ارزیابی کاهش هزینه‌های غیرضروری در برنامه پزشک خانواده با رویکرد جامعیت مراقبت‌ها (کاهش هزینه‌ها در برنامه پزشک خانواده)
محورهای موضوعی : -مدارک پزشکیمحمود کاظمیان 1 , فاطمه کاویان تلوری 2 , شیرعلی میرداروطن 3
1 - استادیار، دانشکده پزشکی، گروه اقتصاد بهداشت، دانشگاه علوم پزشکی شاهد، تهران، ایران
2 - کارشناس ارشد اقتصاد سلامت، مرکز تحقیقات مدیریت سلامت و توسعه اجتماعی، دانشگاه علوم پزشکی گلستان، گرگان، ایران
3 - کارشناس ارشد مدیریت خدمات بهداشتی، دانشگاه علوم پزشکی گلستان، گرگان، ایران
کلید واژه: جامعیت مراقبت‌ها, هزینه‌های غیرضروری, نقض نظام ارجاع, خدمات قبل از ارجاع,
چکیده مقاله :
مقدمه: برنامه پزشک خانواده با هدف کاهش هزینه‌های غیرضروری در برنامه پزشک خانواده، از سال 1384 در روستاها و شهرهای زیر 20 هزار نفر به اجرا درآمد. در این پژوهش، این هدف با معیار جامعیت مراقبت‌ها در سطح 17 مرکز بهداشت شهرستان گرگان ارزیابی گردیده است. روش پژوهش: ارزیابی در یک دوره 24 ماه و در 17 مرکز بهداشت روستایی شهرستان گرگان بر اساس مدل رگرسیونی خطا-تصحیح در چارچوب مدل داده‌های ترکیبی با استفاده از نرم‌افزار تحلیل اقتصادسنجی Ewios8 انجام گردید. نتیجه تخمین رگرسیونی در ابتدا میزان جامعیت مراقبت‌ها را نشان می‌دهد و سپس با استفاده از ضرایب تاثیر جامعیت مراقبت‌ها برکاهش هزینه‌های غیرضروری نشان می‌دهد. یافته‌ها: مطابق انتظار تأثیر پزشک خانواده برای کاهش هزینه‌های غیرضروری به طور قابل ملاحظه حدود 6/6 % ملاحظه گردید. در مقابل تأثیر پرستار در برنامه پزشک خانواده بسیار ناچیز، حدود 2/0%، و تأثیر خدمات آزمایشگاه تشخیصی نیز در سطح محدود، حدود 7/1%، مشاهده گردید. خدمات عرضه دارو نیز مطابق انتظار نبوده است. نتیجه‌گیری: در برنامه پزشک خانواده برای کاهش هزینه‌های غیرضروری، کامل بودن خدمات قبل از ارجاع یا جامعیت مراقبت‌ها در مراکز بهداشتی درمانی تحت سرپرستی پزشک مراقبت‌های اولیه یا پزشک خانواده ضروری می‌‌باشد. اما انتظارات از جامعیت مراقبت‌ها در مراکز بهداشت شهرستان گرگان به جهت تأثیر محدود مراقبت‌های پرستاری و خدمات آزمایشگاه تشخیصی بر کاهش هزینه‌های غیرضروری هنوز محقق نشده است.
Introduction: Family medicine program with the aim of reduction in unnecessary cost, has been implemented in Iran, in rural and under 20,000 population urban areas in 1384. In this study, this targeting has been assessed by comprehensive care criterion in 17 health centers of Gorgan city in Iran. Methods: In this research, the assessment of Rural Family Physician Program in 17 rural health centers of Gorgan city in 24 months has been carried out within an error-correction regression model in panel data framework. The results of regression estimations showed the weight/importance coefficients in comprehensive health car indicator, and then, the main/elasticity coefficients for the indicators, differentiating short-term and long-term trends on unnecessary cost indicator. Results: The effect of family physician on reduction in unnecessary cost, expectedly, was considerable, accounting for 6.6 percent. In contrast, the effect of nursing services in the program was too low, accounting for 0.2 percent, and the effect of lab services was much limited, accounting for 1.7 percent. Also, pharmaceutical (drug supply) services not expected. Conclusion: In the family medicine program, to reduce in unnecessary cost, it is important to provide adequate pre-referral services, regarding comprehensive health care in the health centers under management of primary health care physician. But, comprehensive care in the Gorgan health centers has failed to meet expectations, since the shares and effects of nursing and laboratory services in the program were low.
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2- GLIED S. MANAGED CARE. Handbook of health economics, Mailman School of Public Health,Columbia University, 2000; 13: 708-745.
3- Starfield B,Chang Y,Lemke K.W,Weiner JP. Ambulatory specialist use by nonhospitalized patient in US health plans. The Journal of Ambulatory Care Management, 2009; 32(3): 216-225.
4- A Vision for Canada Family Practice – The Patient’s Medical Home.The College of Family Physicians of Canada; 2011.
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6- Starfield B. The medical home,access to care ,and insurance:a review of evidence .Pediatrics, 2004; 113(4): 1493-1498.
7- Hopman P, de Bruin SR, Forjaz MJ, Rodriguez-Blazquez C, Tonnara G, Lemmens LC, Onder G, Baan CA, Rijken M. Effectiveness of comprehensive care programs for patients with multiple chronic conditions or frailty: A systematic literature review. Health Policy, 2016; 11: 818-832.
8- Referral Systems Assessment and Monitoring Toolkit, MEASURE Evaluation, 2013, United States Agency for International Development, USAID,( http://www.cpc.unc.edu/measure/resources/publications?b_start:int=360)
9- Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Affairs, 2008; 27(3): 759-69.
10- Berwick, Donald M., and Andrew D. Hackbarth. "Eliminating waste in US health care. Jama, 2012; 307(14): 1513-1516.
11- Rural family physician's instructions and cities under 20,000, Version16.Ministry of HealthandMedical Education, Department of Health,NetworkManagement Center, 2015.
12- Forrest CB,Starfield B.Entry in to primary care and continuity: the effects of access.American Journal of Public Health, 1998; 88(9): 1330-36.
13- LoweRA, LocalioJR, Schward, et al. Association between primary care practice characterstics and emergency department use in a Medicaid.managed care organization med care, 2005; 43(8): 792-800.
14- Yip W, Hsiao WC. The Chinese health system at a crossroads. Health Affairs, 2008; 27(2): 460-8.
15- Frise J, Koop C, Carson E, & et al. Reducing health care costs by reducing the need and demand for medical. The New England Journal of medicine, 2013; 321(5): 321-325.
16- Buntin M, Haviland A, McDevitt R, Sood N. Health care spending and pre-ventive care in high-deductible and consumer-directed health plans. AmericanJournal of Managed Care, 2011; 17 (3): 222–230.
17- Huckfeldt P, Haviland A, Mehrotra A, Wagner Z, Sood N. Patient Responsesto Incentives in Consumer-Directed Health Plans: Evidence from Pharmaceut-icals. Working Paper; 2015.
18. Haviland AM, Eisenberg MD, Mehrotra A, Huckfeldt PJ, Sood N. Do “Consumer-Directed” health plans bend the cost curve over time?. Journal of health economics, 2016; 46: 33-51.
_||_1- Gill J M. Use of hospital emergency departments for non-urgent care:a persistent problem with no casy solutions .American Journal of manage care, 1999; 5(12): 1565-1568.
2- GLIED S. MANAGED CARE. Handbook of health economics, Mailman School of Public Health,Columbia University, 2000; 13: 708-745.
3- Starfield B,Chang Y,Lemke K.W,Weiner JP. Ambulatory specialist use by nonhospitalized patient in US health plans. The Journal of Ambulatory Care Management, 2009; 32(3): 216-225.
4- A Vision for Canada Family Practice – The Patient’s Medical Home.The College of Family Physicians of Canada; 2011.
5- The Future of Family Medicine: A Collaborative Project of the Family Medicine Community, Future of Family Medicine Project Leadership Committee; Future of Family Medicine, 2004; 2(1): 1-32.
6- Starfield B. The medical home,access to care ,and insurance:a review of evidence .Pediatrics, 2004; 113(4): 1493-1498.
7- Hopman P, de Bruin SR, Forjaz MJ, Rodriguez-Blazquez C, Tonnara G, Lemmens LC, Onder G, Baan CA, Rijken M. Effectiveness of comprehensive care programs for patients with multiple chronic conditions or frailty: A systematic literature review. Health Policy, 2016; 11: 818-832.
8- Referral Systems Assessment and Monitoring Toolkit, MEASURE Evaluation, 2013, United States Agency for International Development, USAID,( http://www.cpc.unc.edu/measure/resources/publications?b_start:int=360)
9- Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Affairs, 2008; 27(3): 759-69.
10- Berwick, Donald M., and Andrew D. Hackbarth. "Eliminating waste in US health care. Jama, 2012; 307(14): 1513-1516.
11- Rural family physician's instructions and cities under 20,000, Version16.Ministry of HealthandMedical Education, Department of Health,NetworkManagement Center, 2015.
12- Forrest CB,Starfield B.Entry in to primary care and continuity: the effects of access.American Journal of Public Health, 1998; 88(9): 1330-36.
13- LoweRA, LocalioJR, Schward, et al. Association between primary care practice characterstics and emergency department use in a Medicaid.managed care organization med care, 2005; 43(8): 792-800.
14- Yip W, Hsiao WC. The Chinese health system at a crossroads. Health Affairs, 2008; 27(2): 460-8.
15- Frise J, Koop C, Carson E, & et al. Reducing health care costs by reducing the need and demand for medical. The New England Journal of medicine, 2013; 321(5): 321-325.
16- Buntin M, Haviland A, McDevitt R, Sood N. Health care spending and pre-ventive care in high-deductible and consumer-directed health plans. AmericanJournal of Managed Care, 2011; 17 (3): 222–230.
17- Huckfeldt P, Haviland A, Mehrotra A, Wagner Z, Sood N. Patient Responsesto Incentives in Consumer-Directed Health Plans: Evidence from Pharmaceut-icals. Working Paper; 2015.
18. Haviland AM, Eisenberg MD, Mehrotra A, Huckfeldt PJ, Sood N. Do “Consumer-Directed” health plans bend the cost curve over time?. Journal of health economics, 2016; 46: 33-51.