分开但不平等？学术初级保健诊所按付费方组合划分的横断面研究。
Separate But Not Equal? A Cross-Sectional Study of Segregation by Payor Mix in Academic Primary Care Clinics.
机构信息
Brigham and Women's Hospital, Boston, MA, USA.
Yale School of Medicine, CT, New Haven, USA.
出版信息
J Gen Intern Med. 2023 Aug;38(10):2318-2325. doi: 10.1007/s11606-023-08066-x. Epub 2023 Feb 17.
BACKGROUND
At some US Academic Health Centers (AHCs), patients with predominantly Medicaid insurance are seen in one clinic and patients with other insurance are seen in another. The extent of this practice and implications are unknown.
OBJECTIVE
To estimate the proportion of AHCs that have at least two primary care internal medicine clinics that differ substantially in proportion of patients with Medicaid and to compare patient demographic, staffing, and operational features.
PARTICIPANTS
General internal medicine chiefs and clinic directors at 40 randomly selected US AHCs plus the top 10 AHCs in terms of NIH funding.
MAIN MEASURE
An AHC was classified as maintaining clinics that differed substantially in the proportion of patients with Medicaid if any two differed by ≥ 40% (absolute). Other criteria were used for pre-specified secondary analyses (e.g., ≥ 30%).
KEY RESULTS
Thirty-nine of 50 AHCs (78%) participated. Four of 39 (10%; 95% CI, 3 to 24%) had two clinics differing by ≥ 40% in the proportion of patients with Medicaid, eight (21%; 95% CI, 9 to 36%) had clinics differing by ≥ 30%, and 15 (38%; 95% CI, 23 to 55%) had clinics differing by ≥ 20%. Clinics with more patients with Medicaid by any of the three criteria were more likely to employ resident physicians as providers of longitudinal care (with faculty supervision) and more likely to have patients who were Black or Hispanic.
CONCLUSIONS
Some US AHCs maintain separate clinics defined by the proportion of patients with Medicaid. Clinics with a higher proportion of patients insured by Medicaid are more likely to employ residents (with faculty oversight), feature residents as providers of longitudinal care, and serve patients who are Black and Hispanic. Further research is needed to understand why some AHCs have primary care clinics distinguishable by insurance mix with the goal of ensuring that racism and discrimination are not root causes.
背景
在美国一些学术医疗中心（AHCs），主要拥有医疗补助保险的患者在一个诊所就诊，而其他保险的患者在另一个诊所就诊。这种做法的程度和影响尚不清楚。
目的
估计至少有两个初级保健内科诊所的 AHCs 的比例，这些诊所的患者中拥有医疗补助保险的比例有很大差异，并比较患者的人口统计学、人员配备和运营特征。
参与者
从 40 家随机选择的美国 AHCs 的内科主任和诊所主任，以及 NIH 资助排名前 10 的 AHCs。
主要措施
如果任何两个诊所的 Medicaid 患者比例相差≥40%（绝对值），则将 AHC 归类为维持差异较大的诊所。对于预定义的次要分析，使用了其他标准（例如，≥30%）。
主要结果
50 家 AHCs 中有 39 家（78%）参与了研究。在这 39 家 AHCs 中，有 4 家（10%；95%CI，3 至 24%）的两个诊所的 Medicaid 患者比例相差≥40%，8 家（21%；95%CI，9 至 36%）的诊所相差≥30%，15 家（38%；95%CI，23 至 55%）的诊所相差≥20%。任何一个标准中 Medicaid 患者比例较高的诊所，更有可能雇用住院医师作为纵向护理的提供者（有教员监督），并且更有可能有黑人和西班牙裔患者。
结论
美国一些 AHCs 维持按 Medicaid 患者比例定义的单独诊所。拥有更多 Medicaid 保险患者的诊所更有可能雇用住院医师（有教员监督），并将住院医师作为纵向护理的提供者，为黑人和西班牙裔患者提供服务。需要进一步研究以了解为什么一些 AHCs 的初级保健诊所可以根据保险组合来区分，目的是确保种族主义和歧视不是根本原因。
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