Bullock Justin B, Bradford W David
Bush School of Government and Public Service, Texas A&M University, College Station, USA.
Department of Public Administration and Policy, University of Georgia, 204 Baldwin Hall, Athens, GA, 30602, USA.
Int J Health Econ Manag. 2016 Mar;16(1):65-88. doi: 10.1007/s10754-015-9182-0. Epub 2016 Jan 22.
Adequate access to primary care is not universally achieved in many countries, including the United States, particularly for vulnerable populations. In this paper we use multiple years of the U.S.-based Community Tracking Survey to examine whether a variety of physician compensation structures chosen by practices influence the likelihood that the practice takes new patients from a variety of different types of insurance. Specifically, we examine the roles of customer satisfaction and quality measures on the one hand, and individual physician productivity measures on the other hand, in determining whether or not firms are more likely to accept patients who have private insurance, Medicare, or Medicaid. In the United States these different types of insurance mechanisms cover populations with different levels of vulnerability. Medicare (elderly and disabled individuals) and Medicaid (low income households) enrollees commonly have lower ability to pay any cost sharing associated with care, are more likely to have multiple comorbidities (and so be more costly to treat), and may be more sensitive to poor access. Further, these two insurers also generally reimburse less generously than private payors. Thus, if lower reimbursements interact with compensation mechanisms to discourage physician practices from accepting new patients, highly vulnerable populations may be at even greater risk than generally appreciated. We control for the potential endogeneity of incentive choice using a multi-level propensity score method. We find that the compensation incentives chosen by practices are statistically and economically significant predictors for the types of new patients that practices accept. These findings have important implications for both policy makers and private health care systems.
在包括美国在内的许多国家，并非普遍都能充分获得初级医疗服务，尤其是对弱势群体而言。在本文中，我们使用多年来基于美国的社区追踪调查，来研究医疗机构选择的各种医生薪酬结构是否会影响该机构接收来自不同类型保险患者的可能性。具体而言，我们一方面研究客户满意度和质量指标的作用，另一方面研究个体医生生产力指标的作用，以确定机构是否更有可能接受拥有私人保险、医疗保险或医疗补助的患者。在美国，这些不同类型的保险机制覆盖了不同脆弱程度的人群。医疗保险（老年人和残疾人）和医疗补助（低收入家庭）的参保者通常支付与医疗相关的任何费用分摊的能力较低，更有可能患有多种合并症（因此治疗成本更高），并且可能对就医不便更为敏感。此外，这两家保险公司的报销额度通常也比私人支付方要低。因此，如果较低的报销额度与薪酬机制相互作用，导致医生诊所不愿接收新患者，那么高度脆弱的人群可能面临比普遍认为的更大风险。我们使用多层次倾向得分法来控制激励选择的潜在内生性。我们发现，医疗机构选择的薪酬激励措施在统计和经济意义上都是该机构接收新患者类型的重要预测指标。这些发现对政策制定者和私立医疗系统都具有重要意义。
