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按人头计费的医疗服务提供系统的定价策略。

Pricing strategies for capitated delivery systems.

作者信息

Gruenberg L, Wallack S S, Tompkins C P

出版信息

Health Care Financ Rev. 1986;1986(Spec No):35-44.

PMID:10311925
原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC4195089/
Abstract

This article discusses alternative methods for establishing a fairer pricing mechanism for Medicare recipients who enroll in health maintenance organizations and other competitive medical plans. The current method, based upon the adjusted average per capita cost, is inadequate because it fails to adjust premium levels for differences in health status; it establishes undesirable incentives that may lead to underservice, and it is tied to costs in the fee-for-service system. Alternative methods would incorporate health status, have Medicare share the risk with HMO's, and base payment on HMO experience.

摘要

本文讨论了为参加健康维护组织及其他竞争性医疗计划的医疗保险受益人建立更公平定价机制的替代方法。当前基于调整后的人均成本的方法并不充分，因为它未能针对健康状况差异调整保费水平；它建立了可能导致服务不足的不良激励机制，并且与按服务收费系统中的成本挂钩。替代方法将纳入健康状况，让医疗保险与健康维护组织分担风险，并根据健康维护组织的经验进行支付。

相似文献

1
Pricing strategies for capitated delivery systems.按人头计费的医疗服务提供系统的定价策略。
Health Care Financ Rev. 1986;1986(Spec No):35-44.
2
Setting capitation payments in markets for health services.设定医疗服务市场中的人头费支付标准。
Health Care Financ Rev. 1987 Summer;8(4):55-64.
3
Medicare program; standardized per capita rates of payments for health maintenance organizations and competitive medical plans for 1986--HCFA. Notice.医疗保险计划；1986年健康维护组织和竞争性医疗计划的标准化人均支付费率——医疗保健财务管理局。通知。
Fed Regist. 1986 Jan 6;51(3):506-49.
4
Paying for HMO care: issues and options in setting capitation rates.为健康维护组织（HMO）的医疗服务付费：设定人头费率的问题与选择
Milbank Q. 1986;64(4):548-65.
5
Rate adjusters for Medicare under capitation.按人头付费的医疗保险费率调整器。
Health Care Financ Rev. 1986;1986(Spec No):45-55.
6
Protecting payment levels under Medicare risk-based contracting.在基于医疗保险风险的合同中保护支付水平。
Healthc Financ Manage. 1997 Oct;51(10):58-62.
7
Medicare reimbursement and regression to the mean.医疗保险报销与均值回归。
Health Care Financ Rev. 1988 Spring;9(3):9-22.
8
Health status adjustments for Medicare capitation.医疗保险按人头付费的健康状况调整
Inquiry. 1987 Winter;24(4):362-75.
9
Setting payment rates for capitated systems: a comparison of various alternatives.为按人头付费系统设定支付费率：各种方案的比较。
Inquiry. 1990 Fall;27(3):225-33.
10
Medicare HMO option draws fire; critics call rate schedule 'flawed'.医疗保险健康维护组织（HMO）选项引发争议；批评者称费率表“有缺陷”。
Mod Healthc. 1985 Nov 22;15(24):28.

引用本文的文献

1
Data transformations to improve the performance of health plan payment methods.数据转换以提高医保支付方式的绩效。
J Health Econ. 2019 Jul;66:195-207. doi: 10.1016/j.jhealeco.2019.05.005. Epub 2019 May 24.
2
Adjusting Medicare capitation payments using prior hospitalization data.利用既往住院数据调整医疗保险人头支付。
Health Care Financ Rev. 1989 Summer;10(4):17-29.
3
Improving the AAPCC (adjusted average per capita cost) with health-status measures from the MCBS (Medicare Current Beneficiary Survey).利用医疗保险当前受益人调查（MCBS）中的健康状况指标来改善调整后人均成本（AAPCC）。
Health Care Financ Rev. 1996 Spring;17(3):59-75.
4
Risk adjustment for a children's capitation rate.儿童按人头付费率的风险调整
Health Care Financ Rev. 1993 Fall;15(1):39-54.

本文引用的文献

1
Using prior utilization to determine payments for Medicare enrollees in health maintenance organizations.利用既往医疗服务利用率来确定健康维护组织中医疗保险参保人的支付金额。
Health Care Financ Rev. 1985 Spring;6(3):27-38.
2
The use and costs of Medicare services in the last 2 years of life.临终前两年医疗保险服务的使用情况及费用。
Health Care Financ Rev. 1984 Spring;5(3):117-31.
3
Pre-enrollment reimbursement patterns of Medicare beneficiaries enrolled in "at-risk" HMOs.参加“风险”健康维护组织（HMO）的医疗保险受益人的预注册报销模式。
Health Care Financ Rev. 1982 Sep;4(1):55-73.
4
Risk differential between Medicare beneficiaries enrolled and not enrolled in an HMO.参加和未参加健康维护组织（HMO）的医疗保险受益人的风险差异。
Health Care Financ Rev. 1980 Winter;1(3):91-9.
5
Improving the Medicare HMO payment formula to deal with biased selection.改进医疗保险健康维护组织（HMO）支付公式以应对选择偏差。
Adv Health Econ Health Serv Res. 1985;6:101-26.
6
Competitive bidding and public insurance programs.竞争性招标和公共保险计划。
J Health Econ. 1984 Aug;3(2):195-8. doi: 10.1016/0167-6296(84)90008-0.
7
Provider behavior under prospective reimbursement. Cost sharing and supply.前瞻性报销下的医疗服务提供者行为。成本分摊与供应。
J Health Econ. 1986 Jun;5(2):129-51. doi: 10.1016/0167-6296(86)90002-0.
8
Health maintenance organizations and the rationing of medical care.健康维护组织与医疗保健的配给
Milbank Mem Fund Q Health Soc. 1982 Spring;60(2):268-306.
9
Evidence for self-selection among health maintenance organization enrollees.
JAMA. 1983 Nov 25;250(20):2826-9.
10
Hospital readmissions in the Medicare population.医疗保险人群中的医院再入院情况。
N Engl J Med. 1984 Nov 22;311(21):1349-53. doi: 10.1056/NEJM198411223112105.

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