Scheid Teresa L
University of North Carolina at Charlotte, Charlotte, NC 28223, USA.
J Health Soc Behav. 2003 Jun;44(2):142-61.
Managed care represents a response to the wider institutional demand for technical rationality and efficiency, and it may be in conflict with professionally generated logics of mental health care which emphasize the delivery of quality care, as well as providing services to all who need care. The organizational and policy conundrum is to balance conflicting institutional demands for efficiency (cost savings) and effectiveness (access and quality). This paper examines managed care in one public sector mental health care system that has attempted to incorporate the principles of managed care into a community based system of care and to overcome the potential contradictions between demands for efficiency and professional logics of care. Both qualitative and quantitative data are used to examine changes in organizational structure and service offerings; providers' experience of managed care, and the effect of managed care on working conditions and work experiences, and changes in the goals of the organization as measured by the specification of client outcomes. I find that, while increased performance accountability and outcome assessment (in keeping with demands for efficiency) have the potential to improve mental health care services, in fact, providers report that the primary effect of managed care has been an emphasis on cost containment, and there has been a corresponding de-emphasis on the provision of community based services for clients with long term care needs. However, there is potential for professional logics to be maintained by larger institutional forces demanding quality care.
管理式医疗是对更广泛的机构对技术合理性和效率的需求的一种回应，它可能与专业产生的精神卫生保健逻辑相冲突，后者强调提供高质量的护理，以及为所有需要护理的人提供服务。组织和政策难题在于平衡对效率（成本节约）和有效性（可及性和质量）的相互冲突的机构需求。本文考察了一个公共部门精神卫生保健系统中的管理式医疗，该系统试图将管理式医疗的原则纳入基于社区的护理系统，并克服效率需求与专业护理逻辑之间的潜在矛盾。定性和定量数据都被用于考察组织结构和服务提供的变化；提供者对管理式医疗的体验，以及管理式医疗对工作条件和工作经历的影响，以及通过客户结果的具体说明来衡量的组织目标的变化。我发现，虽然增加绩效问责和结果评估（符合对效率的要求）有可能改善精神卫生保健服务，但实际上，提供者报告说管理式医疗的主要影响是强调成本控制，并且相应地不再重视为有长期护理需求的客户提供基于社区的服务。然而，要求高质量护理的更大机构力量有可能维持专业逻辑。
