Goroll Allan H, Berenson Robert A, Schoenbaum Stephen C, Gardner Laurence B
Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts 02114, USA.
J Gen Intern Med. 2007 Mar;22(3):410-5. doi: 10.1007/s11606-006-0083-2.
Primary care is essential to the effective and efficient functioning of health care delivery systems, yet there is an impending crisis in the field due in part to a dysfunctional payment system. We present a fundamentally new model of payment for primary care, replacing encounter-based imbursement with comprehensive payment for comprehensive care. Unlike former iterations of primary care capitation (which simply bundled inadequate fee-for-service payments), our comprehensive payment model represents new investment in adult primary care, with substantial increases in payment over current levels. The comprehensive payment is directed to practices to include support for the modern systems and teams essential to the delivery of comprehensive, coordinated care. Income to primary physicians is increased commensurate with the high level of responsibility expected. To ensure optimal allocation of resources and the rewarding of desired outcomes, the comprehensive payment is needs/risk-adjusted and performance-based. Our model establishes a new social contract with the primary care community, substantially increasing payment in return for achieving important societal health system goals, including improved accessibility, quality, safety, and efficiency. Attainment of these goals should help offset and justify the costs of the investment. Field tests of this and other new models of payment for primary care are urgently needed.
初级保健对于医疗服务提供系统的有效和高效运作至关重要，但该领域正面临一场迫在眉睫的危机，部分原因是支付系统功能失调。我们提出了一种全新的初级保健支付模式，用针对全面护理的综合支付取代基于诊疗次数的报销方式。与之前的初级保健按人头付费模式（只是简单地捆绑了不足的按服务收费支付）不同，我们的综合支付模式代表了对成人初级保健的新投资，支付水平比目前大幅提高。综合支付直接用于医疗机构，包括为提供全面、协调护理所必需的现代系统和团队提供支持。初级医生的收入相应增加，以匹配预期的高度责任。为确保资源的最佳分配和对期望结果的奖励，综合支付根据需求/风险进行调整并基于绩效。我们的模式与初级保健社区建立了新的社会契约，大幅增加支付以换取实现重要的社会卫生系统目标，包括提高可及性、质量、安全性和效率。实现这些目标应有助于抵消并证明投资成本的合理性。迫切需要对这种以及其他新的初级保健支付模式进行实地测试。
