Consequences of the 340B Drug Pricing Program.
Consequences of the 340B Drug Pricing Program.
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DOI：
10.1056/nejmsa1706475
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发表时间：
2018-02-08
期刊：
影响因子：
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通讯作者：
McWilliams JM
中科院分区：
文献类型：
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作者：
Desai S;McWilliams JM
340 B药品定价计划使符合条件的医院在门诊药品上获得折扣，增加了药品管理的盈利能力。通过将医院的计划资格与其不成比例份额医院（DSH）调整百分比挂钩，该百分比反映了低收入住院患者的比例，该计划旨在为服务不足的人群扩大资源，但没有直接激励医院使用财务收益来加强对低收入患者的护理。我们使用医疗保险索赔和回归不连续设计，利用一般急症护理医院的计划资格门槛（DSH百分比，>11.75%），以隔离该计划对医院医生整合的影响（即，获得医生执业或医院雇用医生）和在三个经常使用胃肠外药物的专科中由医院拥有的设施进行胃肠外药物的门诊给药。对于低收入患者，我们还评估了该计划对医院提供护理和死亡率的影响。医院符合340 B计划的资格与在医院拥有的设施中执业的2.3名血液学家-肿瘤学家相关，或者与没有该计划的预期相比，血液学家-肿瘤学家增加了230%（P = 0.02），并且每个医院多0.9（或900%）眼科医生（P = 0.08）和每个医院多0.1（或33%）风湿科医生（P = 0.84）。计划资格与血液肿瘤学（高出90%，P = 0.001）和眼科（高出177%，P = 0.03）医疗保险患者医院开出的胃肠外药物索赔数量显著增加相关，但与风湿病无关（高出77%，P = 0.12）。计划资格与血液肿瘤学和眼科的低收入患者比例较低相关，并且医院为低收入群体提供的安全网或住院治疗或医院当地服务区低收入居民的死亡率无显著差异。340 B计划与血液肿瘤学中的医院-医生整合以及血液肿瘤学和眼科中更多基于医院的胃肠外药物给药相关。医院的财务收益与扩大护理或降低低收入患者死亡率的明确证据无关。（由医疗保健研究和质量机构和其他机构资助。
The 340B Drug Pricing Program entitles qualifying hospitals to discounts on outpatient drugs, increasing the profitability of drug administration. By tying the program eligibility of hospitals to their Disproportionate Share Hospital (DSH) adjustment percentage, which reflects the proportion of hospitalized patients who are low-income, the program is intended to expand resources for underserved populations but provides no direct incentives for hospitals to use financial gains to enhance care for low-income patients. We used Medicare claims and a regression-discontinuity design, taking advantage of the threshold for program eligibility among general acute care hospitals (DSH percentage, >11.75%), to isolate the effects of the program on hospital–physician consolidation (i.e., acquisition of physician practices or employment of physicians by hospitals) and on the outpatient administration of parenteral drugs by hospitalowned facilities in three specialties in which parenteral drugs are frequently used. For low-income patients, we also assessed the effects of the program on the provision of care by hospitals and on mortality. Hospital eligibility for the 340B Program was associated with 2.3 more hematologist–oncologists practicing in facilities owned by the hospital, or 230% more hematologist–oncologists than expected in the absence of the program (P = 0.02), and with 0.9 (or 900%) more ophthalmologists per hospital (P = 0.08) and 0.1 (or 33%) more rheumatologists per hospital (P = 0.84). Program eligibility was associated with significantly higher numbers of parenteral drug claims billed by hospitals for Medicare patients in hematology–oncology (90% higher, P = 0.001) and ophthalmology (177% higher, P = 0.03) but not rheumatology (77% higher, P = 0.12). Program eligibility was associated with lower proportions of low-income patients in hematology–oncology and ophthalmology and with no significant differences in hospital provision of safety-net or inpatient care for low-income groups or in mortality among low-income residents of the hospitals’ local service areas. The 340B Program has been associated with hospital–physician consolidation in hematology–oncology and with more hospital-based administration of parenteral drugs in hematology–oncology and ophthalmology. Financial gains for hospitals have not been associated with clear evidence of expanded care or lower mortality among low-income patients. (Funded by the Agency for Healthcare Research and Quality and others.)