Hellinger F J
Center for Organization and Delivery Studies, Agency for Health Care Policy and Research, Rockville, MD 20852, USA.
Am J Manag Care. 1998 May;4(5):663-74.
Recent accounts of enrolees in managed care plans being denied access to potentially lifesaving services have heightened public anxiety about the impact of managed care on the accessibility and appropriateness of care, and this anxiety has been translated into legislative action. The present review focuses on an area of managed care operations that has received considerable attention in state legistlatures and in Congress during the past 2 years: the financial relationship between managed care health plans and physicians. Twelve states now mandate that managed care plans disclose information about their financial relationship with physicians, and 11 states regulate the method used by managed care health plans to compensate physicians. Most laws that regulate methods of compensation prohibit health plans from providing physicians an inducement to reduce or limit the delivery of "medically necessary" services. Moreover, in 1996 the Health Care Financing Administration finalized its regulations governing the financial incentives facing physicians in plans that treat Medicaid or Medicare patients, and these regulations went into effect on January 1, 1997. These regulations also are examined in this study.
最近有报道称，参与管理式医疗计划的参保人被拒绝获得可能挽救生命的服务，这加剧了公众对管理式医疗对医疗可及性和适宜性影响的焦虑，这种焦虑已转化为立法行动。本综述聚焦于管理式医疗运营的一个领域，在过去两年中该领域在州立法机构和国会中受到了相当多的关注：管理式医疗健康计划与医生之间的财务关系。现在有12个州要求管理式医疗计划披露其与医生财务关系的信息，11个州对管理式医疗健康计划补偿医生的方式进行监管。大多数规范补偿方式的法律禁止健康计划诱使医生减少或限制提供“医疗必需”服务。此外，1996年医疗保健财务管理局最终确定了其针对治疗医疗补助或医疗保险患者的计划中医生所面临财务激励的规定，这些规定于1997年1月1日生效。本研究也对这些规定进行了审视。
