跨保险公司的预先授权的比较:来自Medicare Advantage的横截面证据
Ravi Gupta1,2, Jay Fein3, Joseph P Newhouse4,5,6,7
1Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA ravigupta@jhmi.edu.
BMJ (Clinical research ed.)
|March 7, 2024
概括
美国私人保险公司的预先授权 (PA) 政策在美国私人保险公司之间有很大的差异,对其有很广泛的要求,特别是对于药物. 这些变化影响了医疗保险B部分的支出和利用率,突出了覆盖率的差异.
科学领域:
- 医疗保健服务研究 医疗服务研究
- 卫生政策分析 卫生政策分析
- 相对有效性研究研究比较
背景情况:
- 预先授权 (PA) 是医疗保险公司使用的关键利用管理工具,用于控制成本并确保医疗必要性.
- 在不同的保险公司之间存在PA政策的显著差异,这可能导致患者获得护理的不平等.
- 了解这些差异对于评估管理负担和对医疗保健提供的影响至关重要.
研究的目的:
- 测量和比较美国私人保险公司中预先授权 (PA) 政策的范围.
- 量化各种保险公司,医生专业和临床服务类别中PA要求的差异.
- 评估PA政策对医疗保险B部分支出和利用的潜在影响.
主要方法:
- 2021年五家主要美国私人保险公司的PA政策的横截面分析.
- 对传统医疗保险B部分中观察到的使用模式应用的PA要求的评估.
- 计算医疗保险B部分支出和利用的比例,根据医疗保险优势保险公司规则将需要PA.
主要成果:
- 医疗保险B部分服务的大部分需要事先授权,从17%到33%的支出和9%到41%的利用.
- 40%的支出和48%的利用将需要至少一个保险公司的PA;所有保险公司的12%的支出和6%的利用.
- 医生使用的药物,特别是血液学和瘤学,占PA支出的很大一部分,在各个专业之间,PA率存在很大差异.
结论:
- 预先授权政策在美国私人保险公司之间表现出很大差异,应用范围广泛,特别是在药物方面.
- 在政府管理的传统医疗保险和私人管理的医疗保险优势计划之间,覆盖政策存在重大差异.
- 调查结果可以为优化低价值服务的PA提供信息,并减少临床医生和患者的行政负担.
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