Solanki G, Schauffler H H, Miller L S
Center for Health and Public Policy Studies, University of California, Berkeley, School of Public Health 94720-7360, USA.
Health Serv Res. 2000 Feb;34(6):1331-50.
To test empirically a model for estimating the direct and indirect effects of different forms of cost-sharing on the utilization of recommended clinical preventive services. DATA SOURCES/SETTINGS: Stratified random sample of 10,872 employees, 18-64 years, who had belonged to their plan for at least one year, from seven large companies that were members of the Pacific Business Group on Health (PBGH) in 1994.
The 1994 PBGH Health Plan Value Check Survey. 1994 PBGH data on requirements for employee out-of-pocket patient cost-sharing for 52 different health plans.
Five equations were derived to estimate the direct and indirect effects of two forms of cost-sharing (copayments and coinsurance/deductibles) in two forms of managed care (HMOs and PPO/indemnity plans) on four clinical preventive services: mammography screening, cervical cancer screening, blood pressure screening, and preventive counseling. Probit models were used to estimate elasticities for the indirect and direct effects.
Both forms of cost-sharing in both plan types had negative and significant indirect effects on preventive counseling (from -1 percent to -7 percent). The direct effect of cost-sharing was negative for preventive counseling (-5 percent to -9 percent) and Pap smears (from -3 percent to -9 percent) in both HMOs and PPOs, and for mammography only in PPOs (-3 percent to -9 percent). The results of the effects on blood pressure screening are inconclusive.
Both the direct and indirect effects of cost-sharing negatively affected the receipt of preventive counseling in HMOs and PPOs. As predicted, the direct negative effect of cost-sharing was greater than the indirect effect for Pap smears and mammography. Eliminating cost-sharing for these services may be important to increasing their utilization to recommended levels.
通过实证检验一个模型，以估计不同形式的费用分担对推荐的临床预防服务利用情况的直接和间接影响。
数据来源/设置：1994年从太平洋商业健康集团（PBGH）的七家大公司中选取了10872名年龄在18至64岁之间、已加入其保险计划至少一年的员工组成分层随机样本。
1994年PBGH健康计划价值检查调查。1994年PBGH关于52种不同健康计划中员工自付患者费用分担要求的数据。
推导了五个方程，以估计两种形式的管理式医疗（健康维护组织[HMOs]和优先提供者组织/赔偿计划[PPO/indemnity plans]）中两种费用分担形式（共付额和 coinsurance/免赔额）对四种临床预防服务的直接和间接影响：乳房X光检查、宫颈癌筛查、血压筛查和预防咨询。使用Probit模型估计间接和直接影响的弹性。
两种计划类型中的两种费用分担形式对预防咨询均有负面且显著的间接影响（从-1%至-7%）。在HMOs和PPOs中以及仅在PPOs中乳房X光检查方面，费用分担的直接影响对预防咨询（-5%至-9%）和巴氏涂片检查（从-3%至-9%）均为负面，仅在PPOs中乳房X光检查方面为负面（-3%至-9%）。对血压筛查的影响结果尚无定论。
费用分担的直接和间接影响均对HMOs和PPOs中预防咨询的接受情况产生负面影响。正如所预测的，费用分担的直接负面影响在巴氏涂片检查和乳房X光检查方面大于间接影响。消除这些服务的费用分担对于将其利用率提高到推荐水平可能很重要。
