Lefton R
Northeastern Hospital, Philadelphia, PA, USA.
Healthc Financ Manage. 1997 Feb;51(2):50-2, 54-7.
Most managed care arrangements do not properly align provider and HMO incentives and thus unintentionally promote conflicting care management patterns. But appropriate risk-sharing arrangements encourage HMOs and providers to agree on the best methods to achieve member satisfaction; high-quality, cost-effective care; and healthy profits. Quality- and cost-based risk-sharing arrangements withhold a certain portion of providers' payments for placement in a risk pool fund. Providers are penalized financially for poor quality and unsatisfactory cost performance; providers are financially rewarded with risk pool funds for the cost-efficient delivery of high-quality health care. Percent-of-premium or capitation risk-sharing arrangements divide member premiums among the parties to the risk-sharing arrangement based on how much financial risk each party is willing to assume for providing care. The risk of controlling variations in cost is assumed by providers, thus minimizing HMOs' financial exposure. Inpatient case rate risk-sharing arrangements pay providers a flat rate for uncomplicated cases. Such arrangements can improve the relationship between HMOs and providers by giving providers primary control over case management and benefits HMOs by reducing their utilization review activities.
大多数管理式医疗安排未能使医疗服务提供者和健康维护组织（HMO）的激励措施恰当协调一致，从而无意中助长了相互冲突的医疗管理模式。但恰当的风险分担安排会促使HMO和医疗服务提供者就实现会员满意度、高质量且具成本效益的医疗服务以及可观利润的最佳方法达成一致。基于质量和成本的风险分担安排会从支付给医疗服务提供者的款项中扣留一定比例，存入风险池基金。若医疗服务质量不佳且成本绩效不理想，提供者会受到经济处罚；若能高效提供高质量医疗服务，提供者则会从风险池基金中获得经济奖励。保费百分比或人头费风险分担安排会根据风险分担安排各方为提供医疗服务愿意承担的财务风险程度，在各方之间分配会员保费。控制成本变化的风险由医疗服务提供者承担，从而将HMO的财务风险降至最低。住院病例费率风险分担安排会就简单病例向医疗服务提供者支付固定费用。此类安排可赋予医疗服务提供者对病例管理的主要控制权，从而改善HMO与医疗服务提供者之间的关系，同时减少HMO的利用审查活动，对HMO有利。
