医生对患者退款规则的操纵:在岩石和坚硬的地方之间
M K Wynia1, D S Cummins, J B VanGeest
1Institute for Ethics, American Medical Association, Chicago, Ill 60610, USA. matthew_wynia@ama-assn.org
JAMA
|April 19, 2000
概括
医生有时会操纵医疗保险规则,以确保患者获得必要的护理. 这种"秘密宣传"正在增加,这是由于感知到系统的必要性和患者的要求所驱动的.
科学领域:
- 医疗保健服务研究 医疗服务研究
- 医学经济学 医学经济学
- 医生行为 医生行为
背景情况:
- 健康计划利用审查规则强制执行保险合同,但可以限制医生推的患者护理.
- 医生对这些规则的操纵是一个已知的,但未经定量化的现象.
研究的目的:
- 为了确定医生操纵必要服务报销规则的频率.
- 识别与规则操纵相关的医生态度和特征.
主要方法:
- 1998年全国邮政调查1124名执业医生 (64%的响应率).
- 评估了策略的频率,例如夸大患者的病情,改变诊断或捏造症状以确保覆盖.
主要成果:
- 39%的医生"有时"或更频繁地使用至少一种操纵策略.
- 战术使用与对质量护理"游戏系统"的信念相关 (OR 3.67),患者要求欺骗保险公司 (OR 2.44),时间压力 (OR 1.69) 和高的医疗补助病人的数量 (OR 1.60).
- 对欺诈起诉的担忧并没有阻止使用策略; 54%的人报告在5年内使用增加.
结论:
- 显著的少数医生操纵报销规则,以提供被认为是必要的护理.
- 增加的利用限制可能会使医生在没有新的干预措施的情况下使用"秘密宣传"策略.
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