Hirth R A, Chernew M E, Orzol S M
Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor 48109-2029, USA.
Inquiry. 2000 Fall;37(3):282-94.
Advances in medical technology have been implicated as the primary cause of rising health care expenditures. It is not yet known whether the increasing prevalence of managed care mechanisms, particularly capitation, will change substantially incentives for acquiring and using cost-increasing innovations. We examined the decisions of dialysis units (a set of providers that has faced capitation and real decreases in payment for several decades) with respect to use of cost-increasing technologies that enhance quality of care, cost-cutting practices that reduce quality of care, and amenities desired by patients that are unrelated to quality of care. We found that the dialysis payment system does not appear to have blocked access to a number of new, quality-enhancing technologies that were developed in the 1980s. However, facilities made adjustments along other valuable margins to facilitate adoption of these technologies; use of new technologies varied with numerous facility, regulatory, and case-mix characteristics including ownership, chain membership, size, market competition, and certificate of need programs. Interestingly, the trade-offs made by for-profit and nonprofit facilities when faced with fixed prices appeared quite different. For-profits tended to deliver lower technical quality of care but more amenities, while nonprofits favored technical quality of care over amenities. Our findings may have implications for the response of other types of health care providers to capitation and increasing economic constraints.
医疗技术的进步被认为是医疗保健支出不断上升的主要原因。目前尚不清楚管理式医疗机制（尤其是按人头付费）日益普及是否会大幅改变获取和使用成本增加型创新的激励措施。我们研究了透析单位（几十年来一直面临按人头付费和实际支付减少的一组医疗服务提供者）在使用提高护理质量的成本增加型技术、降低护理质量的成本削减措施以及患者所期望的与护理质量无关的便利设施方面的决策。我们发现，透析支付系统似乎并未阻碍使用20世纪80年代开发的一些新的、提高质量的技术。然而，医疗机构在其他有价值的方面进行了调整，以促进这些技术的采用；新技术的使用因众多机构、监管和病例组合特征而异，包括所有权、连锁会员关系、规模、市场竞争和需求证明项目。有趣的是，营利性和非营利性机构在面对固定价格时所做的权衡似乎大不相同。营利性机构往往提供较低的技术护理质量，但有更多便利设施，而非营利性机构则更看重技术护理质量而非便利设施。我们的研究结果可能对其他类型的医疗服务提供者应对按人头付费和日益增加的经济限制的反应具有启示意义。
