Medicare Advantage?

描述（由申请人提供）：医疗保险，为老年人和残疾人提供的公共医疗保险计划，面临着重大挑战;医疗保健成本和医疗保险人口迅速增长，但医疗保险仅覆盖老年人医疗保健支出的45%，因此需要扩大计划和减少支出。长期以来，政策制定者一直将医疗保险管理式医疗（MMC）视为为老年人提供额外福利和减少联邦支出的一种方式。MMC注册人数在2003年医疗保险现代化法案（MMA）改革下迅速增长。MMC参加者接受网络和使用限制，以换取额外的好处和减少成本分担相比，收费服务医疗保险（FFS）。公共政策鼓励MMC注册，尽管目前缺乏关于MMC质量和访问或评估MMC是否有有限的计划支出的实证研究。分析20世纪90年代早期数据的现有研究表明MMC存在质量问题（Experton等人，1999; Riley等人，1999），预防性服务使用除外（Landon等人，2004; Morales等人，2004年）。自那时以来，MMC发生了很大变化，但尚未对改革进行评估。MMC可能会阻止患者使用昂贵的服务，以实现利润最大化，对具有复杂健康需求的注册者产生不利影响，或通过提供预防性服务来保护注册者。这项研究主要力求：1-测试在FFS和MMC的质量和获得保健的差异;支持分析将：2-检查立法支付率和受益人特征对入学的影响;和3-通过测试是否更大的MMC入学率降低县级总成本来评估MMC的成本质量权衡。焦点分析将通过使用一个县的门诊护理敏感（可预防）、转诊敏感和参考住院的数量来检查护理质量和获得护理的机会。可接受的住院治疗被广泛用于评估质量和确定获得保健的潜在问题（澳大利亚人权Q，2004年）。将使用1999 - 2004年亚利桑那州、佛罗里达州、新泽西州和纽约州医疗保健研究和质量机构的州住院患者数据库（SID）与医疗保险和医疗补助服务中心县级MMC登记和支付数据以及来自地区资源文件的县级数据。该研究将包括FFS或MMC涵盖的65岁及以上老年人的所有住院治疗。支付率将用于MMC入组，允许无偏估计固定效应和负二项回归，确定MMC的因果质量、访问、入组和成本效应。调查结果将告知老年人，他们的家人和政策制定者MMC是否在质量上与FFS Medicare相当，并有效降低整体成本。由于参加MMC的人更有可能是低收入的少数族裔老年人，他们负担不起其他健康保险方案，因此必须确保鼓励弱势老年人参加提供优质保健的方案（AHIP，2005年）。

Description (provided by the applicant): Medicare, the public health insurance program for the elderly and disabled, faces major challenges; healthcare costs and the Medicare population are growing rapidly, yet Medicare covers only 45 percent of healthcare spending for the elderly, creating demand for both program expansion and reductions in spending. Policymakers have long viewed Medicare managed care (MMC) as a way to provide seniors with additional benefits and reduce Federal expenditures. MMC enrollment is quickly growing under 2003 Medicare Modernization Act (MMA) reforms. MMC enrollees accept network and utilization restrictions in exchange for additional benefits and reduced cost sharing compared to fee-for-service Medicare (FFS). Public policy encourages MMC enrollment despite an absence of current empirical research about MMC quality and access or assessment of whether MMC has limited program spending. Existing research analyzing data from the early 1990s indicates quality problems in MMC (Experton et al., 1999; Riley et al., 1999) with the exception of preventative service use (Landon et al., 2004; Morales et al., 2004). MMC has changed greatly since that period, though reforms have not been evaluated. MMC may discourage use of expensive services for those who are sick in order to maximize profits, adversely affecting enrollees with complex health needs, or protect enrollees through preventative service provision. This study primarily seeks to: 1- test for differences in quality and access to care in FFS and MMC; supporting analyses will: 2-- examine effects of legislated payment rates and beneficiary characteristics on enrollment; and 3- assess cost-quality tradeoffs of MMC by testing whether greater MMC enrollment reduces total county-level costs. The focal analysis will examine quality and access to care by using the numbers of ambulatory care sensitive (preventable), referral sensitive, and reference hospitalizations in a county. Preventable hospitalizations have been used extensively to assess quality and identify potential problems accessing health care (AHRQ, 2004). Agency for Healthcare Research and Quality's State Inpatient Database (SID) from 1999 - 2004 for Arizona, Florida, New Jersey and New York merged with Centers for Medicare and Medicaid Services county level MMC enrollment and payment data and county level data from the Area Resource File will be used. The study will include all hospitalizations covered by FFS or MMC for seniors aged 65 and over. Payment rates will be used to instrument for MMC enrollment, allowing the unbiased estimation of fixed effects and negative binomial regressions identifying causal quality, access, enrollment, and cost effects of MMC. Findings will inform seniors, their families, and policymakers whether MMC is comparable in quality to FFS Medicare and effective at reducing overall costs. As MMC enrollees are more likely to be low-income, minority seniors who cannot afford alternative health insurance options, it is important to ensure that disadvantaged elders are encouraged to enroll in programs providing quality health care (AHIP, 2005).