wkoiu

作者：Laurie Barclay, MD  
出處：WebMD醫學新聞

　　January 27, 2010 — 根據一項發表於1月28日新英格蘭醫學期刊的研究結果，提高門診老年病患的掛號費可能對健康有不好的結果，且可能增加整體健康照護費用。
　　
　　來自羅德島普羅維登斯布朗大學阿爾珀特醫學院的Amal N. Trivedi醫師與其同事們寫到，當門診照護的自付額增加時，老年病患們可能放棄重要的門診病患照護，導致住院照護費用增加。研究增加門診照護自付額造成影響的研究非常少，即使是這些研究也是非常有限的，因為他們大部分排除老年病患，或是評估門診照護與處方藥物的費用分配同時發生的變化。我們因此檢驗增加門診照護自付額對於住院急性照護使用的影響，研究對象是一個全國具代表性、於照護計畫中的老年醫療保險群體。
　　
　　研究者們針對醫療保險計畫中門診照護自付額增加納保人的門診與住院照護使用變化，與這些自付額沒有改變的相符控制加入計畫病患進行比較。該醫療照護組包括899,060位於2001年到2006年之間收納在36個健康計畫的受益人。平均醫療保險自付額將近加倍，初級照護費用從7.38美元增加到14.38美元，而專科照護從12.66美元增加到22.05美元，但控制組計劃的平均自付額仍然沒有變化，分別是8.33美元與11.38美元。
　　
　　相較於控制組計畫，醫療保險計畫每年門診量在自付額增加的那一年，每100位病患少了19.8次（95%信賴區間[CI]為16.6-23.1），住院量每100位病患增加2.2件（95% CI為1.8-2.6），住院天數每100位病患增加13.4天（95% CI為10.2-16.6），住院病患比例也上升0.7%（95% CI為0.51-0.95）。
　　
　　這項研究的限制在於缺乏隨機分派納保人至病例與控制組計畫、觀察期短、面積小於普查區域的地方無法找到相符的病例與控制組計畫、以及缺乏與住院及門診就診有關的診斷、手續及費用的資料，或是無法分別評估費用分擔增加程度以及之後住院照護使用之間的關係。
　　
　　研究作者們寫到，提高老年病患門診照護費用分擔可能造成不良的健康結果，且可能增加健康照護整體花費。居住在低收入區域以及有高血壓、糖尿病或心肌梗塞病史的納保人，門診照護自付額增加的效應是更大的。
　　
　　Trivedi醫師是輝瑞健康政策學者獎的得獎者，也是退伍軍人事務健康服務研究以及發展服務的職業發展獎項得主。研究作者們表示已無相關資金上的往來。


Raising Copay for Elderly Ambulatory Care May Have Adverse Consequences

By Laurie Barclay, MD
Medscape Medical News

January 27, 2010 — Raising cost sharing for ambulatory care among elderly patients may have negative health consequences and may increase total healthcare costs, according to the results of a study reported in the January 28 issue of The New England Journal of Medicine.

"When copayments for ambulatory care are increased, elderly patients may forgo important outpatient care, leading to increased use of hospital care," write Amal N. Trivedi, MD, MPH, from the Alpert Medical School of Brown University in Providence, Rhode Island, and colleagues. "There have been remarkably few studies of the consequences of increasing copayments for ambulatory care, and even these studies have been limited because they have excluded elderly patients or have evaluated concurrent changes in cost sharing for ambulatory care and prescription drugs. We therefore examined the effect of increasing copayments for ambulatory care on the use of acute care in the hospital among a large, nationally representative cohort of elderly Medicare enrollees in managed-care plans."

The investigators compared changes in the use of outpatient and inpatient care between enrollees in Medicare plans that increased copayments for ambulatory care and enrollees in matched control plans that made no changes in these copayments. The Medicare group consisted of 899,060 beneficiaries enrolled in 36 plans from 2001 through 2006. Mean Medicare copayments nearly doubled, increasing from $7.38 to $14.38 for primary care and from $12.66 to $22.05 for specialty care, whereas mean copayments in control plans remained unchanged at $8.33 and $11.38, respectively.

Compared with control plans, Medicare plans had 19.8 fewer annual outpatient visits per 100 enrollees in the year after the rise in copayments (95% confidence interval [CI], 16.6 - 23.1), as well as 2.2 additional annual hospital admissions per 100 enrollees (95% CI, 1.8 - 2.6), 13.4 more annual inpatient days per 100 enrollees (95% CI, 10.2 - 16.6), and a 0.7 percentage point increase in the proportion of enrollees who were hospitalized (95% CI, 0.51 - 0.95).

Limitations of this study include lack of randomization of enrollees to case and control plans, short period of observation, inability to match case plans with control plans in a geographic area smaller than a census region, and lack of data on the diagnoses, procedures, and costs associated with hospital admissions and outpatient visits. In addition, the effects of increasing cost sharing for primary care visits vs specialty care visits, or the relationship between the magnitude of cost-sharing increases and subsequent use of hospital care, could not be evaluated separately.

"Raising cost sharing for ambulatory care among elderly patients may have adverse health consequences and may increase total spending on health care," the study authors write. "The effects of increases in copayments for ambulatory care were magnified among enrollees living in areas of lower income and education and among enrollees who had hypertension, diabetes, or a history of myocardial infarction."

Dr. Trivedi is the recipient of a Pfizer Health Policy Scholars Award and a career development award from the Veterans Affairs Health Services Research and Development Service. The study authors have disclosed no relevant financial relationships.

N Engl J Med. 2010;362:320-328.