Comparison of Utilization, Costs, and Quality of Medicaid vs Subsidized Private Health Insurance for Low-Income Adults.
Comparison of Utilization, Costs, and Quality of Medicaid vs Subsidized Private Health Insurance for Low-Income Adults.
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对低收入成年人的利用率，成本和质量的利用，成本和质量进行比较。
DOI：
10.1001/jamanetworkopen.2020.32669
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发表时间：
2021-01-04
影响因子：
13.8
通讯作者：
Sommers, Benjamin D.
中科院分区：
文献类型：
--
作者：
Allen, Heidi;Gordon, Sarah H.;Lee, Dennis;Bhanja, Aditi;Sommers, Benjamin D.
公共(医疗补助)和私人(市场)健康保险的利用率、成本和质量如何比较？这项对8182名参与者的横断面研究使用了倾向分数匹配的样本，样本范围缩小到高于和低于联邦贫困水平阈值的5个百分点，联邦贫困水平阈值分隔了医疗补助和市场资格(138%)。与医疗补助相比，市场覆盖范围与急诊科就诊次数减少和办公室就诊次数增加相关，由于价格高得多，市场覆盖范围的总成本高出83%，而市场覆盖范围的自付支出是市场覆盖范围的10倍；医疗质量的结果好坏参半。这项研究发现，医疗补助和市场覆盖在重要方面有所不同：医疗补助中更多的急诊科就诊可能反映出获得门诊护理的机会受到损害或共同支付较低；市场覆盖由于价格较高而成本更高，而且消费者的成本分担也更高。这项横断面研究使用了来自3个州机构的数据，这些机构合并了综合保险索赔与科罗拉多州医疗补助扩展和市场参与者的收入资格数据，以调查低收入成年人的公共和私人医疗保险之间的医疗保健利用率、成本和质量。到目前为止，几乎没有严格的证据将公共医疗保险与私人医疗保险进行比较。随着政策制定者考虑一系列扩大覆盖范围的政策，了解这些覆盖类型之间的权衡至关重要。比较接受医疗补助的低收入成年人和接受补贴的私人(Marketplace)保险的成年人之间的覆盖范围、利用率、质量和成本。这项横断面研究使用了在2014年1月1日至2015年12月31日期间的任何时候参加医疗补助或Marketplace计划的成年人的倾向分数匹配样本。样本仅限于收入略高于或低于联邦贫困水平(FPL)138%的个人，这代表了两个计划之间的资格界限。数据来自3个州机构，将综合保险索赔与科罗拉多州医疗补助扩大和市场参与者的收入资格数据合并。收入数据与所有付款人索赔数据库相联系，并使用广义线性模型来调整临床和人口统计混杂因素。参与者包括8,182名年龄在19岁至之间的低收入非怀孕成年人，他们在2014年至2015年期间参加了医疗补助或市场保险，收入在家庭月收入的134%至143%之间。通过科罗拉多州的医疗补助或科罗拉多州的Marketplace提供医疗保险。主要的分析方法是对倾向得分匹配的样本进行多元回归分析。主要结果包括数月的医疗补助或市场保险覆盖范围、办公室和急诊科(ED)就诊、对门诊护理敏感的住院治疗和总费用。对于二次质量结果，倾向得分匹配的样本被扩大到FPL的129%到148%，以确保有足够的样本量。次要结果包括处方药使用、急诊室就诊类型、住院、自付费用和临床质量指标。初步数据分析是在2018年9月至2019年7月之间进行的，修订工作于2020年11月完成。与倾向得分匹配的窄收入样本总共包括 8182名参与者(4091名符合医疗补助条件的[50%]：平均[SD]年龄，42.8[13.6]岁；2,230名女性[54.5%]；4091名符合市场条件的[50%]：平均[SD]年龄，42.7[13.9]岁；2,229名女性[54.5%])。两组之间的人口统计学差异非常平衡，所有标准化平均差异均小于0.10。市场覆盖范围与急诊就诊(平均0.36[95%CI，0.32-0.40]次vs0.56[95%CI，0.50-0.62]次；P <； .001)和更多的办公室(门诊)就诊(平均2.22[95%CI，2.11-2.32]次vs1.73[95%CI，1.64-1.81]次；P <； .001)相关。对门诊护理敏感的住院治疗没有发现差异(0.004[95%CI，0.001-0.006]vs 0.007[95%CI，0.002-0.011]；P = .15)。在市场覆盖范围内，总成本高出83%(平均为4,553美元[95%CI，$3368-$5738]vs$2484[95%CI，$1760-$3209]；P <； .001)，几乎完全是由于价格上涨，自付成本高出10倍(平均，$569[95%CI，$337-$801]vs$45[95%CI，$26-$65]；P <； .001)。12项二级质量指标中有5项支持私人保险，1项支持医疗补助。在这项横断面倾向得分匹配的研究中，医疗补助和市场覆盖在重要方面有所不同。与私人市场覆盖相比，通过医疗补助的公共覆盖与更多的急诊科就诊和更少的办公室访问相关，这可能反映了门诊护理的障碍或医疗补助中急诊科护理的较低费用分担障碍。结果表明，对受益人和社会来说，医疗补助覆盖的成本比私人覆盖要低得多，在医疗质量方面的结果好坏参半。
How do utilization, cost, and quality compare between public (Medicaid) and private (Marketplace) health insurance? This cross-sectional study of 8182 participants used a propensity score–matched sample narrowed to 5 percentage points above and below the federal poverty level threshold that separates Medicaid and Marketplace eligibility (138%). Marketplace coverage was associated with fewer emergency department visits and more office visits than Medicaid, total costs were 83% higher in Marketplace coverage owing to much higher prices, and out-of-pocket spending was 10 times higher in Marketplace coverage; results for quality of care were mixed. This study found that Medicaid and Marketplace coverage differ in important ways: more emergency department visits in Medicaid may reflect impaired access to outpatient care or lower copayments; Marketplace coverage was more costly owing to higher prices and also had higher cost sharing for consumers. This cross-sectional study uses data from 3 state agencies merging comprehensive insurance claims with income eligibility data for Colorado Medicaid expansion and Marketplace enrollees to investigate health care utilization, cost, and quality between public and private health insurance for low-income adults. There has been little rigorous evidence to date comparing public vs private health insurance. With policy makers considering a range of policies to expand coverage, understanding the trade-offs between these coverage types is critical. To compare months of coverage, utilization, quality, and costs between low-income adults with Medicaid vs those with subsidized private (Marketplace) insurance. This cross-sectional study used a propensity score–matched sample of adults enrolled in either Medicaid or Marketplace plans at any point between January 1, 2014, and December 31, 2015. The sample was restricted to individuals with incomes narrowly above and below 138% of the federal poverty level (FPL), which represented the eligibility cutoff between the programs. Data were obtained from 3 state agencies merging comprehensive insurance claims with income eligibility data for Colorado Medicaid expansion and Marketplace enrollees. Income data were linked with an all-payer claims database, and generalized linear models were used to adjust for clinical and demographic confounders. Participants included 8182 low-income nonpregnant adults aged 19 to 64 years enrolled in Medicaid or Marketplace coverage during the 2014 to 2015 period, with incomes between 134% and 143% of the FPL. Health insurance through Colorado Medicaid or Colorado’s state-based Marketplace. The primary analytical approach was a multivariate regression analysis of the propensity score–matched sample. Primary outcomes were months of coverage in Medicaid or Marketplace insurance, office and emergency department (ED) visits, ambulatory care–sensitive hospitalizations, and total costs. For secondary quality outcomes, the propensity score–matched sample was widened to 129% to 148% of the FPL to ensure adequate sample size. Secondary outcomes included prescription drug utilization, types of ED visits, hospitalizations, out-of-pocket costs, and clinical quality measures. Primary data analysis was between September 2018 to July 2019, with revisions finalized in November 2020. The propensity score–matched narrow-income sample included a total of 8182 participants (4091 Medicaid eligible [50%]: mean [SD] age, 42.8 [13.6] years; 2230 women [54.5%]; 4091 Marketplace eligible [50%]: mean [SD] age, 42.7 [13.9] years; 2229 women [54.5%]). Demographic differences across the 2 groups were well balanced, with all standardized mean differences less than 0.10. Marketplace coverage was associated with fewer ED visits (mean, 0.36 [95% CI, 0.32-0.40] visits vs 0.56 [95% CI, 0.50-0.62] visits; P < .001) and more office (outpatient) visits than Medicaid (mean, 2.22 [95% CI, 2.11-2.32] visits vs 1.73 [95% CI, 1.64-1.81] visits; P < .001). No differences in ambulatory care–sensitive hospitalizations were found (0.004 [95% CI, 0.001-0.006] vs 0.007 [95% CI, 0.002-0.011]; P = .15). Total costs were 83% higher in Marketplace coverage (mean, $4553 [95% CI, $3368-$5738] vs $2484 [95% CI, $1760-$3209]; P < .001) owing almost entirely to higher prices, and out-of-pocket costs were 10 times higher (mean, $569 [95% CI, $337-$801] vs $45 [95% CI, $26-$65]; P < .001). Five of 12 secondary quality measures favored private insurance, and 1 favored Medicaid. In this cross-sectional propensity score–matched study, Medicaid and Marketplace coverage differed in important ways. Public coverage through Medicaid was associated with more ED visits and fewer office visits than private Marketplace coverage, which may reflect barriers to outpatient care or lower cost-sharing barriers to ED care in Medicaid. Results suggest that Medicaid coverage was substantially less costly to beneficiaries and society than private coverage, with mixed results on health care quality.
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