Donaldson C, Gerard K
Department of Public Health, University of Sydney, Australia.
Health Policy. 1991 Feb;17(1):51-76. doi: 10.1016/0168-8510(91)90117-g.
In this paper, the empirical evidence addressing the particular issue of how hospitals may be reimbursed is reviewed. Most forthcoming is the indeterminate effect of prospective payment systems using diagnosis-related groups as a means of controlling costs. Such systems, by controlling only the price of hospital care, remain vulnerable to compensatory increase in patient throughput, cost-shifting and patient-shifting despite hospital cost per case being reduced. Health maintenance organisations have been shown to reduce hospital costs, but their effects on patients selection and patient outcome are unclear. Selective contracting in California (similar to the U.K. Government's proposed internal market) has also been shown to reduce costs by affecting both the price and quantity of hospital care. But these effects have occurred only in areas with high concentrations of hospitals. Global and clinical budgeting (which control price times quantity) seem to offer the most potential for cost reduction whilst maintaining patient outcome. By monitoring both cost and outcome within clinical budgets it should be possible to reduce wasteful variations in health care and so establish more efficient hospital practice.
本文回顾了关于医院如何获得补偿这一特定问题的实证证据。最突出的是采用诊断相关组作为控制成本手段的前瞻性支付系统的不确定效果。此类系统仅控制医院护理价格，尽管每例患者的医院成本有所降低，但仍易受到患者流量的补偿性增加、成本转嫁和患者转移的影响。健康维护组织已被证明能降低医院成本，但其对患者选择和患者治疗结果的影响尚不清楚。加利福尼亚州的选择性签约（类似于英国政府提议的内部市场）也已被证明通过影响医院护理的价格和数量来降低成本。但这些效果仅在医院高度集中的地区出现。总额预算制和临床预算制（控制价格乘以数量）似乎在保持患者治疗结果的同时，具有最大的降低成本潜力。通过在临床预算内监测成本和治疗结果，应该有可能减少医疗保健中的浪费性差异，从而建立更高效的医院实践。
