Cangialose C B, Cary S J, Hoffman L H, Ballard D J
White Institute for Health Services Research, Decatur, GA 30030, USA.
Am J Manag Care. 1997 Aug;3(8):1153-70.
Each strategy for managing healthcare risk has important and unique implications for the patient-provider relationship and for quality of care. Not only are different incentive structures created by different risk-sharing arrangements, but these incentives differ from those in a fee-for-service environment. With fee-for-service and traditional indemnity insurance, physicians have incentives to provide healthcare services of marginal value to the patient; under managed care, physicians have fewer incentives to provide marginally beneficial services. However, the impact of financial arrangements on quality of care remains ambiguous, because it depends on the strategic behavior of physicians with regard to their informational advantage over their patients. Using the framework of an agency theory model, we surveyed the current scientific literature to assess the impact of managed care on quality of care. We considered three different dimensions of quality of care: patient satisfaction, clinical process and outcomes of care measures, and resource utilization. Although we found no systematic differences in patient satisfaction and clinical process and outcomes between managed care and fee-for-service plans, resource utilization appears to be decreased under managed care arrangements. Given the strengths and weaknesses of fee-for-service and managed care, it is unlikely that either will displace the other as the exclusive mechanism for arranging health insurance contracts. Policy makers may be able to take advantage of the strengths of both fee-for-service and managed care financial arrangements.
医疗保健风险管理的每一种策略，对医患关系和医疗质量都有着重要且独特的影响。不同的风险分担安排不仅会产生不同的激励结构，而且这些激励措施与按服务收费环境下的激励措施有所不同。在按服务收费和传统的赔偿保险模式下，医生有动机为患者提供边际价值的医疗服务；在管理式医疗模式下，医生提供边际效益服务的动机则较少。然而，财务安排对医疗质量的影响仍不明确，因为这取决于医生相对于患者所具有的信息优势方面的战略行为。我们运用委托代理理论模型框架，对当前的科学文献进行了调查，以评估管理式医疗对医疗质量的影响。我们考虑了医疗质量的三个不同维度：患者满意度、临床过程和护理措施结果以及资源利用情况。虽然我们发现管理式医疗计划与按服务收费计划在患者满意度、临床过程和结果方面没有系统性差异，但在管理式医疗安排下，资源利用似乎有所减少。鉴于按服务收费和管理式医疗的优缺点，两者都不太可能作为安排健康保险合同的唯一机制而相互取代。政策制定者或许能够利用按服务收费和管理式医疗财务安排的优势。
