Cunningham Peter J, Hadley Jack
Center for Studying Health System Change, Washington, DC 20024, USA.
Milbank Q. 2008 Mar;86(1):91-123. doi: 10.1111/j.1468-0009.2007.00514.x.
The decline over the past decade in the percentage of physicians providing care to charity and Medicaid patients has been attributed to both financial pressure and the changing practice environment. Policymakers should be concerned about these trends, since private physicians are a major source of medical care for low-income persons. This study examines how changes in physicians' practice income, ownership, and size affect their decisions to stop or start treating charity care and Medicaid patients.
This study uses panel data from four rounds of the Community Tracking Study Physician Survey. The dependent variables are the likelihood of physicians' (1) dropping charity care, (2) starting to provide charity care, (3) no longer accepting new Medicaid patients, and (4) starting to accept new Medicaid patients. The primary independent variables are changes in physicians' practice income, ownership, and practice type/size. Multivariate analysis controls for the effects of other physician practice characteristics, health policies, and health care market factors.
A decline in physicians' income increased the likelihood that a physician would stop accepting new Medicaid patients but had no effect on his or her decision to provide charity care. Those physicians who switched from being owners to employees or from small to larger practices were more likely to drop charity care and to start accepting Medicaid patients, and physicians who made the opposite practice changes did the reverse.
Changes in their income and practice arrangements make physicians less willing to accept Medicaid and uninsured patients. Moreover, physicians moving into different practice arrangements treat charity and Medicaid patients as substitutes rather than as similar types of patients. To reverse these trends, policymakers should consider raising Medicaid reimbursement rates and subsidizing organizations that encourage private physicians to provide charity care.
在过去十年中，为慈善机构患者和医疗补助患者提供护理的医生比例有所下降，这归因于财务压力和不断变化的执业环境。政策制定者应关注这些趋势，因为私人医生是低收入人群医疗护理的主要来源。本研究考察了医生执业收入、所有权和规模的变化如何影响他们停止或开始治疗慈善护理患者和医疗补助患者的决定。
本研究使用了四轮社区追踪研究医生调查的面板数据。因变量包括医生：（1）停止慈善护理的可能性；（2）开始提供慈善护理的可能性；（3）不再接受新的医疗补助患者的可能性；（4）开始接受新的医疗补助患者的可能性。主要自变量是医生执业收入、所有权和执业类型/规模的变化。多变量分析控制了其他医生执业特征、卫生政策和医疗保健市场因素的影响。
医生收入下降增加了医生停止接受新的医疗补助患者的可能性，但对其提供慈善护理的决定没有影响。那些从所有者转变为雇员或从小型执业转变为大型执业的医生更有可能停止慈善护理并开始接受医疗补助患者，而做出相反执业转变的医生则相反。
收入和执业安排的变化使医生不太愿意接受医疗补助患者和未参保患者。此外，转向不同执业安排的医生将慈善护理患者和医疗补助患者视为替代品，而不是类似类型的患者。为扭转这些趋势，政策制定者应考虑提高医疗补助报销率，并对鼓励私人医生提供慈善护理的组织提供补贴。
