支持医疗和社会复杂患者在医疗补助管理护理中的初级保健
Arlene S Ash1, Matthew J Alcusky1, Randall P Ellis2
1Department of Population and Quantitative Health Sciences, UMass Chan Medical School, Worcester, Massachusetts.
JAMA network open
|February 3, 2025
概括
马萨诸塞州医疗补助 (MassHealth) 在2023年改革了对初级保健实践的支付. 一个新的复杂度调整的支付模式确保支付与患者需求保持一致,支持照顾复杂人群的实践.
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
- 主要护理政策 基本护理政策
背景情况:
- 马萨诸塞州医疗补助 (MassHealth) 在2023年对负责任的护理组织 (ACO) 对初级保健实践的支付进行了强制性的改变.
- 改革旨在增加支付,并转向每月支付,能力增强和历史校准支付.
- 确定了根据患者的复杂性调整支付的关键需求,以避免不公平的退款.
研究的目的:
- 描述大众健康倡议对初级保健支付改革的情况.
- 开发和评估初级保健实践的复杂度调整的支付模式.
主要方法:
- 一项横向研究分析了2022年2月至2024年11月的支付模式发展和表现.
- 该研究包括1,092,742名马萨诸塞州的医疗补助会员,他们在2019年至少注册了183天.
- 初级保健活动水平 (PCAL) 模型是使用医疗和社会复杂度开发的,并使用R平方和观察到预期结果比率进行评估.
主要成果:
- PCAL模型表现出强的性能,R平方为69.6%,准确估计了为高风险人群和各种种族/族群的支出.
- 与年龄/性别调整相比,PCAL模型显著提高了支付准确性,减少了需求较低的群体的过度支付和需求较高的群体的低支付.
- 具体而言,年龄/性别调整导致10%的超支付和34%的低支付,而PCAL模型导致最低分数几乎完全支付,最高分数仅支付6%的低支付.
结论:
- 大众健康2023改革代表了对初级保健的重大投资.
- 开发的风险调整支付模式有效地使初级保健支付与患者需求保持一致,特别是对于那些患有复杂疾病的人.
- 无论是年龄/性别调整还是历史支付通货膨胀,都不能充分支持为最脆弱和最复杂的患者群体提供服务的做法.
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