Lee-Feldstein Anna, Feldstein Paul J, Buchmueller Thomas
Center for Health Policy and Research, Department of Medicine, College of Medicine, University of California, Irvine, California 92697-5800, USA.
Med Care. 2002 May;40(5):362-74. doi: 10.1097/00005650-200205000-00002.
With the growth in enrollment of Medicare patients in HMOs the effectiveness of care received by Medicare/HMO patients continues to be of concern. By considering the relationship of insurance to stage at diagnosis, this study inquires whether HMOs emphasize early diagnosis of colorectal cancer to a greater extent than FFS plans, if particular HMO types (group/nongroup models) are more successful in doing so, and how this pertains to survival.
Data for 1329 Medicare patients with colorectal cancer, diagnosed 1987 to 1993, and residing in northern California, were acquired from a population-based cancer registry. Insurance included two types of Medicare HMOs (group and nongroup model) and three fee-for-service (FFS) categories: Medicare with private supplement, Medicare/Medicaid, and Medicare only. The relationships of insurance to AJCC stage at diagnosis and of insurance to survival following diagnosis were examined, respectively, with logistic regression models and survival analysis (controlling for age, ethnicity, tumor location, educational level, sex, and hospital type).
Likelihood of early stage colorectal cancer was greater for Medicare patients in nongroup model HMOs or having private FFS supplements than for those in group model HMOs, Medicare/Medicaid, or Medicare alone. All-cause and colorectal cancer mortality did not differ significantly among Medicare patients with group model HMO, nongroup model HMO and private FFS supplements. Medicare/Medicaid patients experienced significantly greater all-cause mortality than private FFS patients.
Differences within this study population in early stage diagnosis of colorectal cancer and breast cancer, respectively, by type of Medicare supplemental insurance may be attributable to which preventive screening measures are included in health plan report cards.
随着医疗保险患者加入健康维护组织（HMO）的人数增加，医疗保险/HMO患者所接受治疗的有效性仍然受到关注。通过考虑保险与诊断分期之间的关系，本研究探讨HMO是否比按服务项目付费（FFS）计划更强调结直肠癌的早期诊断，特定的HMO类型（团体/非团体模式）在这方面是否更成功，以及这与生存率有何关联。
从基于人群的癌症登记处获取了1987年至1993年诊断出患有结直肠癌且居住在北加利福尼亚州的1329名医疗保险患者的数据。保险类型包括两种医疗保险HMO（团体和非团体模式）以及三种按服务项目付费（FFS）类别：有私人补充保险的医疗保险、医疗保险/医疗补助以及仅医疗保险。分别使用逻辑回归模型和生存分析（控制年龄、种族、肿瘤位置、教育程度、性别和医院类型）来研究保险与诊断时的美国癌症联合委员会（AJCC）分期之间的关系以及保险与诊断后生存率之间的关系。
非团体模式HMO或有私人FFS补充保险的医疗保险患者患早期结直肠癌的可能性高于团体模式HMO、医疗保险/医疗补助或仅医疗保险的患者。团体模式HMO、非团体模式HMO和有私人FFS补充保险的医疗保险患者之间的全因死亡率和结直肠癌死亡率没有显著差异。医疗保险/医疗补助患者的全因死亡率显著高于私人FFS患者。
在本研究人群中，结直肠癌和乳腺癌早期诊断因医疗保险补充保险类型不同而存在差异，这可能归因于健康计划报告卡中包含哪些预防性筛查措施。
