健康保險費用分擔對參保者急診服務利用影響的系統評價_《中國循證醫學雜志》

作者：

張國杰 ,  賈莉英 , 袁蓓蓓 , 楊冰一 , 馬東平 , 趙世超 , 于海寧 , 常捷

山東大學衛生管理與政策研究中心·衛生部衛生經濟與政策研究重點實驗室（濟南 250012）;

關鍵詞：

費用分擔共付急診系統評價

DOI：

10.7507/1672-2531.20130004

視頻：

導出 下載 收藏 掃碼 引用

摘要 全文 圖表 視頻 參考文獻 施引文獻 補充材料

目的　描述和分析不同健康保險計劃中急診費用分擔對參保者急診服務利用的直接影響以及藥品費用分擔對參保者急診服務利用的間接影響。
方法　計算機檢索18個數據庫（包括循證類、衛生類、經濟類及社會類等），2個灰色文獻數據庫和Google搜索引擎，檢索時限均為2011年6月21日至9月19日。由2位研究者根據納入標準獨立篩選文獻和提取資料，如遇分歧則討論解決或交由第三人裁定。而后采用主題分析法，描述費用分擔對急診利用的直接和間接影響，并分析其副作用。
結果　① 最終納入22篇文獻。其中13篇文獻描述了急診費用分擔直接引起的參保者急診利用變化，9篇文獻描述了藥品費用分擔間接引起的參保者急診利用變化，主要涉及5類健康保險計劃。② 急診服務利用對保險費用分擔具有反應性，共付比例增加時，急診服務利用降低，反之亦然。藥品共付增加會影響基本藥物利用，引起急診利用增加；而急診共付增加，會降低急診不合理利用，不會降低合理利用。
結論　對于參保者，藥品共付增加，會導致急診利用增加等不良事件；而急診共付增加，急診合理利用未降低，無不良事件產生。對于非參保者，費用分擔影響尚有待研究。本系統評價結果提示，可根據地區經濟水平、居民收入等，適當引入急診自付，但藥品自付比例的確定應慎重。

引用本文： 張國杰,賈莉英,袁蓓蓓,楊冰一,馬東平,趙世超,于海寧,常捷. 健康保險費用分擔對參保者急診服務利用影響的系統評價. 中國循證醫學雜志, 2013, 13(1): 5-12. doi: 10.7507/1672-2531.20130004 復制

1.	Newhouse JP. Cost Sharing for Medical Care Services. RAND Corporation, 1984.
2.	Rice T, Morrison KR. Patient cost sharing for medical services: a review of the literature and implications for health care reform. Med Care Rev, 1994, 51(3): 235-287.
3.	Swartz K. Cost-sharing: effects on spending and outcomes. Synth Proj Res Synth Rep. Harvard School of Public Health, 2010.
4.	Rubin RJ, Mendelson DN. Cost sharing in health insurance. N Engl J Med, 1995, 333(11): 733-734.
5.	Newhouse JP, Manning WG, Morris CN, et al. Some interim results from a controlled trial of cost sharing in health insurance. N Engl J Med, 1981, 305(25): 1501-1507.
6.	Newhouse JP. Free for All? Lessons From the RAND Health Insurance Experiment. Cambridge, Mass: Harvard University Press, 1996.
7.	Roblin DW, Platt R, Goodman MJ, et al. Effect of increased cost-sharing on oral hypoglycemic use in five managed care organizations: how much is too much? Med Care, 2005, 43(10): 951-959.
8.	Tamblyn R, Laprise R, Hanley JA, et al. Adverse events associated with prescription drug cost sharing among poor and elderly persons. JAMA, 2001, 285(4): 421-429.
9.	Blustein J. Medicare coverage, supplemental insurance, and the use of mammography by older women. N Engl J Med, 1995, 332(17): 1138-1143.
10.	Soumerai SB, Ross-Degnan D, Avorn J, et al. Effects of Medicaid drug-payment limits on admission to hospitals and nursing homes. N Engl J Med, 1991, 325(15): 1072-1077.
11.	Lowe RA, Fu R, Ong ET, et al. Community characteristics affecting emergency department use by Medicaid enrollees. Med Care, 2009, 47(1): 15-22.
12.	Lowe RA, Localio AR, Schwarz DF, et al. Association between primary care practice characteristics and emergency department use in a Medicaid managed care organization. Med Care, 2005, 43(8): 792-800.
13.	Richardson LD, Hwang U. Access to care: a review of the emergency medicine literature. Acad Emerg Med, 2001, 8(11): 1030-1036.
14.	Andrulis DP, Kellermann AL, Hintz EA, et al. Emergency departments and crowding in United States teaching hospitals. Ann Emerg Med, 1991, 20(9): 980-986.
15.	Baker LC, Baker LS. Excess cost of emergency department visits for nonurgent care. Health Aff (Millwood), 1994, 13(5): 162-171.
16.	Wright BJ, Carlson MJ, Allen H, et al. Raising premiums and other costs for Oregon health plan enrollees drove many to drop out. Health Aff (Millwood). 2010, 29(12): 2311-2316.
17.	Selby JV, Fireman BH, Swain BE. Effect of a copayment on use of the emergency department in a health maintenance organization. N Engl J Med, 1996, 334(10): 635-641.
18.	Billings J, Parikh N, Mijanovich T. Emergency room use: the New York story. Issue Brief (Commonw Fund), 2000, (434): 1-12.
19.	Billings J, Parikh N, Mijanovich T. Emergency department use in New York City: a survey of Bronx patients. Issue Brief (Commonw Fund), 2000, (435): 1-5.
20.	Billings J, Parikh N, Mijanovich T. Emergency department use in New York City: a substitute for primary care? Issue Brief (Commonw Fund), 2000, (433): 1-5.
21.	Tamblyn R, Laprise R, Hanley JA, et al. Adverse events associated with prescription drug cost-sharing among poor and elderly persons. JAMA, 2001, 285(4): 421-429.
22.	Yang W, Kahler KH, Fellers T, et al. Copayment level, treatment persistence, and healthcare utilization in hypertension patients treated with single-pill combination therapy. J Med Econ, 2011, 14(3): 267-278.
23.	Dormuth CR, Maclure M, Glynn RJ, et al. Emergency hospital admissions after income-based deductibles and prescription copayments in older users of inhaled medications. Clin Ther, 2008, 30: 1038-1050.
24.	Austvoll-Dahlgren A, Aaserud M, Vist G, et al. Pharmaceutical policies: effects of cap and co-payment on rational drug use. Cochrane Database Syst Rev, 2008, (1): CD007017.
25.	O’Grady KF, Manning WG, Newhouse JP, et al. The impact of cost sharing on emergency department use. N Engl J Med, 1985, 313(8): 484-490.
26.	Hsu J, Reed M, Brand R, et al. Cost-sharing: patient knowledge and effects on seeking emergency department care. Med Care, 2004, 42(3): 290-296.
27.	Hsu J, Price M, Brand R, et al. Cost-sharing for emergency care and unfavorable clinical events: findings from the safety and financial ramifications of ED copayments study. Health Serv Res, 2006, 41(5): 1801-1820.
28.	Reed M, Fung V, Brand R, et al. Care-seeking behavior in response to emergency department copayments. Med Care, 2005, 43(8): 810-816.
29.	Lowe RA, McConnell KJ, Fu R, et al. Changes in access to primary care for Medicaid beneficiaries and the uninsured: the emergency department perspective. Am J Emerg Med, 2006, 24(1): 33-37.
30.	Lowe RA, McConnell KJ, Vogt ME, et al. Impact of Medicaid cutbacks on emergency department use: the Oregon experience. Ann Emerg Med, 2008, 52(6): 626-634.
31.	Lowe RA, Fu R, Gallia CA. Impact of policy changes on emergency department use by Medicaid enrollees in Oregon. Med Care, 2010, 48(7): 619-627.
32.	Wallace NT, McConnell KJ, Gallia CA, et al. How effective are copayments in reducing expenditures for low-income adult Medicaid beneficiaries? Experience from the Oregon health plan. Health Serv Res, 2008, 43(2): 515-530.
33.	Wharam JF, Landon BE, Galbraith AA, et al. Emergency department use and subsequent hospitalizations among members of a high-deductible health plan. JAMA, 2007, 297(10): 1093-1102.
34.	Waters TM, Chang CF, Cecil WT, et al. Impact of high-deductible health plans on health care utilization and costs. Health Serv Res, 2011, 46(1Pt1): 155-172.
35.	Magid DJ, Koepsell TD, Every NR, et al. Absence of association between insurance copayments and delays in seeking emergency care among patients with myocardial infarction. N Engl J Med, 1997, 336(24): 1722-1729.
36.	Lischko AM. Cost sharing: do employees understand cost sharing and do increases in cost sharing really have an impact on the utilization of health care services? Boston: Boston University, 2008.
37.	Dormuth CR, Neumann P, Maclure M, et al. Effects of prescription coinsurance and income-based deductibles on net health plan spending for older users of inhaled medications. Med Care, 2009, 47(5): 508-516.
38.	Gibson TB, Mark TL, Axelsen K, et al. Impact of statin copayments on adherence and medical care utilization and expenditures. Am J Manag Care, 2006, 12 Spec no.: SP11-19.
39.	Gibson TB, Song X, Alemayehu B, et al. Cost sharing, adherence, and health outcomes in patients with diabetes. Am J Manag Care, 2010, 16(8): 589-600.
40.	Fairman KA, Motheral BR, Henderson RR. Retrospective, long-term follow-up study of the effect of a three-tier prescription drug copayment system on pharmaceutical and other medical utilization and costs. ClinTher, 2003, 25(12): 3147-3161.
41.	Nair KV, Miller K, Park J, et al. Prescription co-pay reduction program for diabetic employees. Popul Health Manag, 2010, 13(5): 235-245.
42.	Goldman DP, Joyce GF, Karaca-Mandic P. Varying pharmacy benefits with clinical status: the case of cholesterol-lowering therapy. Am J Manag Care, 2006, 12(1): 21-28.
43.	Soumerai SB, McLaughlin TJ, Ross-Degnan D, et al. Effects of limiting Medicaid drug reimbursement benefits on the use of psychotropic agents and acute mental health services by patients with schizophrenia. N Engl J Med, 1994, 331(10): 650-655.
44.	Soumerai SB, Ross-Degnan D, Avorn J, et al. Effects of Medicaid drug payment limits on admission to hospitals and nursing homes. N Engl J Med, 1991, 325(15): 1072-1077.
45.	Brook RH, Ware JE, Rogers WH, et al. Does free care improve adults’ health? Results from a randomized controlled trial. N Engl J Med, 1983, 309(23): 1426-1434.
46.	Zweifel P, Manning WG. Moral Hazard and Consumer Incentives in Health Care. In: Culyer AJ, Newhouse JP. Handbook of Health Economics edition 1, 2000: 409-459.

1. Newhouse JP. Cost Sharing for Medical Care Services. RAND Corporation, 1984.
2. Rice T, Morrison KR. Patient cost sharing for medical services: a review of the literature and implications for health care reform. Med Care Rev, 1994, 51(3): 235-287.
3. Swartz K. Cost-sharing: effects on spending and outcomes. Synth Proj Res Synth Rep. Harvard School of Public Health, 2010.
4. Rubin RJ, Mendelson DN. Cost sharing in health insurance. N Engl J Med, 1995, 333(11): 733-734.
5. Newhouse JP, Manning WG, Morris CN, et al. Some interim results from a controlled trial of cost sharing in health insurance. N Engl J Med, 1981, 305(25): 1501-1507.
6. Newhouse JP. Free for All? Lessons From the RAND Health Insurance Experiment. Cambridge, Mass: Harvard University Press, 1996.
7. Roblin DW, Platt R, Goodman MJ, et al. Effect of increased cost-sharing on oral hypoglycemic use in five managed care organizations: how much is too much? Med Care, 2005, 43(10): 951-959.
8. Tamblyn R, Laprise R, Hanley JA, et al. Adverse events associated with prescription drug cost sharing among poor and elderly persons. JAMA, 2001, 285(4): 421-429.
9. Blustein J. Medicare coverage, supplemental insurance, and the use of mammography by older women. N Engl J Med, 1995, 332(17): 1138-1143.
10. Soumerai SB, Ross-Degnan D, Avorn J, et al. Effects of Medicaid drug-payment limits on admission to hospitals and nursing homes. N Engl J Med, 1991, 325(15): 1072-1077.
11. Lowe RA, Fu R, Ong ET, et al. Community characteristics affecting emergency department use by Medicaid enrollees. Med Care, 2009, 47(1): 15-22.
12. Lowe RA, Localio AR, Schwarz DF, et al. Association between primary care practice characteristics and emergency department use in a Medicaid managed care organization. Med Care, 2005, 43(8): 792-800.
13. Richardson LD, Hwang U. Access to care: a review of the emergency medicine literature. Acad Emerg Med, 2001, 8(11): 1030-1036.
14. Andrulis DP, Kellermann AL, Hintz EA, et al. Emergency departments and crowding in United States teaching hospitals. Ann Emerg Med, 1991, 20(9): 980-986.
15. Baker LC, Baker LS. Excess cost of emergency department visits for nonurgent care. Health Aff (Millwood), 1994, 13(5): 162-171.
16. Wright BJ, Carlson MJ, Allen H, et al. Raising premiums and other costs for Oregon health plan enrollees drove many to drop out. Health Aff (Millwood). 2010, 29(12): 2311-2316.
17. Selby JV, Fireman BH, Swain BE. Effect of a copayment on use of the emergency department in a health maintenance organization. N Engl J Med, 1996, 334(10): 635-641.
18. Billings J, Parikh N, Mijanovich T. Emergency room use: the New York story. Issue Brief (Commonw Fund), 2000, (434): 1-12.
19. Billings J, Parikh N, Mijanovich T. Emergency department use in New York City: a survey of Bronx patients. Issue Brief (Commonw Fund), 2000, (435): 1-5.
20. Billings J, Parikh N, Mijanovich T. Emergency department use in New York City: a substitute for primary care? Issue Brief (Commonw Fund), 2000, (433): 1-5.
21. Tamblyn R, Laprise R, Hanley JA, et al. Adverse events associated with prescription drug cost-sharing among poor and elderly persons. JAMA, 2001, 285(4): 421-429.
22. Yang W, Kahler KH, Fellers T, et al. Copayment level, treatment persistence, and healthcare utilization in hypertension patients treated with single-pill combination therapy. J Med Econ, 2011, 14(3): 267-278.
23. Dormuth CR, Maclure M, Glynn RJ, et al. Emergency hospital admissions after income-based deductibles and prescription copayments in older users of inhaled medications. Clin Ther, 2008, 30: 1038-1050.
24. Austvoll-Dahlgren A, Aaserud M, Vist G, et al. Pharmaceutical policies: effects of cap and co-payment on rational drug use. Cochrane Database Syst Rev, 2008, (1): CD007017.
25. O’Grady KF, Manning WG, Newhouse JP, et al. The impact of cost sharing on emergency department use. N Engl J Med, 1985, 313(8): 484-490.
26. Hsu J, Reed M, Brand R, et al. Cost-sharing: patient knowledge and effects on seeking emergency department care. Med Care, 2004, 42(3): 290-296.
27. Hsu J, Price M, Brand R, et al. Cost-sharing for emergency care and unfavorable clinical events: findings from the safety and financial ramifications of ED copayments study. Health Serv Res, 2006, 41(5): 1801-1820.
28. Reed M, Fung V, Brand R, et al. Care-seeking behavior in response to emergency department copayments. Med Care, 2005, 43(8): 810-816.
29. Lowe RA, McConnell KJ, Fu R, et al. Changes in access to primary care for Medicaid beneficiaries and the uninsured: the emergency department perspective. Am J Emerg Med, 2006, 24(1): 33-37.
30. Lowe RA, McConnell KJ, Vogt ME, et al. Impact of Medicaid cutbacks on emergency department use: the Oregon experience. Ann Emerg Med, 2008, 52(6): 626-634.
31. Lowe RA, Fu R, Gallia CA. Impact of policy changes on emergency department use by Medicaid enrollees in Oregon. Med Care, 2010, 48(7): 619-627.
32. Wallace NT, McConnell KJ, Gallia CA, et al. How effective are copayments in reducing expenditures for low-income adult Medicaid beneficiaries? Experience from the Oregon health plan. Health Serv Res, 2008, 43(2): 515-530.
33. Wharam JF, Landon BE, Galbraith AA, et al. Emergency department use and subsequent hospitalizations among members of a high-deductible health plan. JAMA, 2007, 297(10): 1093-1102.
34. Waters TM, Chang CF, Cecil WT, et al. Impact of high-deductible health plans on health care utilization and costs. Health Serv Res, 2011, 46(1Pt1): 155-172.
35. Magid DJ, Koepsell TD, Every NR, et al. Absence of association between insurance copayments and delays in seeking emergency care among patients with myocardial infarction. N Engl J Med, 1997, 336(24): 1722-1729.
36. Lischko AM. Cost sharing: do employees understand cost sharing and do increases in cost sharing really have an impact on the utilization of health care services? Boston: Boston University, 2008.
37. Dormuth CR, Neumann P, Maclure M, et al. Effects of prescription coinsurance and income-based deductibles on net health plan spending for older users of inhaled medications. Med Care, 2009, 47(5): 508-516.
38. Gibson TB, Mark TL, Axelsen K, et al. Impact of statin copayments on adherence and medical care utilization and expenditures. Am J Manag Care, 2006, 12 Spec no.: SP11-19.
39. Gibson TB, Song X, Alemayehu B, et al. Cost sharing, adherence, and health outcomes in patients with diabetes. Am J Manag Care, 2010, 16(8): 589-600.
40. Fairman KA, Motheral BR, Henderson RR. Retrospective, long-term follow-up study of the effect of a three-tier prescription drug copayment system on pharmaceutical and other medical utilization and costs. ClinTher, 2003, 25(12): 3147-3161.
41. Nair KV, Miller K, Park J, et al. Prescription co-pay reduction program for diabetic employees. Popul Health Manag, 2010, 13(5): 235-245.
42. Goldman DP, Joyce GF, Karaca-Mandic P. Varying pharmacy benefits with clinical status: the case of cholesterol-lowering therapy. Am J Manag Care, 2006, 12(1): 21-28.
43. Soumerai SB, McLaughlin TJ, Ross-Degnan D, et al. Effects of limiting Medicaid drug reimbursement benefits on the use of psychotropic agents and acute mental health services by patients with schizophrenia. N Engl J Med, 1994, 331(10): 650-655.
44. Soumerai SB, Ross-Degnan D, Avorn J, et al. Effects of Medicaid drug payment limits on admission to hospitals and nursing homes. N Engl J Med, 1991, 325(15): 1072-1077.
45. Brook RH, Ware JE, Rogers WH, et al. Does free care improve adults’ health? Results from a randomized controlled trial. N Engl J Med, 1983, 309(23): 1426-1434.
46. Zweifel P, Manning WG. Moral Hazard and Consumer Incentives in Health Care. In: Culyer AJ, Newhouse JP. Handbook of Health Economics edition 1, 2000: 409-459.

《中國循證醫學雜志》

健康保險費用分擔對參保者急診服務利用影響的系統評價

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《中國循證醫學雜志》

健康保險費用分擔對參保者急診服務利用影響的系統評價

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