Fox M H, Phua K L
Policy and Health Statistics Administration, Maryland Department of Health and Mental Hygiene, Baltimore, USA.
Public Health Rep. 1995 May-Jun;110(3):319-26.
Raising fees is one of the primary means that State Medicaid Programs employ to maintain provider participation. While a number of studies have sought to quantify the extent to which this policy retains or attracts providers, few have looked at the impact of these incentives on patients. In this study, the authors used Medicaid claims data to examine changes in volume and site of prenatal care among women who delivered babies after the Maryland Medicaid Program raised physicians fees for deliveries 200 percent at the end of its 1986 fiscal year. Although the State's intent was to stabilize the pool of nonhospital providers who were willing to deliver Medicaid babies, it was also hoped that women would benefit through greater access to prenatal care, especially care rendered in a nonhospital setting. The authors' hypotheses were that (a) the fee increase for obstetrical deliveries would result in an increase in prenatal visits by women on Medicaid, and (b) the fee increase would lead to a shift in prenatal visits from hospital to community based providers. The data for Maryland's Medicaid claims for the fiscal years 1985 through 1987 were used. Comparisons were made in the average number of prenatal visits and the ratio of hospital to nonhospital prenatal visits before and after the fee increase. Data for continuously enrolled women who delivered in the last 4 months of each fiscal year were analyzed for between and within year differences using Student's t-test and ANOVA techniques. The findings indicate very little overall change in either the amount or location of prenatal care during the year after the large fee increase for deliveries.Though significant increases in the number of prenatal visits occurred for women who lived outside of Baltimore City, it is difficult to attribute these changes solely to the fee increase. Where an effect was observed, it appeared to be greatest in non urban areas of the State, probably because coordination of care by fewer Medicaid providers is more common in such areas.The findings do not support the hypotheses that raising fees for obstetrical deliveries uniformly increase community-based prenatal care. Instead, the findings suggest that tying fee increases for obstetrical deliveries to the amount of prenatal care provided for each patient may be the best way of increasing the commitment of Medicaid obstetrical providers to give their patients more comprehensive perinatal care.
提高费用是州医疗补助计划用来维持医疗服务提供者参与度的主要手段之一。虽然有多项研究试图量化这一政策在保留或吸引医疗服务提供者方面的程度，但很少有研究关注这些激励措施对患者的影响。在本研究中，作者利用医疗补助计划的理赔数据，研究了在马里兰州医疗补助计划于1986财年末将分娩医生费用提高200%后分娩的女性产前护理的数量和地点变化。虽然该州的意图是稳定愿意接生医疗补助计划婴儿的非医院医疗服务提供者群体，但人们也希望女性能够通过更多地获得产前护理，特别是在非医院环境中提供的护理而受益。作者的假设是：(a) 产科分娩费用的增加将导致医疗补助计划覆盖的女性产前检查次数增加，以及 (b) 费用的增加将导致产前检查从医院转向社区医疗服务提供者。使用了1985年至1987年马里兰州医疗补助计划理赔的数据。对费用增加前后的产前检查平均次数以及医院与非医院产前检查的比例进行了比较。对在每个财年最后4个月分娩的连续参保女性的数据，使用学生t检验和方差分析技术分析了年度间和年度内的差异。研究结果表明，在分娩费用大幅增加后的一年里，产前护理的数量或地点总体变化很小。虽然巴尔的摩市以外地区的女性产前检查次数有显著增加，但很难将这些变化完全归因于费用的增加。在观察到有影响的地方，这种影响在该州的非城市地区似乎最大，可能是因为在这些地区，较少的医疗补助计划提供者进行护理协调更为常见。研究结果不支持产科分娩费用提高会统一增加社区产前护理的假设。相反，研究结果表明，将产科分娩费用的增加与为每位患者提供的产前护理量挂钩，可能是增加医疗补助计划产科提供者为患者提供更全面围产期护理投入的最佳方式。
