Department of Community Health, Alpert Medical School of Brown University, Providence, RI 02912, USA.
N Engl J Med. 2010 Jan 28;362(4):320-8. doi: 10.1056/NEJMsa0904533.
When copayments for ambulatory care are increased, elderly patients may forgo important outpatient care, leading to increased use of hospital care.
We compared longitudinal changes in the use of outpatient and inpatient care between enrollees in Medicare plans that increased copayments for ambulatory care and enrollees in matched control plans--similar plans that made no changes in these copayments. The study population included 899,060 beneficiaries enrolled in 36 Medicare plans during the period from 2001 through 2006.
In plans that increased copayments for ambulatory care, mean copayments nearly doubled for both primary care ($7.38 to $14.38) and specialty care ($12.66 to $22.05). In control plans, mean copayments for primary care and specialty care remained unchanged at $8.33 and $11.38, respectively. In the year after the rise in copayments, plans that increased cost sharing had 19.8 fewer annual outpatient visits per 100 enrollees (95% confidence interval [CI], 16.6 to 23.1), 2.2 additional annual hospital admissions per 100 enrollees (95% CI, 1.8 to 2.6), 13.4 more annual inpatient days per 100 enrollees (95% CI, 10.2 to 16.6), and an increase of 0.7 percentage points in the proportion of enrollees who were hospitalized (95% CI, 0.51 to 0.95), as compared with concurrent trends in control plans. These estimates were consistent among a cohort of continuously enrolled beneficiaries. The effects of increases in copayments for ambulatory care were magnified among enrollees living in areas of lower income and education and among enrollees who had hypertension, diabetes, or a history of myocardial infarction.
Raising cost sharing for ambulatory care among elderly patients may have adverse health consequences and may increase total spending on health care.
当门诊护理的共付额增加时，老年患者可能会放弃重要的门诊护理，导致更多地使用住院护理。
我们比较了参加门诊护理共付额增加的 Medicare 计划的参保人和参加没有这些共付额变化的匹配对照组计划的参保人在门诊和住院护理使用方面的纵向变化。研究人群包括 2001 年至 2006 年期间参加 36 个 Medicare 计划的 899060 名参保人。
在门诊护理共付额增加的计划中，初级保健的平均共付额几乎翻了一番（从 7.38 美元增加到 14.38 美元），专科护理的共付额也从 12.66 美元增加到 22.05 美元。在对照组计划中，初级保健和专科保健的平均共付额保持不变，分别为 8.33 美元和 11.38 美元。在共付额增加的次年，增加费用分担的计划中，每 100 名参保人每年的门诊就诊次数减少 19.8 次（95%置信区间[CI]，16.6 至 23.1），每年的住院人数增加 2.2 次（95%CI，1.8 至 2.6），每年的住院天数增加 13.4 天（95%CI，10.2 至 16.6），以及住院参保人数比例增加 0.7 个百分点（95%CI，0.51 至 0.95），而对照组计划中则呈现出同期趋势。这些估计在一组连续参保人中是一致的。在收入和教育程度较低的地区以及患有高血压、糖尿病或心肌梗死病史的参保人中，门诊护理共付额的增加放大了其影响。
提高老年患者的门诊护理共付额可能会产生不良的健康后果，并可能增加医疗保健总支出。
