Health care expenditures after introduction of a gatekeeper and a global budget in a Swiss health insurance plan.
OBJECTIVE
To assess whether the introduction of "managed care" (capitated budget and utilisation control by general practitioners) in a Swiss health insurance plan caused a selective disenrolment of plan members, and whether it achieved its goal of reducing health care expenditures.


METHODS
Controlled before-after analysis of health insurance claims.


METHODS
Health insurance plan of the University of Geneva, Switzerland, which introduced managed care at the end of 1992, and comparison plan, which reimbursed health care expenditures without setting a budget or controlling access.


METHODS
Analysis of self selection: university plan members who accepted (3993) or refused (659) transfer to managed care. Analysis of change in expenditures: cohorts of persons continuously enrolled in the university (1575) and comparison (3384) plans in 1992 and 1993.


RESULTS
During 1992, the year before the transformation of the university plan, persons who refused managed care had generated 35% higher expenditures than those who accepted managed care (p < 0.001). Between 1992 and 1993, expenditures per member decreased by 9% in the university cohort and increased by 11% in the comparison cohort (p = 0.004). Technical procedures (laboratory tests, physical therapy, drugs) decreased most in the university plan. No impact on hospital admissions was detected.


CONCLUSIONS
Introduction of gatekeeping and budget management by physicians caused a favourable self selection process for the university plan. In addition, the managed care plan achieved a substantial decrease in overall health care expenditures in its first year of operation, chiefly by reducing outlays for technical procedures.
Institute of Social and Preventive Medicine, University of Geneva, Switzerland.
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Etter
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Perneger
D000328:Adult; D002017:Budgets / Q000458:organization & administration; D015331:Cohort Studies; D005260:Female; D005500:Follow-Up Studies; D017048:Health Care Costs / Q000706:statistics & numerical data; D006801:Humans; D007344:Insurance Claim Reporting / Q000706:statistics & numerical data; D008297:Male; D008329:Managed Care Programs / Q000191:economics / Q000458:organization & administration / Q000706:statistics & numerical data; D012044:Regression Analysis; D013557:Switzerland