EFFECTS OF MEDICAID DRUG-PAYMENT LIMITS ON ADMISSION TO HOSPITALS AND NURSING-HOMES
EFFECTS OF MEDICAID DRUG-PAYMENT LIMITS ON ADMISSION TO HOSPITALS AND NURSING-HOMES
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DOI：
10.1056/nejm199110103251505
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发表时间：
1991-10-10
影响因子：
158.5
通讯作者：
CHOODNOVSKIY, I
中科院分区：
文献类型：
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作者：
SOUMERAI, SB;ROSSDEGNAN, D;CHOODNOVSKIY, I
背景许多州的医疗补助计划限制了患者可以获得的可报销药物的数量。我们假设，这种限制可能会导致病情恶化或入院的机构，没有上限的药物报销。我们分析了来自新罕布什尔州和新泽西的36个月的医疗补助索赔数据，新罕布什尔州在其中11个月内对每位患者的三种药物限制，而新泽西州则没有。在新罕布什尔州的研究患者（n = 411）和在新泽西的匹配对照队列（n = 1375）是60岁或以上的医疗补助接受者，他们在基线年每月服用三种或更多种药物，包括至少一种用于某些慢性疾病的维持药物。生存率（定义为留在社区）和时间序列分析进行，以确定对入院和疗养院的报销上限的影响。队列的基线人口统计学特征几乎相同。在新罕布什尔州，研究药物的使用在应用上限后下降了35%，这与疗养院入院率的增加有关;在比较队列中没有观察到变化（RR = 1.8; 95%置信区间，1.2至2.6）。住院风险没有显著增加。在新罕布什尔州的患者中，在基线时定期服用三种或三种以上的研究药物，在上限期间入住疗养院的相对风险为2.2（95%置信区间，1.2至4.1），住院的风险为1.2（95%置信区间，0.8至1.6）。当11个月后停止使用上限时，药物的使用几乎恢复到基线水平，进入养老院的过度风险也停止了。一般而言，入住疗养院的患者没有返回社区。限制对有效药物的报销使体弱、低收入、老年患者在养老院机构化的风险增加，并可能增加医疗补助费用。
Background. Many state Medicaid programs limit the number of reimbursable medications that a patient can receive. We hypothesized that such limitations may lead to exacerbations of illness or to admissions to institutions where there are no caps on drug reimbursements.Methods. We analyzed 36 months of Medicaid claims data from New Hampshire, which had a three-drug limit per patient for 11 of those months, and from New Jersey, which did not. The study patients in New Hampshire (n = 411) and a matched comparison cohort in New Jersey (n = 1375) were Medicaid recipients 60 years of age or older who in a base-line year had been taking three or more medications per month, including at least one maintenance drug for certain chronic diseases. Survival (defined as remaining in the community) and time-series analyses were conducted to determine the effect of the reimbursement cap on admissions to hospitals and nursing homes.Results. The base-line demographic characteristics of the cohorts were nearly identical. In New Hampshire, the 35 percent decline in the use of study drugs after the cap was applied was associated with an increase in rates of admission to nursing homes; no changes were observed in the comparison cohort (RR = 1.8; 95 percent confidence interval, 1.2 to 2.6). There was no significantly increased risk of hospitalization. Among the patients in New Hampshire who regularly took three or more study medications at base line, the relative risk of admission to a nursing home during the period of the cap was 2.2 (95 percent confidence interval, 1.2 to 4.1), and the risk of hospitalization was 1.2 (95 percent confidence interval, 0.8 to 1.6). When the cap was discontinued after 11 months, the use of medications returned nearly to base-line levels, and the excess risk of admission to a nursing home ceased. In general, the patients who were admitted to nursing homes did not return to the community.Conclusions. Limiting reimbursement for effective drugs puts frail, low-income, elderly patients at increased risk of institutionalization in nursing homes and may increase Medicaid costs.