Fronstin P
Employee Benfit Research Institute.
EBRI Issue Brief. 1994 Oct(154):1-22.
This Issue Brief discusses the evolution of the health care delivery and financing systems and its effects on health care cost management and describes the changes in the health care delivery system as they pertain to managed care. It presents empirical evidence on the effectiveness of managed care and concludes with an analysis of the potential of future health care reform to influence the evolution of the health care delivery system and affect health care costs. Between 1987 and 1993, total enrollment in health maintenance organizations (HMOs) increased from 28.6 million to 39.8 million, representing an additional 11.2 million individuals, or 4 percent of the U.S. population. At the same time, new forms of managed care organizations emerged. Enrollment in preferred provider organizations increased from 12.2 million individuals in 1987 to 58 million in 1992, and enrollment in point-of-service plans increased from virtually none in 1987 to 2.3 million individuals in 1992. In addition, the percentage of traditional fee-for-service plans with some form of utilization review increased to 95 percent in 1990 from 41 percent in 1987. Measuring the effects of the changing delivery system on the costs and quality of health care services has been a difficult task, resulting in considerable disagreement as to whether or not costs have been affected. In a recent report, the Congressional Budget Office recognizes two new major findings. First, managed care can provide cost-effective health care at a level of quality comparable with the care typically provided by a fee-for-service plan. Second, independent practice associations can be as effective as group- or staff-model HMOs under certain conditions. In the future, we are likely to see a continued movement of Americans into managed care arrangements, an increase in the number of physicians forming networks, a reduction in the number of insurers, an increase in the number of employers joining coalitions to purchase health care services for their employees, and a health care system that is generally more concentrated and vertically integrated.
本问题简报讨论了医疗服务提供和融资系统的演变及其对医疗成本管理的影响，并描述了与管理式医疗相关的医疗服务提供系统的变化。它提供了关于管理式医疗有效性的实证证据，并以对未来医疗改革影响医疗服务提供系统演变和影响医疗成本的潜力分析作为结论。1987年至1993年间，健康维护组织（HMO）的总参保人数从2860万增加到3980万，新增1120万人，占美国人口的4%。与此同时，新形式的管理式医疗组织出现。优选提供者组织的参保人数从1987年的1220万人增加到1992年的5800万人，服务点计划的参保人数从1987年几乎为零增加到1992年的230万人。此外，采用某种形式利用审查的传统按服务收费计划的比例从1987年的41%增加到1990年的95%。衡量不断变化的医疗服务提供系统对医疗服务成本和质量的影响一直是一项艰巨的任务，导致对于成本是否受到影响存在相当大的分歧。在最近的一份报告中，国会预算办公室认可了两项新的主要发现。第一，管理式医疗能够以与传统按服务收费计划提供的医疗服务质量相当的水平提供具有成本效益的医疗服务。第二，在某些条件下，独立执业协会可以与团体或员工模式的健康维护组织一样有效。未来，我们可能会看到美国人继续转向管理式医疗安排，组建网络的医生数量增加，保险公司数量减少，加入联盟为员工购买医疗服务的雇主数量增加，以及一个总体上更加集中和纵向整合的医疗系统。
