Risk adjusting for Medicaid participation in Medicare Advantage.
Risk adjusting for Medicaid participation in Medicare Advantage.
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调整医疗补助参与Medicare Advantage的风险。
DOI：
10.37765/ajmc.2020.44076
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发表时间：
2020-08-01
期刊：
影响因子：
--
通讯作者：
Buntin MB
中科院分区：
文献类型：
--
作者：
Keohane LM;Stevenson DG;Stewart L;Thapa S;Freed S;Buntin MB
确定适当的资本支付对符合双重资格的Medicare Advantage（MA）成员具有重要的访问影响。在2017年，MA计划开始为受益人提供更高的资本化付款，当付款开始根据医疗补助福利水平而不是任何医疗补助参与进行风险调整时。这种方法可能有利于MA计划在国家更慷慨的医疗补助计划，更多的受益人有资格获得全额医疗补助，从而更高的资本支付。为了理解这个问题，我们研究了具有不同医疗补助资格标准的州的双重资格受益人的调整后的医疗保险支出。回顾性分析2007-2015年65岁及以上双重资格受益人的传统医疗保险数据。我们比较了调整任何医疗补助参与和不同医疗补助资格要求的各州医疗补助福利水平后的预测每位受益人支出水平。与最严格的州相比，医疗补助要求最慷慨的州有更多的双重资格受益人获得全额医疗补助（中位数为82%对55%）。在全国范围内，完全与部分医疗补助参与者的医疗保险支出水平是1.3倍（各州范围为0.8-1.7）。当每个受益人的支出根据医疗补助福利水平而不是任何医疗补助参与进行调整时，具有更慷慨的医疗补助资格的州在每个双重资格受益人的预测支出方面的收益大于医疗补助覆盖范围较不慷慨的州（1.7% vs 1.3%增加）。在MA付款中区分部分和全部医疗补助可能会不成比例地增加MA付款，因为更慷慨的医疗补助资格，这些州有更多的医疗补助受益人。
Determining appropriate capitated payments has important access implications for dual-eligible Medicare Advantage (MA) members. In 2017, MA plans began receiving higher capitated payments for beneficiaries with full vs partial Medicaid when payments started being risk adjusted for level of Medicaid benefits instead of any Medicaid participation. This approach could favor MA plans in states with more generous Medicaid programs where more beneficiaries qualify for full Medicaid and thus a higher capitated payment. To understand this issue, we examined adjusted Medicare spending for dual-eligible beneficiaries across states with differing Medicaid eligibility criteria. Retrospective analysis of 2007–2015 traditional Medicare data for dual-eligible beneficiaries 65 years and older. We compared predicted per-beneficiary spending levels after adjusting for any Medicaid participation and for level of Medicaid benefits across states with varying Medicaid eligibility requirements. States with the most generous Medicaid requirements had more dual-eligible beneficiaries with full Medicaid compared with the most restrictive states (median, 82% vs 55%). Nationally, Medicare spending levels were 1.3 times greater for full vs partial Medicaid participants (range across states, 0.8–1.7). When per-beneficiary spending was adjusted for level of Medicaid benefits, rather than any Medicaid participation, states with more generous Medicaid eligibility had larger gains in predicted spending per dual-eligible beneficiary than states with less generous Medicaid coverage (1.7% vs 1.3% increase). Distinguishing between partial and full Medicaid in MA payments may disproportionately increase MA payments in states that have more full Medicaid beneficiaries due to more generous Medicaid eligibility.
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影响因子：
3.4
作者：
Roberts, Eric T.;Mellor, Jennifer M.;Sabik, Lindsay M.
通讯作者：
Sabik, Lindsay M.
影响因子：
9.7
作者：
Roberts, Eric T.;Welsh, Jacqueline Hayley;Sabik, Lindsay M.
通讯作者：
Sabik, Lindsay M.
DOI：
10.1177/1077558717737152
发表时间：
2019-12
期刊：
Medical care research and review : MCRR
影响因子：
--
作者：
Keohane LM;Trivedi A;Mor V
通讯作者：
Mor V
影响因子：
9.7
作者：
Coughlin, Teresa A.;Waidmann, Timothy A.;Phadera, Lokendra
通讯作者：
Phadera, Lokendra
影响因子：
3.5
作者：
Mommaerts C
通讯作者：
Mommaerts C