健康保险费用分担对参保者急诊服务利用影响的系统评价

目的描述和分析小同健康保险计划中急诊费用分担埘参保者急诊服务利用的直接影响以及药品费用分担对参保者急诊服务利用的间接影响。方法计算机检索18个数据库（包括循证类、卫生类、经济类及社会类等），2个灰色文献数据库和Google搜索引擎，检索时限均为2011年6月21日至9月19日。由2位研究者根据纳入标准独立筛选文献和提取资料，如遇分歧则讨论解决或交由第三人裁定。而后采用主题分析法，描述费用分担对急诊利用的直接和间接影响，并分析其副作用。结果①最终纳入22篇文献。其中13篇文献描述了急诊费用分担直接引起的参保者急诊利用变化，9篇文献描述了药品费用分扫间接引起的参保者急诊利用变化，主要涉及5类健康保险计划。②急诊服务利用对保险费用分扣具有反应性，共付比例增加时，急诊服务利用降低，反之亦然。药品共付增加会影响基本药物利用，引起急诊利用增加；而急诊共付增加，会降低急诊不合理利用，不会降低合理利用。结论对于参保者，药品共付增加，会导致急诊利用增加等不良事件；而急诊共付增加，急诊合理利用未降低，无不良事件产生。对于非参保者，费用分担影响尚有待研究。本系统评价结果提示，可根据地区经济水平、居民收入等，适当引入急诊自付，但药品自付比例的确定应慎重。

Impact of Cost Sharing on Emergency Service Utilization in Health Insurance Plans:A Systematic Review

Objective To describe and analyze both the direct impact of emergency service （ES） cost sharing and the indirect impact of drug cost sharing on emergency service utilization （ESU） in health insurance plans. Methods The author searched18 electronic databases which were in the evidence-based, public health, economic and social categories, respectively, 2 grey literature review resources and Google search engine, and the retrieval time was from June 21st, 2011 to September 19th, 2011. According to the inclusion criteria, data screening and extraction were conducted by two reviewers independently, and the differences were discussed by a third person or a review group. The theme analysis was adopted to systematically analyze both the direct and indirect impacts of cost sharing on ESU. Additionally, the side effects were analyzed too. Results Among total 22 studies included, 13 described the direct impact of ESU cost sharing, while the other 9 referred to the indirect impact of drug cost sharing. There were mainly 5 categories of health plans involved in. The results showed that, ESU could respond to the cost sharing： ESU decreased when the proportion of copayment increased, and vice versa. The increase of drug copayment impaired the use of essential drugs and finally increased ESU. However, a modest ES copayment decreased the irrational ESU rather than the rational ESU. Conclusion To the insured, the increase of ES cost sharing would not decrease the rational ESU and has no adverse events, while the increase of drug cost sharing would lead to some adverse events such as the increase of ESU. To the uninsured, the impact of cost sharing needs to be further disccussed. So this review suggests, the proper ES self-payment should be introduced into the health insurance plans according to local economic status, resident income, etc.; in addition, the drug self-payment ratio should be determined cautiously.