Gold Marsha R, Lake Timothy, Hurley Robert, Sinclair Michael
Mathematica Policy Research, Inc., Washington, DC 20024, USA.
Inquiry. 2002 Spring;39(1):34-44. doi: 10.5034/inquiryjrnl_39.1.34.
The transfer of financial risk from health maintenance organizations (HMOs) to providers is controversial. To provide timely national data on these practices, we conducted a telephone survey in 1999 of a multi-staged probability sample of HMOs in 20 of the nation's 60 largest markets, accounting for 86% of all HMO enrollees nationally. Among those sampled, 82% responded. We found that HMOs' provider networks with physicians, hospitals, skilled nursing homes, and home health agencies are complex and multi-tiered Seventy-six percent of HMOs in our study use contracts for their HMO products that involve global, professional services, or hospital risk capitation to intermediate entities. These arrangements account for between 24.5 million and 27.4 million of the 55.9 million commercial and Medicare HMO enrollees in the 60 largest markets. While capitation arrangements are particularly common in California, they are more common elsewhere than many assume. The complex layering of risk sharing and delegation of care management responsibility raise questions about accountability and administrative costs in managed care. Do complex structures provide a way to involve providers more directly in managed care, or do they diffuse authority and add to administrative costs?
健康维护组织（HMOs）将财务风险转移给医疗服务提供者这一做法存在争议。为了提供关于这些做法的及时全国性数据，我们于1999年对全国60个最大市场中20个市场的HMOs进行了多阶段概率抽样电话调查，这些市场的HMOs参保人数占全国所有HMOs参保人数的86%。在抽样对象中，82%做出了回应。我们发现，HMOs与医生、医院、专业护理院和家庭健康机构的医疗服务提供网络复杂且多层次。在我们的研究中，76%的HMOs在其HMO产品中使用合同，这些合同涉及向中间实体进行整体、专业服务或医院风险人头付费。在60个最大市场的5590万商业和医疗保险HMO参保人中，这些安排涉及2450万至2740万人。虽然人头付费安排在加利福尼亚州尤为常见，但在其他地方比许多人认为的更为普遍。风险分担的复杂分层和护理管理责任的委托引发了关于管理式医疗中的问责制和行政成本的问题。复杂的结构是提供了一种让医疗服务提供者更直接参与管理式医疗的方式，还是分散了权力并增加了行政成本？
