险得分的比较:基数 (不包括HRA/图表审查诊断),HRA的增量得分和图表审查的增量得分.
检查这些风险分数与MA资源使用之间的关系.

主要成果:

来自HRA和图表审查的增量风险得分解释了53.5%至64.5%的资源使用相对于基本得分.
35.5%至46.5%的增量风险得分与增加的资源使用无关.
医疗健康评估和图表审查有助于更全面的诊断编码,但包括在没有相应的资源利用的情况下进行密集编码.

结论:

虽然HRA和图表审查提高了Medicare Advantage计划中的诊断编码完整性,但它们也引入了密集的编码实践.
通过这些密集编码方法捕获的大量诊断并没有伴随着医疗保健资源利用率的增加.
结果表明,在MA风险调整中,编码强度和实际医疗保健需求之间可能存在脱节.

关键词:

医疗保险的优势图表审查图表审查图表审查编码强度的编码强度评估健康风险评估健康风险

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