Soumerai S B, Ross-Degnan D, Avorn J, McLaughlin T j, Choodnovskiy I
Department of Social Medicine, Harvard Medical School, Boston, MA 02115.
N Engl J Med. 1991 Oct 10;325(15):1072-7. doi: 10.1056/NEJM199110103251505.
Many state Medicaid programs limit the number of reimbursable medications that a patient can receive. We hypothesized that such limitations may lead to exacerbations of illness or to admissions to institutions where there are no caps on drug reimbursements.
We analyzed 36 months of Medicaid claims data from New Hampshire, which had a three-drug limit per patient for 11 of those months, and from New Jersey, which did not. The study patients in New Hampshire (n = 411) and a matched comparison cohort in New Jersey (n = 1375) were Medicaid recipients 60 years of age or older who in a base-line year had been taking three or more medications per month, including at least one maintenance drug for certain chronic diseases. Survival (defined as remaining in the community) and time-series analyses were conducted to determine the effect of the reimbursement cap on admissions to hospitals and nursing homes.
The base-line demographic characteristics of the cohorts were nearly identical. In New Hampshire, the 35 percent decline in the use of study drugs after the cap was applied was associated with an increase in rates of admission to nursing homes; no changes were observed in the comparison cohort (RR = 1.8; 95 percent confidence interval, 1.2 to 2.6). There was no significantly increased risk of hospitalization. Among the patients in New Hampshire who regularly took three or more study medications at base line, the relative risk of admission to a nursing home during the period of the cap was 2.2 (95 percent confidence interval, 1.2 to 4.1), and the risk of hospitalization was 1.2 (95 percent confidence interval, 0.8 to 1.6). When the cap was discontinued after 11 months, the use of medications returned nearly to base-line levels, and the excess risk of admission to a nursing home ceased. In general, the patients who were admitted to nursing homes did not return to the community.
Limiting reimbursement for effective drugs puts frail, low-income, elderly patients at increased risk of institutionalization in nursing homes and may increase Medicaid costs.
许多州的医疗补助计划限制了患者可报销药物的数量。我们推测，此类限制可能会导致病情加重，或导致患者入住药物报销无上限的机构。
我们分析了新罕布什尔州36个月的医疗补助索赔数据（其中11个月对每位患者有三种药物的限制）以及新泽西州（无此类限制）的相关数据。新罕布什尔州的研究患者（n = 411）以及新泽西州匹配的对照队列（n = 1375）均为60岁及以上的医疗补助受益患者，在基线年份每月服用三种或更多药物，包括至少一种用于某些慢性病的维持药物。进行生存分析（定义为仍留在社区）和时间序列分析，以确定报销上限对医院和疗养院入院率的影响。
各队列的基线人口统计学特征几乎相同。在新罕布什尔州，实施报销上限后研究药物使用量下降35%，这与疗养院入院率增加相关；对照队列未观察到变化（相对风险 = 1.8；95%置信区间，1.2至2.6）。住院风险没有显著增加。在新罕布什尔州基线时定期服用三种或更多研究药物的患者中，报销上限期间入住疗养院的相对风险为2.2（95%置信区间，1.2至4.1），住院风险为1.2（95%置信区间，0.8至1.6）。11个月后报销上限取消时，药物使用量几乎恢复到基线水平，入住疗养院的额外风险也随之消失。一般来说，入住疗养院的患者没有重返社区。
限制有效药物的报销会使体弱、低收入的老年患者入住疗养院的风险增加，并可能增加医疗补助成本。
