在传统医疗保险中缺乏持续的编码可能会扩大风险得分差距与医疗保险优势
Niru Ghoshal-Datta1, Michael E Chernew2, J Michael McWilliams3
1Niru Ghoshal-Datta, Harvard University, Boston, Massachusetts.
Health affairs (Project Hope)
|December 3, 2024
概括
传统医疗保险中的不完整的诊断编码显著扩大了医疗保险优势风险评分差距,耗资数十亿美元. 在两个医疗保险系统中解决编码完整性对于准确的支付至关重要.
科学领域:
- 卫生经济学 卫生经济学
- 卫生政策 卫生政策
- 医疗信息学医学信息学
背景情况:
- 医疗保险优势 (MA) 支付依赖于使用诊断数据的风险调整模型.
- 传统的医疗保险和医疗补助计划之间诊断编码的差异可能导致支付不平等.
- 以前的研究主要研究了MA编码,忽视了传统的医疗保险的编码完整性.
研究的目的:
- 为了比较传统的医疗保险和MA计划之间的慢性疾病的诊断编码持久性.
- 量化传统医疗保险的编码差距对医疗保险优势风险评分差距的影响.
- 为政策提供有关风险调整模型准确性和医疗保险支出的信息.
主要方法:
- 对传统医疗保险索赔数据 (2017-2019年) 的分析.
- 对医疗保险优势遇到数据 (2017-2019年) 的分析.
- 对16种慢性疾病的诊断编码持久性的比较.
主要成果:
- 传统医疗保险中缺乏持久编码占2020年风险评分差距的22.3%.
- 这种编码差异导致医疗保险支出约为81亿美元.
- 敏感性分析表明这种低估,不包括急性和事件条件.
结论:
- 传统医疗保险中的诊断编码不完整是Medicare Advantage风险评分差距的一个重要驱动因素.
- 准确的风险调整需要在传统的医疗保险和药物管理计划中解决编码做法.
- 需要全面的战略来确保公平而准确的医疗保险支付.
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