Learning from Program Differences between Medicaid and Medicare

摘要 医疗保险和医疗补助是美国最大的社会健康保险计划 为超过1.3亿美国人提供医疗保险。虽然这些程序共享一些关键属性，但它们 在重要方面也有不同，关键的制度差异是国家对 他们的医疗补助计划的设计，而医疗保险是在国家一级管理的。尽管他们 对美国医疗保健系统的重要性，几乎没有严格的准实验工作来研究如何 两个项目在以下方面进行了比较：医疗服务的可及性、质量和结果 注册人员。在这个项目中，我们将通过跟踪成年人来检验这两个项目的相对效果 在65岁之前参加联邦医疗补助并在65岁及以上参加联邦医疗保险的残疾人士-即 只有医疗补助的残疾成年人转变为同时参加医疗补助和医疗保险的双重资格。 在65岁之前同时参加医疗补助和医疗保险的残疾成年人将担任 对照组，因为他们在65岁时不会经历不同计划之间的过渡。研究这些变化以 双重资格将使我们能够隔离州医疗补助计划对患者护理和 与结构上不同的医疗保险计划相关的结果(例如，参与提供者的范围更广 而不是医疗补助)，以及探索这些影响在各州医疗补助计划的不同特征中的变化。在……里面 目标1，我们将评估在这两个计划中参与者的护理和结果有何不同。在目标2中，我们将 探索项目差异背后的机制。要做到这一点，我们将利用这样一个事实，即没有 一项医疗补助计划，但有51项，提供者获得和支付的程度各不相同。具体地说，我们将分析 医疗补助-医疗保险过渡在医疗服务提供者支付金额较高的州(相对于联邦医疗保险)与 供应商付款较低的州。我们将以同样的方式比较那些将条款外包出去的州 医疗补助计划受益于私人管理的医疗保健计划，而不是州政府。这将提供新的证据 这两个重要因素在多大程度上解释了医疗补助和医疗保险的总体差异，并将产生 对程序设计的影响。在目标3中，我们重点关注医疗补助和医疗保险的一个特定组成部分 福利包：处方药。我们将使用联邦医疗保险D部分的推出(将双重- 符合条件的人，从Medicaid药品覆盖范围到Medicare药品覆盖范围)，以评估药品福利组成部分 这两个方案对参与者的药物使用和相关的健康结果有不同的影响。在这里，我们将 还利用各州医疗补助计划的差异来探索机制，重点是州内的差异 使用对受益人可以填写的处方数量和事先授权要求的上限。这些 分析将为重要的计划设计决策(付款率、 管理式医疗、药物上限、事先授权)对低收入和 残障美国人。

ABSTRACT Medicare and Medicaid are the largest social health insurance programs in the United States, together providing health insurance for over 130 million Americans. While the programs share some key attributes, they also differ in important ways, with the key institutional difference being that states have significant control over the design of their Medicaid programs while Medicare is managed at the national level. Despite their importance to the U.S. health care system, there is little rigorous quasi-experimental work studying how the two programs compare to each other in terms of their effects on health care access, quality, and outcomes for enrollees. In this project, we will examine the relative effects of these two programs by following adults with disabilities who are enrolled in Medicaid before age 65 into Medicare at age 65 and beyond—that is, as disabled adults with only Medicaid switch to become dual-eligibles enrolled in both Medicaid and Medicare. Adults with disabilities who are dually enrolled in both Medicaid and Medicare before age 65 will serve as the control group, as they do not experience a transition between programs at age 65. Studying these changes to dual eligibility will allow us to isolate the average effects of state Medicaid programs on patient care and outcomes relative to a structurally different Medicare program (e.g., with a wider set of participating providers than Medicaid), as well as to explore variation in these effects across features of state Medicaid programs. In Aim 1, we will estimate how enrollees' care and outcomes differ in these two programs. In Aim 2, we will explore the mechanisms behind the program differences. To do this, we will leverage the fact that there is not one Medicaid program but 51, with varying levels of provider access and payment. Specifically, we will analyze how the Medicaid-Medicare transition differs in states with high provider payments (relative to Medicare) vs. states with low provider payments. We will do the same to compare states that contract out the provision of Medicaid benefits to private managed care plans vs. states that do not. This will provide new evidence on the extent to which these two important factors explain overall Medicaid-Medicare differences and will have implications for program design. In Aim 3, we focus on one specific component of the Medicaid and Medicare benefit packages: prescription drugs. We will use the introduction of Medicare Part D (which shifted dual- eligibles from Medicaid drug coverage to Medicare drug coverage) to assess how the drug benefit component of these two programs differentially affects enrollees' use of drugs and related health outcomes. Here, we will also leverage variation across state Medicaid programs to explore mechanisms, focusing on variation in state use of caps on the number of prescriptions beneficiaries can fill and prior authorization requirements. These analyses will provide critical lessons for the effects of important program design decisions (payment rates, managed care, drug caps, prior authorization) on health care delivery and health outcomes for low-income and disabled Americans.