Addressing Serious Illness Care in Medicare Advantage.
Addressing Serious Illness Care in Medicare Advantage.
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解决 Medicare Advantage 中的严重疾病护理问题。
DOI：
10.1056/nejmp2302252
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发表时间：
2023
期刊：
影响因子：
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通讯作者：
Teno,JoanM
中科院分区：
文献类型：
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作者：
Ankuda,ClaireK;Aldridge,MelissaD;Braun,RTyler;Coe,NormaB;Grabowski,DavidC;Meyers,DavidJ;Ryan,Andrew;Stevenson,David;Teno,JoanM
由于48%的Medicare受益人参加了Medicare Advantage计划，1为这些计划所涵盖的严重疾病患者提供高质量护理的挑战迫在眉睫。虽然它以前比传统的医疗保险保险更健康的受益人，但平均而言，医疗保险优势越来越多地根据特殊需求计划为患有严重疾病的人提供保险，这些计划迎合了那些有双重资格获得医疗保险和医疗补助的受益人，那些居住在机构中的人，以及那些患有某些慢性疾病的人。联邦医疗保险优势计划的注册人数在黑人和拉丁裔人群中增长不成比例，因此该计划中的任何质量缺陷都可能导致护理质量和结果的种族和民族差异。尽管联邦医疗保险优势计划的目标是提供协调、胜任、公平和以人为本的高质量护理，但计划管理人员面临控制成本的经济激励，因为他们收到资本化的付款，因此可以保留一部分付款作为利润。对于患有严重疾病的注册者，他们通常需要在多个环境中提供广泛的护理，该计划的成本控制机制，如覆盖拒绝，狭窄的提供者网络和事先授权要求，可能会破坏接受必要或高质量护理的能力。我们认为，有必要采取一种全面的方法，优先提高数据透明度和质量衡量，以确保医疗保险优势计划促进提供高质量和公平的护理。
With 48% of Medicare beneficiaries enrolled in the Medicare Advantage program, 1 the challenge of providing high-quality care for people with serious illness who are covered by such plans is pressing. Though it previously insured healthier beneficiaries than did traditional Medicare, on average, Medicare Advantage increasingly insures people with serious illness under special-needs plans that cater to beneficiaries who are dually eligible for Medicare and Medicaid, those residing in institutions, and those with certain chronic illnesses. Medicare Advantage enrollment has grown disproportionately among Black and Latinx people, so any quality deficiencies in the program may result in racial and ethnic disparities in quality of care and outcomes.Although the goal of the Medicare Advantage program is to provide high-quality care that is coordinated, competent, equitable, and person-centered, plan administrators face financial incentives to contain costs, since they receive capitated payments and therefore may keep a portion of payments as profit. For enrollees with serious illness, who often require extensive care provided in multiple settings, the program’s cost-control mechanisms—such as coverage denials, narrow provider networks, and prior-authorization requirements—may undermine the ability to receive necessary or high-quality care. We believe a comprehensive approach that prioritizes improving data transparency and quality measurement is necessary to ensure that the Medicare Advantage program facilitates the delivery of high-quality and equitable care.