医疗保险优势计划的出价与支付给计划的费用之间的差异越来越大。

Health affairs scholar Pub Date : 2024-08-05 eCollection Date: 2024-08-01 DOI:10.1093/haschl/qxae093
Grace McCormack, Erin Trish
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引用次数: 0

摘要

随着医疗保险优势计划(MA)参保人数和费用的增长,人们越来越担心联邦向医疗保险计划支付的费用超过了必要的水平。据估计,在 2023 年,MA 计划为每位参保者支付的费用将比该受益人参加传统医疗保险 (TM) 所需的费用高出 6%。我们评估了造成这种超额支付的因素,分析了从 2023 年《可负担医疗法案》(pre-ACA)之前的水平到 2023 年的医疗保险基准、投标和总支付的趋势。我们发现,尽管相对于经风险调整的 TM 参保者平均费用而言,经风险调整的出价总体上有所下降,但自 2015 年以来,向计划支付的总金额却略有增加。将这些趋势分解为医疗保险支付公式中的各种因素,我们发现基准和出价的不同趋势部分是由于支付调整的影响越来越大,如四分位支出调整、质量奖励支付和风险调整。我们的研究结果表明,现行的支付规则导致了超额支付,因此有必要进行政策改革。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Growing divergence between Medicare Advantage plan bids and payments to plans.

As the Medicare Advantage (MA) program grows in enrollment and costs, there has been increasing concern that federal payments to MA plans exceed necessary levels. Estimates suggest that, in 2023, MA plans were paid up to 6% more per enrollee than would have been spent had that beneficiary instead enrolled in traditional Medicare (TM). We evaluated the factors driving this overpayment, characterizing trends in MA benchmarks, bids, and total payments from pre-Affordable Care Act (pre-ACA) levels through 2023. We found that, despite an overall decrease in risk-adjusted bids relative to average risk-adjusted TM enrollee costs, total payments to plans have modestly increased since 2015. Decomposing these trends into various factors in the MA payment formula, we found that divergent trends in benchmarks and bids are, in part, due to the increasing influence of payment adjustments, such as quartile spending adjustments, quality bonus payments, and risk adjustment. Our results suggest that current payment rules have contributed to overpayments and policy reform may be necessary.

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