Within the context of Medicare’s enunciated triple aims of better health, better care, and lower costs, we examine the effectiveness of medical loss ratio (MLR) on health outcomes of Medicare Advantage insurers. We simultaneously examine the effect of an efficiency measure for the insurer performance: medical service utilization efficiency (an assessment of how efficiently an insurer provides medical services). This research is based upon collection and integration of several data sources: health outcome data, financial data, and medical service utilization data. The assessment procedure employs a two-stage analytical approach: efficiency analysis followed by regressions. We quantify insurer efficiency using data envelopment analysis (DEA), which determines the relative efficiency of an insurer when the inputs and outputs can both be multivariate. We then run regressions with the dependent variables being functional health outcomes (“improving or maintaining mental health,” “improving or maintaining physical health,” and “improving or maintaining physical and mental health”) and health improvement efficiency (how cost-efficient the insurer is in improving functional health outcomes). Independent variables include MLR, medical service utilization efficiency, and a rich set of control variables. We find that neither MLR nor medical service utilization efficiency provides a good regulatory and evaluation indicator for stimulating/producing functional health outcomes. On the other hand, they do both significantly relate to health improvement efficiency, and hence are both reasonable regulatory and monitoring indicators for efficiently producing positive health outcomes. Our results suggest that to enhance health improvement efficiency, medical service utilization efficiency should be incorporated as a cost-efficient regulatory and monitoring indicator when evaluating Medical Advantage insurers.

在 Medicare 阐明的更好健康、更好护理和更低成本三重目标的背景下，我们研究了医疗损失率 (MLR) 对 Medicare Advantage 保险公司健康结果的有效性。我们同时研究了效率指标对保险公司绩效的影响：医疗服务利用效率（对保险公司提供医疗服务效率的评估）。这项研究基于多个数据源的收集和整合：健康结果数据、财务数据和医疗服务利用数据。评估程序采用两阶段分析方法：效率分析和回归。我们使用数据包络分析 (DEA) 来量化保险公司的效率，该分析确定了当输入和输出均为多元时保险公司的相对效率。然后，我们以功能性健康结果（“改善或维持心理健康”、“改善或维持身体健康”和“改善或维持身心健康”）和健康改善效率（改善或维持身心健康）为因变量进行回归。保险公司正在改善功能性健康结果）。自变量包括MLR、医疗服务利用效率以及丰富的控制变量。我们发现MLR和医疗服务利用效率都没有为刺激/产生功能性健康结果提供良好的监管和评估指标。另一方面，它们确实与健康改善效率显着相关，因此都是有效产生积极健康结果的合理监管和监测指标。