医疗保险优势计划支出和在临终关怀下支付的开支
Meghan Bellerose1, Andrew M Ryan1, Claire K Ankuda2
1Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island.
JAMA network open
|August 19, 2025
概括
医疗保险优势计划在入学者选择住院护理时获得了大量的过剩支付. CMS可以调整支付,使其与实际医疗保健支出保持一致,并确保公平的补偿.
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
- 老年医疗护理 医疗护理
背景情况:
- 医疗保险和医疗补助服务中心 (CMS) 之前测试了一种基于价值的保险设计 (VBID) 模型,用于医疗保险优势 (MA) 内的宿舍服务.
- 广泛的不满导致VBID模式于2024年12月终止,恢复了宿舍分离模式.
- 在 carve-out 模式下,医疗保险的服务费 (FFS) 覆盖了临终关怀,而MA 计划收到资本化支付减去临终关怀相关费用.
研究的目的:
- 估计医疗保险优势 (MA) 计划支出与选择住院护理的MA入学者的溢价和折扣支付有关.
- 根据宿舍分离模式,量化对MA计划的潜在过剩支付.
主要方法:
- 一项横截面研究分析了2017-2019年对选择住院的MA入学者的数据.
- 数据来源包括FFS索赔 (2016-2020年),MA遭遇记录和公开可用的计划级数据.
- 估计了MA计划支出,保费和回扣支付,以确定净支付和过剩支付.
主要成果:
- 该研究包括314,087名MA入学者,平均住院时间为1.76个月.
- 在临终关怀选后,平均MA支出下降到每月57美元/入学者,81%的人没有MA可承担的费用.
- 马计划继续收到每月120美元的保费和折扣,导致每年超过23-5800万美元的额外支付.
结论:
- 在受益人选择住院后,MA计划尽管医疗保健支出最小,但却获得了大量的溢价和折扣支付.
- 建议包括CMS要求MA计划报告补充福利使用情况,并调整宿舍后支付以反映实际成本.
- 政策调整是必要的,以使MA计划支付与宿舍入学者的医疗保健利用保持一致.
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