较少的诊断是否更好? 评估改善医疗保险优惠支付系统的提案
Richard Kronick1, F Michael Chua2, Ramona Krauss3
1Richard Kronick (rkronick@ucsd.edu), University of California San Diego, La Jolla, California.
Health affairs (Project Hope)
|January 6, 2025
概括
由于更完整的诊断报告,医疗保险优势计划过度支付传统医疗保险. 排除十个诊断组可以使支付平等,但可能会增加风险选择激励.
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
- 医学编码分析 医学编码分析
背景情况:
- 医疗保险优势 (MA) 计划比传统医疗保险更完整的诊断报告.
- 这种差异导致了对MA计划的更高支付,由于差异编码,预计到2024年将达到500亿美元.
- 当前的支付结构可能无法准确地反映不同医疗保险部门受益人的真正健康需求.
研究的目的:
- 分析政策变化,以减少因差异诊断编码造成的医疗保险优势过度支付.
- 评估从支付模式中排除特定诊断组对MA计划支付和风险评分的影响.
- 评估支付公平性和MA计划中潜在的不利激励之间的权衡.
主要方法:
- 分析医疗保险优势和传统医疗保险之间的诊断编码模式.
- 从MA支付算法中排除十个高强度诊断组的影响建模.
- 评估平均风险得分的变化以及编码强度与风险得分之间的关系.
主要成果:
- 将十个诊断组排除在MA支付模式之外,几乎可以消除合同层面的公平性和效率问题.
- 这种排除将使MA的平均风险得分与传统医疗保险的平均风险得分保持一致.
- 然而,排除这些群体可能会增加对风险选择的激励,并减少对某些受益者的护理质量的激励.
结论:
- 排除特定的诊断群体为因编码差异而导致的MA支付差异提供了潜在的解决方案.
- 政策制定者必须仔细权衡改善支付公平性的好处与增加选择激励措施的风险.
- 平衡这些因素对于优化医疗保险优势支付系统和受益人护理至关重要.
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