Association of Ambulance Use in New York City With the Implementation of the Patient Protection and Affordable Care Act
Association of Ambulance Use in New York City With the Implementation of the Patient Protection and Affordable Care Act
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DOI：
10.1001/jamanetworkopen.2019.6419
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发表时间：
2019-06-01
影响因子：
13.8
通讯作者：
Rees, Daniel I.
中科院分区：
文献类型：
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作者：
Courtemanche, Charles;Friedson, Andrew I.;Rees, Daniel I.
重要性扩大保险覆盖范围可能与过度使用医疗护理有关，因为新参保的患者不必支付全额费用。目的检查纽约市(NYC)患者保护和平价医疗法案(ACA)推出前后救护车运输的使用情况。设计、设置和参与这项病例对照研究的人员，检查了ACA推出前后纽约市因轻伤而派遣的救护车数量。数据来自对2013年1月1日至2016年7月31日期间纽约市所有救护车调度量的普查。使用救护车调度更严重的伤害，这是更难被描述为不必要的，作为对照组。分析从2017年8月17日到2019年5月10日进行。主要结果和措施主要结果是每个调度区每月定义的轻伤救护车调度量。对于2014年1月1日开始的调度，使用指标变量1来衡量ACA的实施情况，对于2014年1月1日之前的调度，使用0作为指标变量。伤员和重伤的救护车出动次数被用来解释长期趋势。调度员根据911呼叫者的信息对伤害程度进行分类，严重程度评分从1到8，其中1为最严重；轻伤为7分；伤害为5分；重伤为3分。结果在研究期间，纽约市共出动了4787 180辆救护车。在2014年ACA扩大保险覆盖范围后，与较严重伤害的调度相比，针对轻伤的救护车调度有所增加。与实施前每个调度区每月20.75次(14.24次)轻伤调度的平均水平相比，每个调度区每月比其他类型伤害调度增加7.71次(95%可信区间，1.23-14.19)次轻伤调度，增长37.2%。鉴于纽约市有31个调度区，这一增长相当于每月增加约239次调度，或每年增加2868次轻伤调度。结论和相关性ACA保险扩大后，纽约市轻伤救护车的使用显著增加，这表明医疗保险结构的变化与非紧急情况下紧急医疗服务的使用增加有关。未来对美国医疗保险制度的改革应该考虑到在非紧急情况下增加使用紧急医疗服务的可能性，文献表明，这可能会导致拥堵和反应时间变慢。
IMPORTANCE Expanding insurance coverage may be associated with overuse of medical care because newly insured patients are insulated from having to pay the full cost.OBJECTIVE To examine the use of ambulance transport before and after the rollout of the Patient Protection and Affordable Care Act (ACA) in New York City (NYC), New York.DESIGN, SETTING, AND PARTICIPANTS In this case-control study, the volume of ambulance dispatches in NYC for minor injuries before and after the rollout of the ACA was examined. Data were drawn from a census of all ambulance dispatches in NYC between January 1, 2013, and July 31, 2016. Ambulance dispatches for more severe injuries, which are more difficult to characterize as unnecessary, were used as the control group. Analyses were conducted from August 17, 2017, to May, 10, 2019.MAIN OUTCOME AND MEASURES The main outcome was the number of ambulance dispatches for minor injuries, defined per month per dispatch zone. The implementation of the ACA was measured using an indicator variable of 1 for dispatches starting January 1, 2014, and 0 for dispatches before January 1, 2014. The number of ambulance dispatches for injuries and major injuries was used to account for secular trends. Injury severity was classified by the dispatchers based on information from the 911 callers with a severity score on a scale of 1 to 8, where 1 is the most severe; minor injuries had a score of 7; injuries, 5; and major injuries, 3.RESULTS There were 4 787 180 ambulance dispatches in NYC during the study. After the 2014 expansion of insurance coverage under the ACA, there was an increase in ambulance dispatches for minor injuries compared with dispatches for more severe injuries. Compared with the preimplementation mean (SD) of 20.75 (14.24) minor injury dispatches per dispatch zone per month, there were 7.71 (95% CI, 1.23-14.19) additional minor injury dispatches per dispatch zone per month compared with dispatches for other types of injuries, an increase of 37.2%. Given that NYC has 31 dispatch zones, this increase is equivalent to approximately 239 additional dispatches per month or 2868 additional dispatches per year for minor injuries.CONCLUSIONS AND RELEVANCE There was a significant increase in use of ambulance transport for minor injuries in NYC after the ACA insurance expansion, suggesting that the change in health insurance structure was associated with increased use of emergency medical services in nonemergent situations. Future reforms to the US health insurance system should take into account the potential for increased use of emergency medical services in nonemergent situations, which the literature suggests may lead to congestion and slower response times.