The policy community generally has assumed Medicare Advantage (MA) plans negotiate hospital payment rates similar to those for commercial insurance products and well above those in traditional Medicare. After surveying senior hospital and health plan executives, we found, however, that MA plans nominally pay only 100-105 percent of traditional Medicare rates and, in real economic terms, possibly less. Respondents broadly identified three primary reasons for near-payment equivalence: statutory and regulatory provisions that limit out-of-network payments to traditional Medicare rates, de facto budget constraints that MA plans face because of the need to compete with traditional Medicare and other MA plans, and a market equilibrium that permits relatively lower MA rates as long as commercial rates remain well above the traditional Medicare rates. We explored a number of policy implications not only for the MA program but also for the problem of high and variable hospital prices in commercial insurance markets.
The decisions made by stakeholders in the nation's health care system that affect the quality of care experienced by patients are too often made without the benefit of scientific evidence. A multidisciplinary set of investigators conducting health services research have traditionally filled this gap between research findings and clinical decision making, but several barriers are hindering this work. This article offers several recommendations-restructuring organizations, ensuring funding, developing infrastructure, strengthening the community of researchers, and forging new links among stakeholders-to promote high-quality information for health decision makers.
The decisions made by stakeholders in the nation's health care system that affect the quality of care experienced by patients are too often made without the benefit of scientific evidence. A multidisciplinary set of investigators conducting health services research have traditionally filled this gap between research findings and clinical decision making, but several barriers are hindering this work. This article offers several recommendations—restructuring organizations, ensuring funding, developing infrastructure, strengthening the community of researchers, and forging new links among stakeholders—to promote high-quality information for health decision makers.
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