Grembowski David E, Cook Karen S, Patrick Donald L, Roussel Amy Elizabeth
Department of Health Services, University of Washington, Seattle 98195-7660, USA.
Soc Sci Med. 2002 Apr;54(8):1167-80. doi: 10.1016/s0277-9536(01)00087-9.
Many countries are importing managed care and price competition from the US to improve the performance of their health care systems. However, relatively little is known about how power is organized and exercised in the US health care system to control costs, improve quality and achieve other objectives. To close this knowledge gap, we applied social exchange theory to examine the power relations between purchasers, managed care organizations, providers and patients in the US health care system at three interrelated levels: (1) exchanges between purchasers and managed care organizations (MCOs); (2) exchanges between MCOs and physicians; and (3) exchanges between physicians and patients. The theory and evidence indicated that imbalanced exchange, or dependence, at all levels prompts behavior to move the exchange toward power balance. Collective action is a common strategy at all levels for reducing dependence and therefore, increasing power in exchange relations. The theoretical and research implications of exchange theory for the comparative study of health care systems are discussed.
许多国家正在引入美国的管理式医疗和价格竞争，以改善其医疗保健系统的绩效。然而，对于美国医疗保健系统中权力是如何组织和行使以控制成本、提高质量并实现其他目标的，人们了解得相对较少。为了填补这一知识空白，我们应用社会交换理论，在三个相互关联的层面审视了美国医疗保健系统中购买方、管理式医疗组织、医疗服务提供者和患者之间的权力关系：（1）购买方与管理式医疗组织（MCO）之间的交换；（2）MCO与医生之间的交换；以及（3）医生与患者之间的交换。理论和证据表明，各级不平衡的交换，即依赖，会促使行为朝着权力平衡的方向推动交换。集体行动是各级减少依赖从而增加交换关系中权力的常见策略。讨论了交换理论对医疗保健系统比较研究的理论和研究意义。
