Medicare Advantage?

描述(由申请人提供)：联邦医疗保险是为老年人和残疾人提供的公共健康保险计划，面临着重大挑战；医疗成本和联邦医疗保险人口迅速增长，但联邦医疗保险仅覆盖老年人医疗支出的45%，这创造了扩大计划和削减支出的需求。长期以来，政策制定者一直将联邦医疗保险管理保健(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。根据2003年《联邦医疗保险现代化法案》(MMA)的改革，MMC的注册人数正在迅速增长。与按服务付费的医疗保险(FFS)相比，MMC参与者接受网络和使用限制，以换取额外的福利和更低的成本分担。公共政策鼓励MMC的注册，尽管目前缺乏关于MMC质量和准入的实证研究，也没有对MMC是否有有限的计划支出的评估。分析1990年代早期数据的现有研究表明，除预防性服务使用外，MMC存在质量问题(Experton等人，1999；Riley等人，1999)(Landon等人，2004；Morales等人，2004)。自那以来，MMC发生了很大变化，尽管改革尚未得到评估。MMC可能不鼓励为生病的人使用昂贵的服务，以实现利润最大化，从而对有复杂健康需求的登记人产生不利影响，或通过预防性服务保护登记人。这项研究主要寻求：1-测试FFS和MMC在质量和获得护理方面的差异；支持性分析将：2-检查立法付款率和受益人特征对注册的影响；3-通过测试更多的MMC注册是否降低县级总成本来评估MMC的成本-质量权衡。重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。可预防的住院治疗已被广泛用于评估质量和确定获得医疗保健的潜在问题(AHRQ，2004)。卫生保健研究和质量署1999-2004年在亚利桑那州、佛罗里达州、新泽西州和纽约州的州住院患者数据库(SID)与医疗保险和医疗补助服务中心合并后将使用地区资源文件中的县级MMC登记和支付数据和县级数据。这项研究将包括FFS或MMC为65岁及以上老年人提供的所有住院治疗。付款率将用于MMC注册的工具，允许对确定MMC的因果质量、准入、注册和成本影响的固定影响和负二项回归进行无偏估计。调查结果将告知老年人、他们的家人和政策制定者，MMC在质量上是否与FFS Medicare相当，并在降低总体成本方面有效。由于MMC的参与者更有可能是负担不起替代医疗保险选择的低收入少数族裔老年人，因此重要的是确保鼓励弱势老年人参加提供高质量医疗保健的计划(AHIP，2005)。

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).