Use Of Patient Health Survey Data For Risk Adjustment To Limit Distortionary Coding Incentives In Medicare.

A core problem with the current risk-adjustment system in Medicare Advantage and accountable care organization (ACO) programs-the Hierarchical Condition Categories (HCC) model-is that the inputs (coded diagnoses) can be influenced for gain by risk-bearing plans or providers. Using existing survey data on health status (which provide less manipulable inputs), we found that the use of a hybrid risk score drawing from survey data and a scaled-back set of HCCs would, in addition to mitigating coding incentives, modestly lessen risk-selection incentives, strengthen payment incentives to deliver efficient care, allocate payment across ACOs more efficiently according to markers of population health that are not as affected by practice patterns or coding efforts, and redistribute payment in a manner that supports equity goals. Although sampling error and survey nonresponse present challenges, analyses suggest that these should not be prohibitive.

Strengths And Weaknesses Of Introducing An Inflation Factor Into The Medicare Physician Fee Schedule.

Unlike most other Medicare fee schedules, the Medicare Physician Fee Schedule does not include an automatic inflation update. We describe the history of Physician Fee Schedule update systems and present paradigms for evaluating the merits of adding an inflation-based adjustment factor to the schedule's updating formulas. We adopt an incentive paradigm, which emphasizes how access to care and the consolidation of health care facilities are affected by fees.

Promoting Access To Hospital Care In Rural Areas: Current Approaches And Ongoing Challenges.

Financial distress among rural hospitals is a significant concern for policy makers. Poor financial performance increases the likelihood of hospital closure and merger, and it can limit hospitals' ability to invest in quality improvements. In response to these challenges, policy makers are actively seeking ways to ensure access to affordable, high-quality care for rural communities.

Medicare Advantage: National Carriers Expand Market Share While Regional Carriers Without Affiliation Decline, 2012-23.

This study examined the evolving landscape of insurer competition in the Medicare Advantage (MA) program from both national and local perspectives. Data from the Centers for Medicare and Medicaid Services revealed that the MA market has become more concentrated. National carriers expanded their national market share significantly from 2012 to 2023, whereas the collective market share of regional carriers without affiliation to Blue Cross and Blue Shield organizations declined because of acquisitions.

Lack Of Persistent Coding In Traditional Medicare May Widen The Risk-Score Gap With Medicare Advantage.

Payments to Medicare Advantage (MA) plans are adjusted by a risk-score model that is calibrated on diagnostic and demographic data from traditional Medicare beneficiaries and then applied to MA beneficiaries. If MA plans capture more diagnostic codes than traditional Medicare, they receive payment that is higher than the amount that would be spent in traditional Medicare. Although most previous research has focused on the coding practices of MA plans, less attention has been paid to the completeness of coding in traditional Medicare.