Berenson R A, Hastings D A, Kopit W G
Baxter Health Policy Rev. 1996;2:235-65.
Largely because of its indifference to spiraling costs, the professional domination model is being replaced by a market model based on competition among managed care plans and integrated delivery systems. In general, the more fully integrated previously competing providers become--for instance, by assuming financial risk together--the less legal risk is present, because of a decreased possibility of improper conspiratorial or collective behavior. Nevertheless, provider joint ventures and integrated delivery systems face a complex interaction of practical challenges and various legal and regulatory risks. This chapter explores ways in which laws involving fraud and abuse, self-referral, private inurement, corporate practice of medicine, Medicare reimbursement policy, and antitrust enforcement affect typical integrated delivery systems. From a legal standpoint, it might seem logical that the laws regulating health care providers would support and promote integration. A permissive legal environment to foster development of an integrated service network model assumes its development in a delivery system in which networks are at financial risk for the services provided. However, many of the laws and regulations governing integrated provider development were established at a time when joint ventures and other alliances were organizing in a predominantly fee-for-service environment and were generating significant increases in health care costs without producing demonstrable efficiencies or quality enhancements. The results is a fundamental inconsistency in government policy. The demand for collaboration by purchasers and legislatures does not necessarily cause the vast body of health care regulators to revise their concerns that many of the very collaborative activities being encouraged trigger potentially illegal acts and relationships. In a market model, the application of federal and state antitrust laws is especially important. In 1993 and 1994, the Department of Justice and the Federal Trade Commission jointly issued "Statements of Antitrust Enforcement Policy" in a number of areas of provider uncertainty. For integrated delivery systems, the primary focus of antitrust analysis is "market power." Systems without market power (i.e., the ability to force a purchaser to do something that the purchaser would not do in a competitive market) cannot harm consumers and should be free from serious antitrust risk. Where a network may have market power, its activities may be limited only if demonstrable anticompetitive effects outweigh the benefits of the efficiencies claimed by the new arrangement. The chapter concludes that vigorous antitrust enforcement may be required to promote market competition among integrated networks of providers and the managed care plans they serve.
专业主导模式正 largely 被基于管理式医疗计划和综合服务提供系统之间竞争的市场模式所取代，这主要是因为它对不断攀升的成本漠不关心。一般来说，以前相互竞争的供应商整合得越充分——例如，通过共同承担财务风险——法律风险就越小，因为不当的合谋或集体行为的可能性降低了。然而，供应商合资企业和综合服务提供系统面临着实际挑战与各种法律和监管风险的复杂相互作用。本章探讨了涉及欺诈与滥用、自我转诊、私人获利、行医公司化、医疗保险报销政策以及反垄断执法的法律如何影响典型的综合服务提供系统。从法律角度看，规范医疗服务提供者的法律似乎理应支持和促进整合。营造允许综合服务网络模式发展的宽松法律环境，假定其在一个服务网络需为所提供服务承担财务风险的服务提供系统中发展。然而，许多管理综合服务提供者发展的法律法规是在合资企业和其他联盟主要在按服务收费环境中组建且导致医疗成本大幅增加而又未产生明显效率提升或质量改善的时候制定的。结果是政府政策存在根本上的不一致。购买方和立法机构对合作的需求不一定会使大量医疗监管机构改变他们的担忧，即许多受到鼓励的合作活动会引发潜在的非法行为和关系。在市场模式中，联邦和州反垄断法的适用尤为重要。1993 年和 1994 年，美国司法部和联邦贸易委员会在供应商存在不确定性的多个领域联合发布了“反垄断执法政策声明”。对于综合服务提供系统而言，反垄断分析的主要焦点是“市场力量”。没有市场力量（即迫使购买方做在竞争市场中购买方不会做的事情的能力）的系统不会损害消费者，并且应无严重的反垄断风险。如果一个网络可能具有市场力量，只有在可证明的反竞争效果超过新安排所声称的效率带来的好处时，其活动才可能受到限制。本章得出结论，可能需要大力执行反垄断法，以促进供应商综合网络与其所服务的管理式医疗计划之间的市场竞争。
