Philbin E F, DiSalvo T G
Heart Failure and Transplantation Center, Massachusetts General Hospital, and Harvard Medical School, Boston, USA.
Am Heart J. 1998 Sep;136(3):553-61. doi: 10.1016/s0002-8703(98)70234-0.
Although health maintenance organizations (HMO) are insuring an increasing number of Americans, there are concerns that cost-reduction strategies may limit access to medical care or jeopardize its quality. This study was conducted to examine the influence of insurance payer status on the process of care and resource utilization among patients hospitalized for congestive heart failure (CHF).
Administrative information on all 1995 New York State hospital discharges assigned ICD-9-CM codes indicative of CHF in the principal diagnosis position were obtained from the Statewide Planning and Research Cooperative System database. The following were compared among patients with HMO, indemnity, Medicaid fee-for-service, and Medicare fee-for-service insurance coverage: demographics, comorbid illness, process of care, length of stay, hospital charges, mortality rate, and CHF readmission rate. A total of 43,157 patients were identified (HMO, 1322; indemnity, 4350; Medicaid, 3878; Medicare, 33 607). Noninvasive procedures were used with similar frequency, whereas greater use of invasive techniques was observed among HMO and indemnity patients. After adjustment for patient characteristics and hospital type and location, HMO care was associated with shorter length of stay and lower hospital charges, the latter partially explained by fewer hospital days. Medicaid patients had the longest length of stay, greatest hospital charges, and highest CHF readmission rate. The adjusted risk of death during the index hospitalization did not vary among insurance groups.
Though insuring only a small proportion of New Yorkers hospitalized for CHF, managed care plans provide similar access to clinical services while generating fewer charges. Whether these observed differences in short-term outcomes derive from patient mix or quality of care is uncertain and deserves wider prospective study.
尽管健康维护组织（HMO）为越来越多的美国人提供保险，但人们担心成本削减策略可能会限制医疗服务的可及性或危及医疗质量。本研究旨在探讨保险支付方身份对因充血性心力衰竭（CHF）住院患者的医疗过程和资源利用的影响。
从全州规划与研究合作系统数据库中获取了1995年纽约州所有医院出院患者的行政信息，这些患者的国际疾病分类第九版临床修订本（ICD - 9 - CM）编码在主要诊断位置表明为CHF。对拥有HMO、赔偿保险、医疗补助按服务收费以及医疗保险按服务收费保险的患者在人口统计学、合并症、医疗过程、住院时间、医院费用、死亡率和CHF再入院率等方面进行了比较。共识别出43157例患者（HMO患者1322例；赔偿保险患者4350例；医疗补助患者3878例；医疗保险患者33607例）。非侵入性检查的使用频率相似，但在HMO和赔偿保险患者中观察到侵入性技术的使用更多。在对患者特征、医院类型和地点进行调整后，HMO保险患者的住院时间较短且医院费用较低，后者部分原因是住院天数较少。医疗补助患者的住院时间最长、医院费用最高且CHF再入院率最高。各保险组在首次住院期间的调整后死亡风险没有差异。
尽管HMO保险只为纽约州因CHF住院的一小部分患者提供保险，但管理式医疗计划在提供类似临床服务的同时费用更低。这些观察到的短期结果差异是源于患者构成还是医疗质量尚不确定，值得进行更广泛的前瞻性研究。
