Physician Reimbursement in Medicare Advantage Compared With Traditional Medicare and Commercial Health Insurance
Physician Reimbursement in Medicare Advantage Compared With Traditional Medicare and Commercial Health Insurance
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DOI：
10.1001/jamainternmed.2017.2679
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发表时间：
2017-09-01
影响因子：
39
通讯作者：
Joyce, Geoffrey
中科院分区：
文献类型：
--
作者：
Trish, Erin;Ginsburg, Paul;Joyce, Geoffrey
重要性 近三分之一的 Medicare 受益人加入了 Medicare Advantage (MA) 计划，但人们对 MA 计划为医生服务支付的价格知之甚少。 Medicare Advantage 保险公司通常也销售商业计划，而 MA 医生报销在多大程度上反映传统 Medicare (TM) 费率与协商商业价格的情况尚不清楚。 目的 比较 MA、传统 Medicare 和商业计划中为医生和其他医疗保健服务支付的价格。 设计、设置和参与者 对索赔数据进行回顾性分析，评估 2007 年至 2012 年间支付给医生、实验室服务和耐用医疗设备的 MA 价格。 348 个美国核心统计区域。研究人群包括在两个市场运营的大型国民健康保险公司的所有 MA 和商业参与者，以及 20% 的 TM 受益人样本。 风险 参与 MA 计划。 主要结果和措施 向 MA 和商业参与者支付给医生、实验室和耐用医疗设备供应商的平均报销金额，相对于跨 7 个地点的 11 个医疗保健通用程序编码系统 (HCPCS) 代码的 TM 费率care.结果 样本包含 1.44 亿份索赔。尽管 MA 计划支付给医生的费用往往低于 TM，但 MA 的医生报销与 TM 费率的联系比商业价格更紧密。对于已确定患者的中层办公室就诊（当前程序术语 [CPT] 代码 99213），平均 MA 价格为 TM 的 96.9%（95% CI，96.7%-97.2%）。在我们评估的常见医生服务中，平均 MA 报销范围为门诊手术中心白内障摘除术的 TM 的 91.3%（CPT 66984；95% CI，90.7%-91.9%）到急诊科患者复杂评估和管理的 TM 的 102.3%（CPT 99285；95% CI， 102.1%-102.6%）。然而，对于实验室服务和耐用医疗设备，其商业价格低于 TM 价格，MA 计划利用这些较低的商业价格，范围从步行器的 67.4%（HCPCS 代码 E0143；95% CI，66.3%-68.5%）到全血细胞计数的 75.8%（CPT 85025；95% CI， 75.0%-76.6%). 结论和相关性 尽管 MA 计划成功地为 TM 支付过高的其他医疗保健服务谈判降低了价格，但传统 Medicare 的行政设定费率是 MA 市场中医生报销的有力支柱。将医疗保险计划转向某些保费支持模式的改革可能会极大地影响医生和其他临床医生的报酬方式。
IMPORTANCE Nearly one-third of Medicare beneficiaries are enrolled in a Medicare Advantage (MA) plan, yet little is known about the prices that MA plans pay for physician services. Medicare Advantage insurers typically also sell commercial plans, and the extent to which MA physician reimbursement reflects traditional Medicare (TM) rates vs negotiated commercial prices is unclear.OBJECTIVE To compare prices paid for physician and other health care services inMA, traditional Medicare, and commercial plans.DESIGN, SETTING, AND PARTICIPANTS Retrospective analysis of claims data evaluatingMA prices paid to physicians and for laboratory services and durable medical equipment between 2007 and 2012 in 348 US core-based statistical areas. The study population included all MA and commercial enrollees with a large national health insurer operating in both markets, as well as a 20% sample of TM beneficiaries.EXPOSURES Enrollment in an MA plan.MAIN OUTCOMES AND MEASURES Mean reimbursement paid to physicians, laboratories, and durable medical equipment suppliers forMA and commercial enrollees relative to TMrates for 11 Healthcare Common Procedure Coding Systems (HCPCS) codes spanning 7 sites of care.RESULTS The sample consisted of 144 million claims. Physician reimbursement in MA was more strongly tied to TM rates than commercial prices, although MA plans tended to pay physicians less than TM. For a mid-level office visit with an established patient (Current Procedural Terminology [CPT] code 99213), the mean MA price was 96.9% (95% CI, 96.7%-97.2%) of TM. Across the common physician services we evaluated, mean MA reimbursement ranged from 91.3% of TM for cataract removal in an ambulatory surgery center (CPT 66984; 95% CI, 90.7%-91.9%) to 102.3% of TMfor complex evaluation and management of a patient in the emergency department (CPT 99285; 95% CI, 102.1%-102.6%). However, for laboratory services and durable medical equipment, where commercial prices are lower than TM rates, MA plans take advantage of these lower commercial prices, ranging from 67.4% for a walker (HCPCS code E0143; 95% CI, 66.3%-68.5%) to 75.8% for a complete blood cell count (CPT 85025; 95% CI, 75.0%-76.6%).CONCLUSIONS AND RELEVANCE Traditional Medicare's administratively set rates act as a strong anchor for physician reimbursement in the MA market, although MA plans succeed in negotiating lower prices for other health care services for which TM overpays. Reforms that transition the Medicare program toward some premium support models could substantially affect how physicians and other clinicians are paid.