Safran D G, Tarlov A R, Rogers W H
Health Institute, New England Medical Center, Boston, MA 02111.
JAMA. 1994 May 25;271(20):1579-86.
To examine differences in the quality of primary care delivered in prepaid and fee-for-service (FFS) health care systems.
Longitudinal study of 1208 adult patients with chronic disease whose health insurance was through a traditional indemnity (FFS) plan, an independent practice association (IPA), or a health maintenance organization (HMO). Both IPA and HMO represent prepaid care systems. Patient- and physician-provided information was obtained by self-administered questionnaires.
A total of 303 physician offices (family medicine, general internal medicine, endocrinology, or cardiology) in solo and group practices in three US cities.
Seven indicators of primary care quality--accessibility (financial and organizational), continuity, comprehensiveness, coordination, and accountability (interpersonal and technical) of care. Performance on each was evaluated in FFS, IPA, and HMO settings. Analyses controlled for patient and physician characteristics.
Financial access was highest in prepaid systems. Organizational access, continuity, and accountability were highest in the FFS system. Coordination was highest and comprehensiveness was lowest in HMOs.
The results mark notable differences in core dimensions of primary care quality in each of three payment systems and raise questions regarding the associated cost inefficiencies and outcomes of care. In the current health care delivery reform climate, these findings call for consideration of the relative strengths and weaknesses of each system. We suggest strategies for elevating performance in each.
研究预付制和按服务收费（FFS）医疗保健系统中初级保健质量的差异。
对1208名成年慢性病患者进行纵向研究，这些患者的医疗保险分别通过传统的赔偿（FFS）计划、独立执业协会（IPA）或健康维护组织（HMO）获得。IPA和HMO均代表预付制医疗系统。通过自行填写问卷获取患者和医生提供的信息。
美国三个城市的303个医生办公室（家庭医学、普通内科、内分泌科或心脏病科），包括单人执业和团体执业。
初级保健质量的七个指标——可及性（财务和组织方面）、连续性、全面性、协调性以及问责性（人际和技术方面）。在FFS、IPA和HMO环境中对每个指标的表现进行评估。分析对患者和医生的特征进行了控制。
预付制系统中的财务可及性最高。FFS系统中的组织可及性、连续性和问责性最高。HMO中的协调性最高，全面性最低。
结果表明三种支付系统中初级保健质量的核心维度存在显著差异，并引发了有关相关成本效率低下和护理结果的问题。在当前医疗保健提供改革的背景下，这些发现要求考虑每个系统的相对优势和劣势。我们提出了提高每个系统绩效的策略。
