Lerner W M
Jewish Hospital of St. Louis.
Med Care Rev. 1990 Winter;47(4):503-23. doi: 10.1177/107755879004700406.
The primary purpose of the government's prospective payment system was to decrease the rate of federal spending for Medicare patients by paying fixed prices for services and by transferring the financial risk for the care provided to the hospital. While PPS certainly has affected all hospitals, this article has attempted to identify some of the expected and unexpected consequences of the change in reimbursement on publicly and privately owned university hospitals. Of importance is the discussion that has analyzed the specific effects of PPS on the components of the UHs' missions. The implementation of PPS may exaggerate the effects of the payment change on both types of UHs. The provision of broadly based primary and specialty care services may be in question as institutions find themselves potentially unable to deliver these services on a price-competitive yet profitable basis. The costs associated with educational, research, and community service programs can no longer be subsidized by excess patient care revenues as payers streamline payments to reflect only the costs of clinical care. Thus, university hospitals may be forced to reexamine their missions and change their operating plans to reflect the current fiscal environment. If taken to an extreme, it is likely that the local society may be negatively affected by these actions. Clinical and community services that increase access, assure continuity of care, or provide needed but costly (public) health services may be eliminated or reduced in scope in an effort to contain costs. Even those services that are cost beneficial from a societal perspective may be eliminated without some form of subsidy or direct payment as institutions are forced to reallocate their limited funds from these types of public health services to support nonprofitable, but critical clinical or academic programs. The potential impact on access, continuity of care, and morbidity and mortality will not be known for many years. Although it is not known how these changes will eventually affect university hospitals, two outcomes seem clear. University hospitals with different governance and management structures may not change their missions and means for achieving institutional goals as much as might have been expected. The interdependence of the university hospitals' goals and the role they play in their local communities may force them to begin to explore new ways to achieve their missions. Public-private sector cooperation is suggested as one approach to use in response to the demands of payers and patients while the institution remains true to its historical mission.(ABSTRACT TRUNCATED AT 400 WORDS)
政府预期支付系统的主要目的是通过为服务支付固定价格以及将所提供护理的财务风险转移给医院，来降低联邦政府为医疗保险患者的支出率。虽然预期支付系统肯定对所有医院都产生了影响，但本文试图确定报销方式的变化对公立和私立大学医院产生的一些预期和意外后果。重要的是，所进行的讨论分析了预期支付系统对大学医院使命组成部分的具体影响。预期支付系统的实施可能会夸大支付变化对这两类大学医院的影响。随着各机构发现自己可能无法在具有价格竞争力且有利可图的基础上提供这些服务，提供广泛的初级和专科护理服务可能会受到质疑。随着支付方简化支付方式以仅反映临床护理成本，与教育、研究和社区服务项目相关的成本再也不能由多余的患者护理收入来补贴。因此，大学医院可能被迫重新审视其使命并改变其运营计划，以适应当前的财政环境。如果走极端，当地社会很可能会受到这些行动的负面影响。为了控制成本，那些增加就医机会、确保护理连续性或提供所需但成本高昂（公共）卫生服务的临床和社区服务可能会被削减或范围缩小。即使那些从社会角度来看具有成本效益的服务，如果没有某种形式的补贴或直接支付，也可能会被取消，因为各机构被迫将其有限资金从这些类型的公共卫生服务重新分配，以支持无利可图但至关重要的临床或学术项目。这些变化对就医机会、护理连续性以及发病率和死亡率的潜在影响在许多年内都不会知晓。虽然尚不清楚这些变化最终将如何影响大学医院，但有两点似乎很明确。具有不同治理和管理结构的大学医院可能不会像预期的那样改变其使命和实现机构目标的方式。大学医院目标的相互依存性以及它们在当地社区所起的作用可能会迫使它们开始探索实现其使命的新途径。建议公私部门合作作为一种应对支付方和患者需求的方法，同时该机构仍忠于其历史使命。（摘要截选至400字）
