Dranove D, White W D
Department of Management and Strategy, Northwestern University, Evanston, IL 60208, USA.
Health Serv Res. 1998 Jun;33(2 Pt 1):163-85.
To examine how private hospitals dependent on Medicaid for a large proportion of their revenues have fared in the face of substantial Medicaid (and more modest Medicare) reimbursement cutbacks and growing managed care. We specifically test three hypotheses regarding Medicaid-dependent hospitals: (1) that they are more likely to "cost-shift" cutbacks to private patients; (2) that they are more likely to cut services for Medicaid (and other) patients; and (3) that they are more likely to close. DATA/STUDY SETTING: Private short-term hospitals in California a state that has experienced a rapid growth in managed care since the early 1980s. Data are drawn from the California Office of Statewide Health Planning and Development (OSHPD) Hospital Disclosure Files for fiscal years 1983 and 1992.
We compare changes in net prices and the provision of services, proxied by list price-adjusted charges, at hospitals for Medicaid, Medicare, and privately insured patients between fiscal years 1983 and 1992 controlling for hospital and market characteristics, case mix, and the proportion of revenues from Medicaid patients. We also examine the probability that a hospital closed during the study period as a function of hospital and market characteristics and payer mix. Although the growth of managed care is hypothesized to reduce opportunities for "cost shifting," it may also confound our analysis of price changes if Medicaid-dependent hospitals are unattractive to managed care patients and respond by offering lower prices to plans.
We find no evidence that Medicaid-dependent hospitals raised prices to private patients in response to Medicaid (or Medicare) cutbacks; if anything, they lowered them. However, we find that service levels fell for Medicaid (and Medicare) patients relative to those for privately insured patients and that reductions were greater at Medicaid-dependent hospitals. In addition, our findings suggest that service levels also fell for private patients at Medicaid-dependent hospitals, although reductions were smaller for these patients, suggesting that quality, may be a public good at hospitals. Finally, Medicaid-dependent hospitals were more likely to close.
It been suggested that private hospitals may respond to public reimbursement cutbacks by simply "shifting" costs to privately insured patients, limiting overall cost savings but insulating public patients and hospitals from the effects of cutbacks. We find no evidence of cost shifting. Rather, our results suggest that patients and hospitals bore the brunt of cutbacks; service levels fell at Medicaid-dependent hospitals and such hospitals were more likely to go out of business. This suggests that the consequences of proposed Medicare and Medicaid cutbacks could be severe for public patients and the hospitals that care for them.
研究那些在很大程度上依赖医疗补助计划（Medicaid）获取收入的私立医院，在面对医疗补助计划（以及幅度较小的医疗保险计划（Medicare））大幅削减报销额度和管理式医疗不断发展的情况下，经营状况如何。我们专门检验了关于依赖医疗补助计划的医院的三个假设：（1）它们更有可能将削减成本“转嫁”给私立患者；（2）它们更有可能削减为医疗补助计划（及其他）患者提供的服务；（3）它们更有可能倒闭。数据/研究背景：加利福尼亚州的私立短期医院，自20世纪80年代初以来，该州的管理式医疗发展迅速。数据取自加利福尼亚州全州卫生规划与发展办公室（OSHPD）1983财年和1992财年的医院披露档案。
我们比较了1983财年和1992财年之间，医院向医疗补助计划、医疗保险计划和私立保险患者提供服务的净价格变化以及以标价调整后的收费为代表的服务提供情况，同时控制医院和市场特征、病例组合以及来自医疗补助计划患者的收入比例。我们还研究了在研究期间医院倒闭的概率与医院和市场特征以及付款人组合之间的关系。尽管假设管理式医疗的发展会减少“成本转嫁”的机会，但如果依赖医疗补助计划的医院对管理式医疗患者缺乏吸引力，并通过向保险计划提供更低价格来做出反应，那么这也可能会混淆我们对价格变化的分析。
我们没有发现证据表明依赖医疗补助计划的医院会因医疗补助计划（或医疗保险计划）的削减而提高对私立患者的收费；相反，它们降低了收费。然而，我们发现相对于私立保险患者，医疗补助计划（和医疗保险计划）患者的服务水平下降了，而且在依赖医疗补助计划的医院中下降幅度更大。此外，我们的研究结果表明，依赖医疗补助计划的医院中私立患者的服务水平也下降了，尽管这些患者的下降幅度较小，这表明在医院中质量可能是一种公共产品。最后，依赖医疗补助计划的医院更有可能倒闭。
有人提出私立医院可能会通过简单地将成本“转嫁”给私立保险患者来应对公共报销额度的削减，这样虽然限制了总体成本节约，但使公立患者和医院免受削减的影响。我们没有发现成本转嫁的证据。相反，我们的结果表明患者和医院首当其冲受到了削减的影响；依赖医疗补助计划的医院的服务水平下降了，而且这类医院更有可能倒闭。这表明拟议中的医疗保险计划和医疗补助计划削减对公立患者以及为他们提供治疗的医院可能会产生严重后果。
