The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756, USA.
Department of Economics, Dartmouth College, The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, and the National Bureau of Economic Research, Hanover, NH 03755, USA.
Mil Med. 2024 Aug 30;189(9-10):e2170-e2176. doi: 10.1093/milmed/usae074.
There is a longstanding debate about whether health care is more efficiently provided by the public or private sector. The debate is particularly relevant to the Military Health System (MHS), which delivers care through a combination of publicly funded federal facilities and privately contracted providers. This study compares outcomes, treatments, and costs for MHS patients obtaining care for low back pain (LBP) from public versus private providers.
A retrospective cohort study was completed using TRICARE Prime claims data from April 2015 to December 2018. The cohort was identified using International Classification of Diseases Ninth Revision and Tenth Revision diagnostic codes and then followed for 12 months after the index diagnosis to assess treatments, outcomes, and costs. Claims were classified as originating from either public or private providers. The primary outcome measure was resolution of LBP, defined as an absence of LBP diagnoses during the 6-to-12-month window following the index event. Instrumental variable models were used to assess the impact of care setting (i.e., private versus public), conditioning on the covariates. A regional measure of the fraction of private care was used as an instrument.
Resolution of LBP was achieved for 79.7% of 144,866 patients in the cohort. No significant association was found between resolution of LBP and fraction of privately provided care. Higher fraction of private care was associated with a greater likelihood of opioid treatments (odds ratio, 1.22; 95% CI, 1.02-1.46) and a lower likelihood of benzodiazepine (odds ratio, 0.56; 95% CI, 0.45-0.70) and physical therapy (odds ratio 0.55; 95% CI, 0.42-0.74) treatments; manual therapy was not significantly associated with the fraction of private care. There was a significant negative association between the fraction of private care and cost (coefficient -0.27; 95% CI, -0.44, -0.10).
This study found that privately provided care was associated with significantly higher opioid prescribing, less use of benzodiazepines and physical therapy, and lower costs. No systematic differences in outcomes (as measured by resolved cases) were identified. The findings suggest that publicly funded health care within the MHS context can attain quality comparable to privately provided care, although differences in treatment choices and costs point to possibilities for improved care within both systems.
关于医疗保健是由公共部门还是私营部门更有效地提供，长期以来一直存在争议。这场争论与军事卫生系统（MHS）特别相关，该系统通过公共资助的联邦设施和私人承包的提供者相结合来提供医疗服务。本研究比较了 MHS 患者因腰痛（LBP）从公共和私人提供者处获得护理的结果、治疗和成本。
使用 2015 年 4 月至 2018 年 12 月的 TRICARE Prime 索赔数据完成了一项回顾性队列研究。该队列是使用国际疾病分类第 9 版和第 10 版诊断代码确定的，然后在索引诊断后 12 个月内对其进行随访，以评估治疗、结果和成本。索赔被归类为来自公共或私人提供者。主要结局指标是 LBP 的缓解，定义为在索引事件后的 6 至 12 个月窗口期间没有 LBP 诊断。使用工具变量模型评估护理环境（即私人与公共）的影响，条件是协变量。使用区域私人护理比例衡量作为工具。
队列中 144866 名患者中有 79.7%的患者实现了 LBP 的缓解。LBP 缓解与私人提供的护理比例之间没有发现显著关联。更高的私人护理比例与阿片类药物治疗的可能性更高（优势比，1.22；95%置信区间，1.02-1.46）和苯二氮䓬类药物（优势比，0.56；95%置信区间，0.45-0.70）和物理治疗（优势比 0.55；95%置信区间，0.42-0.74）治疗的可能性较低；手法治疗与私人护理比例无显著相关性。私人护理比例与成本之间存在显著负相关（系数-0.27；95%置信区间，-0.44，-0.10）。
本研究发现，私人提供的护理与阿片类药物的开具显著相关更高，苯二氮䓬类药物和物理治疗的使用较少，成本较低。（测量为已解决病例）没有发现结果的系统差异。研究结果表明，MHS 范围内的公共资助医疗保健可以达到与私人提供的护理相当的质量，尽管在治疗选择和成本方面存在差异，但这两个系统都有可能改善护理。
