Fortney John C, Booth Brenda M, Kirchner JoAnn E, Han Xiaotong
VA HSR&D Center for Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, USA.
J Rural Health. 2003 Summer;19(3):292-8. doi: 10.1111/j.1748-0361.2003.tb00576.x.
Different types of health plan cost-containment strategies (eg, gatekeeping, selective contracting, and cost-sharing) may affect the utilization of behavioral health services differently in urban and rural areas.
This research compares the cost-containment strategies used by the health plans of insured at-risk drinkers residing in rural and urban areas.
A screening instrument for at-risk drinking was administered by phone to approximately 12,000 residents of 6 southern states; 442 at-risk drinkers completed 4 interviews over a 2-year period and consented to release insurance and medical records. Two thirds of the sample (n=294) were insured during the last 6 months of the study. In 1998, health plan characteristics were successfully collected for 217 (72.3%) of the insured at-risk drinkers, representing 113 different health plans and 206 different policies.
Compared with urban at-risk drinkers, rural at-risk drinkers were significantly less likely to be enrolled in a health plan with gatekeeping policies for both behavioral health (P = .001), and physical health (P = .031). Compared with urban enrollees, rural enrollees were significantly more likely to pay deductibles (P = .042), to pay coinsurance for physical health services (P = .002), and to have limits placed on physical health services use (P = .067), but they were less likely to pay copayments for physical health (P = .046). Rural enrollees were less likely to face higher copayments (P = .007) and higher coinsurance (P = .076) for mental health than for physical health, compared to urban enrollees.
Because rural residents were more likely to be enrolled in indemnity plans and less likely to be enrolled in health maintenance organizations, rural at-risk drinkers were enrolled in plans that relied less on supply-side cost-containment strategies and more on demand-side cost-containment strategies targeting physical health service use, compared with their urban counterparts. Rural at-risk drinkers were less likely to be enrolled in health plans with greater cost-sharing for mental health than for physical health compared to urban at-risk drinkers.
不同类型的医保成本控制策略（如守门人制度、选择性签约和费用分担）可能对城乡地区行为健康服务的利用产生不同影响。
本研究比较了城乡地区有风险饮酒者的医保计划所采用的成本控制策略。
通过电话对美国南部6个州的约12000名居民进行了有风险饮酒筛查；442名有风险饮酒者在2年时间内完成了4次访谈，并同意提供保险和医疗记录。样本的三分之二（n = 294）在研究的最后6个月内参保。1998年，成功收集到217名（72.3%）参保有风险饮酒者的医保计划特征，代表113种不同的医保计划和206种不同的保险政策。
与城市有风险饮酒者相比，农村有风险饮酒者参加同时具有行为健康守门人政策（P = 0.001）和身体健康守门人政策（P = 0.031）的医保计划的可能性显著更低。与城市参保者相比，农村参保者支付免赔额（P = 0.042）、支付身体健康服务的共保费用（P = 0.002）以及对身体健康服务的使用设置限制（P = 0.067）的可能性显著更高，但支付身体健康服务的自付费用的可能性更低（P = 0.046）。与城市参保者相比，农村参保者因心理健康支付更高自付费用（P = 0.007）和更高共保费用（P = 0.076）的可能性低于因身体健康支付的情况。
由于农村居民更有可能参加赔偿计划，而参加健康维护组织的可能性较低，与城市有风险饮酒者相比，农村有风险饮酒者参加的医保计划较少依赖供应方成本控制策略，而更多地依赖针对身体健康服务使用的需求方成本控制策略。与城市有风险饮酒者相比，农村有风险饮酒者参加心理健康费用分担更高的医保计划的可能性低于参加身体健康费用分担更高的医保计划的可能性。
