Kristensen Troels, Olsen Kim Rose, Schroll Henrik, Thomsen Janus Laust, Halling Anders
Faculty of Health Sciences, COHERE-Centre of Health Economics Research, Institute of Public Health, University of Southern Denmark, Windsløwparken 9A, J.B. Winsløws Vej 9, 5000, Odense C, Denmark,
Eur J Health Econ. 2014 Jul;15(6):599-610. doi: 10.1007/s10198-013-0499-7. Epub 2013 Jul 2.
In primary care, fee-for-services (FFS) tariffs are often based on political negotiation rather than costing systems. The potential for comprehensive measures of patient morbidity to explain variation in negotiated FFS expenditures has not previously been examined.
To examine the relative explanatory power of morbidity measures and related general practice (GP) clinic characteristics in explaining variation in politically negotiated FFS expenditures.
We applied a multilevel approach to consider factors that explain FFS expenditures among patients and GP clinics. We used patient morbidity characteristics such as diagnostic markers, multimorbidity casemix adjustment based on resource utilisation bands (RUB) and related GP clinic characteristics for the year 2010. Our sample included 139,527 patients visiting GP clinics.
Out of the individual expenditures, 31.6% were explained by age, gender and RUB, and around 18% were explained by RUB. Expenditures increased progressively with the degree of resource use (RUB0-RUB5). Adding more patient-specific morbidity measures increased the explanatory power to 44%; 3.8-9.4% of the variation in expenditures was related to the GP clinic in which the patient was treated.
Morbidity measures were significant patient-related FFS expenditure drivers. The association between FFS expenditure and morbidity burden appears to be at the same level as similar studies in the hospital sector, where fees are based on average costing. However, our results indicate that there may be room for improvement of the association between politically negotiated FFS expenditures and morbidity in primary care.
在初级医疗保健中，按服务收费（FFS）的费率通常基于政治谈判而非成本核算系统。此前尚未研究过用患者发病率的综合指标来解释谈判达成的FFS支出差异的可能性。
研究发病率指标及相关全科医疗（GP）诊所特征在解释政治谈判达成的FFS支出差异方面的相对解释力。
我们采用多层次方法来考虑解释患者和GP诊所FFS支出的因素。我们使用了患者发病率特征，如诊断标志物、基于资源利用分组（RUB）的多重疾病病例组合调整以及2010年相关的GP诊所特征。我们的样本包括139,527名就诊于GP诊所的患者。
在个体支出中，31.6%可由年龄、性别和RUB解释，约18%可由RUB解释。支出随着资源使用程度（RUB0 - RUB5）逐步增加。增加更多患者特异性发病率指标可将解释力提高到44%；支出差异的3.8 - 9.4%与患者接受治疗的GP诊所有关。
发病率指标是与患者相关的FFS支出的重要驱动因素。FFS支出与发病率负担之间的关联似乎与医院部门的类似研究处于同一水平，在医院部门费用基于平均成本核算。然而，我们的结果表明，在初级医疗保健中，政治谈判达成的FFS支出与发病率之间的关联可能仍有改进空间。
