Finkelstein B S, Silvers J B, Marrero U, Neuhauser D, Cuttler L
Department of Pediatrics, Case Western Reserve University, Cleveland, OH 44106, USA.
JAMA. 1998 Mar 4;279(9):663-8. doi: 10.1001/jama.279.9.663.
There is concern in both the medical community and the general public about mechanisms of medical decision making and the interplay of physician and insurer decisions in determining access to care.
To examine the medical process influencing access to growth hormone (GH) therapy for childhood short stature by comparing coverage policies of US insurers with the treatment recommendations of US physicians.
Independent national representative surveys were mailed to insurers (private, Blue Cross/Blue Shield, health maintenance organizations, programs for Children with Special Health Care Needs, and Medicaid programs, n=113), primary care physicians (n=1504), and pediatric endocrinologists (n=534) with response rates of 75%, 60%, and 81%, respectively. Each survey included identical case scenarios. Primary care physicians were asked decisions about referrals to pediatric endocrinologists. Endocrinologists were asked GH treatment recommendations. Insurers were asked coverage decisions for GH therapy.
Insurer coverage decisions for GH in specific case scenarios were compared with the recommendations of primary care physicians and pediatric endocrinologists.
Physician recommendations and insurance coverage decisions differed strikingly. For example, while 96% of pediatric endocrinologists recommended GH therapy for children with Turner syndrome, insurer policies covered GH therapy for only 52% of these children. Overall, referral and treatment decisions by physicians resulted in recommendations for GH therapy in 78% of children with GH deficiency, Turner syndrome, or renal failure; of those recommended for treatment, 28% were denied coverage by insurers. Similarly, GH therapy would be recommended by physicians for only 9% of children with idiopathic short stature, but insurers would not cover GH for the vast majority of these children. Furthermore, the data indicated considerable variation among insurers regarding coverage policies for GH (P<.01).
Access to GH therapy differs depending on the type of insurance coverage. The deep discord between physician recommendations and insurance coverage decisions, exemplified by these findings, represents a major challenge to mechanisms of health care decision making, access, and costs.
医学界和普通公众都对医疗决策机制以及医生和保险公司在决定医疗服务可及性方面的相互作用表示关注。
通过比较美国保险公司的承保政策与美国医生的治疗建议，研究影响儿童身材矮小患者获得生长激素（GH）治疗的医疗过程。
向保险公司（私营、蓝十字/蓝盾、健康维护组织、特殊医疗需求儿童项目和医疗补助项目，n = 113）、初级保健医生（n = 1504）和儿科内分泌学家（n = 534）邮寄独立的全国代表性调查问卷，回复率分别为75%、60%和81%。每份调查问卷包含相同的病例场景。询问初级保健医生关于转诊至儿科内分泌学家的决策。询问内分泌学家关于GH治疗的建议。询问保险公司关于GH治疗的承保决策。
将特定病例场景中保险公司对GH的承保决策与初级保健医生和儿科内分泌学家的建议进行比较。
医生的建议与保险承保决策存在显著差异。例如，虽然96%的儿科内分泌学家建议为特纳综合征患儿使用GH治疗，但保险公司政策仅为其中52%的患儿承保GH治疗。总体而言，医生的转诊和治疗决策导致78%的生长激素缺乏症、特纳综合征或肾衰竭患儿被建议使用GH治疗；在那些被建议治疗的患儿中，28%被保险公司拒绝承保。同样，医生仅会为9%的特发性身材矮小患儿建议使用GH治疗，但保险公司不会为绝大多数这类患儿承保GH。此外，数据表明保险公司在GH承保政策方面存在相当大的差异（P <.01）。
获得GH治疗的机会因保险覆盖类型而异。这些发现所体现的医生建议与保险承保决策之间的严重不一致，对医疗保健决策机制、可及性和成本构成了重大挑战。
