案例库 · 财务与会计 · 战略决策 · 2000–2024
这条还没译成中文，下面是英文原文。
Medicare paid insurers by expected risk, so taking sicker members was worth it
CMS-HCC risk adjustment pays private plans more for sicker enrollees, so covering high-cost seniors is no longer penalised.
Centers for Medicare & Medicaid Services · Medicare Advantage insurers · Medicare
那一手
Private Medicare Advantage plans are paid a per-member monthly amount by the government.
That amount is risk-adjusted so plans covering sicker members receive higher payments.
The CMS-HCC model uses diagnoses to predict each member's expected future cost.
This is meant to prevent adverse selection against high-cost enrollees.
为什么管用
- Risk adjustment compensates plans for genuinely sicker populations.
- It reduces the payoff to cherry-picking healthy enrollees.
- Payments track predicted cost, so coverage of expensive members is viable.
- It aligns the plan's interest with serving high-need patients.
可以搬走什么
If you pay the average, you select away the costly customers. Price the risk, and the market will serve whoever it is paid to serve.
后来呢
The model works as designed to offset risk, but it also created an incentive to document more diagnoses to raise payments. Analyses by KFF found chart reviews raised payments for about 1 in 6 enrollees, showing how a risk-adjustment system can be gamed when diagnoses drive revenue.
资料来源
- Chart Reviews Increase Payments to Medicare Advantage Insurers for 1 in 6 Enrollees
- UnitedHealthcare, Humana are gaming Medicare Advantage risk adjustment
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