The mechanics of risk adjustment and incentives for coding intensity in Medicare.
The mechanics of risk adjustment and incentives for coding intensity in Medicare.
复制标题
医疗保险中风险调整机制和编码强度激励机制。
DOI：
10.1111/1475-6773.14272
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发表时间：
2024
影响因子：
3.4
通讯作者：
Jung,Jeah
中科院分区：
文献类型：
--
作者：
Carlin,CarolineS;Feldman,Roger;Jung,Jeah
目的研究医疗保险计划中的诊断编码强度，并检查2024年医疗保险和医疗补助服务中心（CMS）采用的风险模型变化的影响。数据来源和研究设置来自CMS数据仓库的传统医疗保险（TM）受益人和医疗保险优势（MA）登记者的索赔和遭遇数据。研究设计我们创建了MA登记者队列，责任关怀组织（ACO）的TM受益人和TM非ACO受益人。使用CMS的2019年分层条件类别（HCC）软件，我们从基础记录中计算HCC患病率和评分，然后从健康风险评估（HRA）和图表审查（CR）记录中计算增量患病率和评分。数据收集/提取方法我们使用CMS的2019年随机20%的个体样本及其2018年诊断史，主要发现MA和TM ACO个体的测量健康风险在倾向评分匹配队列的基础记录中相当，而TM非ACO受益人的风险较低。由于HRA记录中的诊断而导致的增量健康风险在覆盖队列中增加，这与最大化风险评分的激励措施一致：TM非ACO为+0.9%，TM ACO为+1.2%，MA为+3.6%。包括HRA和CR记录，匹配队列中MA风险评分增加了9.8%。我们确定了肝癌组的最大的敏感性，这些来源的编码强度之间的MA入组，比较这些群体的新模型的目标changes. ConclusionsConsistently与以前的文献，我们发现MA与HRA和CR记录的健康风险增加。我们还证明了有意义的影响，健康风险度量的医疗保险覆盖队列的HRA。CMS的模型变化有可能降低编码强度，但它们并没有针对对编码强度敏感的层次结构的全部范围。
ObjectiveTo study diagnosis coding intensity across Medicare programs, and to examine the impacts of changes in the risk model adopted by the Centers for Medicare and Medicaid Services (CMS) for 2024.Data Sources and Study SettingClaims and encounter data from the CMS data warehouse for Traditional Medicare (TM) beneficiaries and Medicare Advantage (MA) enrollees.Study DesignWe created cohorts of MA enrollees, TM beneficiaries attributed to Accountable Care Organizations (ACOs), and TM non‐ACO beneficiaries. Using the 2019 Hierarchical Condition Category (HCC) software from CMS, we computed HCC prevalence and scores from base records, then computed incremental prevalence and scores from health risk assessments (HRA) and chart review (CR) records.Data Collection/Extraction MethodsWe used CMS's 2019 random 20% sample of individuals and their 2018 diagnosis history, retaining those with 12 months of Parts A/B/D coverage in 2018.Principal FindingsMeasured health risks for MA and TM ACO individuals were comparable in base records for propensity‐score matched cohorts, while TM non‐ACO beneficiaries had lower risk. Incremental health risk due to diagnoses in HRA records increased across coverage cohorts in line with incentives to maximize risk scores: +0.9% for TM non‐ACO, +1.2% for TM ACO, and + 3.6% for MA. Including HRA and CR records, the MA risk scores increased by 9.8% in the matched cohort. We identify the HCC groups with the greatest sensitivity to these sources of coding intensity among MA enrollees, comparing those groups to the new model's areas of targeted change.ConclusionsConsistent with previous literature, we find increased health risk in MA associated with HRA and CR records. We also demonstrate the meaningful impacts of HRAs on health risk measurement for TM coverage cohorts. CMS's model changes have the potential to reduce coding intensity, but they do not target the full scope of hierarchies sensitive to coding intensity.