衡量医疗保险优势网络的限制性:基于索赔的方法
Yevgeniy Feyman1,2, Steven D Pizer1,2, Paul R Shafer1,2
1Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts, USA.
Health services research
|November 12, 2023
概括
医疗保险优势 (MA) 计划表现出不同的供应商网络限制性,卫生维护组织计划是最具限制性的. 这项研究开发了一种经过验证的方法,使用索赔数据来衡量网络限制性.
科学领域:
- 医疗保健服务研究 医疗服务研究
- 卫生经济学 卫生经济学
- 卫生政策 卫生政策
背景情况:
- 医疗保险优势 (MA) 计划越来越普遍,但了解其提供者网络的限制性对于受益者获取至关重要.
- 以前评估网络限制性的方法存在局限性.
研究的目的:
- 开发和验证医疗保险优势人口中提供者网络限制性的定量衡量标准.
- 在MA计划中评估影响网络限制性的因素.
主要方法:
- 使用的处方药事件数据和医疗保险D部分注册人的受益人信息.
- 使用传统医疗保险 (TM) 受益人开发了一个预测模型,以估计预期的提供者访问.
- 计算了观察到预期 (O/E) 的比率来量化网络限制性.
主要成果:
- 与HMO服务点 (67.2%) 和优先提供者组织 (PPO) 计划 (74.7%) 相比,健康维护组织 (HMO) 计划的限制性更高 (O/E = 55.5%).
- 农村地区的限制性网络 (31.6%) 比大都市地区 (61.5%) 更多.
- 增加的供应商供应与不那么严格的网络有关.
结论:
- 通过使用索赔数据,成功开发和验证了一种可靠的方法来估计MA中的供应商网络限制性.
- 这种方法为监管和市场分析的更广泛应用提供了信心.
- 调查结果突出显示,网络限制性在计划类型和地理位置之间存在显著差异.
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