Woodward C A, Hutchison B, Norman G R, Brown J A, Abelson J
Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ont.
CMAJ. 1998 Jan 27;158(2):197-202.
To determine the extent of variation in physicians' charges for health care encounters with unannounced standardized patients and factors associated with the variation.
Cross-sectional study.
Family practices open to new patients within 1 hour's drive of Hamilton, Ont.
A stratified random sample of 125 physicians who had responded to an earlier survey regarding preventive care were invited to participate. Of the 125, 44 (35.2%) declined to participate, and an additional 19 (15.2%) initially consented but later withdrew because they closed their practices to new patients. Sixty-two physicians thus participated in the study.
Unannounced standardized patients posing as new patients to the practice visited study physicians' practices between September 1994 and August 1995, portraying 4 scenarios: 28-year-old woman, 52-year-old woman, 48-year-old man and 70-year-old man.
Physician characteristics, encounter characteristics and charges made for services.
The 62 physicians had 246 encounters with the standardized patients. Charges were made to the health insurance plan for services by 59 physicians for up to 4 encounters (215 encounters in all). Charges varied considerably both within and across patient scenarios. Time spent with the patient was an important factor predicting charges made (p < 0.01), although the effect of time spent on charges varied across scenarios (p < 0.01). Fee-for-service physicians charged more for their services than physicians who usually had alternative billing arrangements (p < 0.01). Female physicians charged more for their services than their male colleagues (p = 0.03). No relation was found between quality of preventive care and charges made (p = 0.15).
Physician-related factors are better able to account for the variability in charges for their services than patient-related factors. Physicians seeing comparable patients may earn much more or less than their colleagues because of differences in the services they provide and the way they apply the fee schedule. Quality-assurance techniques are likely needed to reduce the variability in charges seen and increase value for money spent in health care.
确定医生对未预约的标准化患者进行医疗服务收费的差异程度以及与该差异相关的因素。
横断面研究。
安大略省汉密尔顿市一小时车程内接纳新患者的家庭诊所。
邀请了125名曾对早期一项关于预防保健的调查做出回应的医生作为分层随机样本参与研究。这125名医生中，44名（35.2%）拒绝参与，另有19名（15.2%）最初同意但后来退出，原因是他们不再接纳新患者。因此，62名医生参与了该研究。
1994年9月至1995年8月期间，未预约的标准化患者以新患者身份前往参与研究的医生诊所就诊，呈现4种情景：28岁女性、52岁女性、48岁男性和70岁男性。
医生特征、就诊特征以及服务收费情况。
62名医生与标准化患者进行了246次就诊。59名医生向医疗保险计划收取了最多4次就诊（共计215次就诊）的服务费用。不同患者情景下以及同一情景内收费差异都很大。与患者相处的时间是预测收费的一个重要因素（p < 0.01），不过不同情景下与患者相处时间对收费的影响有所不同（p < 0.01）。按服务收费的医生比通常采用其他计费方式的医生收费更高（p < 0.01）。女医生比男同事收费更高（p = 0.03）。未发现预防保健质量与收费之间存在关联（p = 0.15）。
与患者相关的因素相比，与医生相关的因素更能解释其服务收费的差异。由于所提供的服务以及应用收费表方式的不同，诊治类似患者的医生收入可能比同事高得多或低得多。可能需要采用质量保证技术来减少所观察到的收费差异，并提高医疗保健支出的性价比。
