Hillman A L, Welch W P, Pauly M V
Section of General Internal Medicine, University of Pennsylvania, Philadelphia.
Med Care. 1992 Feb;30(2):136-48. doi: 10.1097/00005650-199202000-00005.
Concern about certain contractual arrangements between health maintenance organizations (HMOs) and primary care physicians has led policymakers to consider curbing these arrangements; one law has already been passed. However, these arrangements are complex and their impact is neither obvious nor well understood. This article first presents a conceptual approach to understanding the relationship between HMOs and primary care physicians and discusses how they influence the locus of financial risk and managerial control. It then refines understanding of two critical dimensions (three-tiered HMOs and risk pools) by examining survey responses of 260 HMOs (representing over 50% of total HMO enrollment.) Results of the evaluation led to the conclusion that primary care physicians in three-tiered HMOs are sheltered from some of the financial incentives and contractual arrangements enacted by the HMO and that the reason for using risk pools may be due more to peer group effects or interaction with other incentives, rather than the direct financial implications of the risk pool on individual physicians. These concepts and observations have relevance for other types of health care systems in this country and elsewhere. Policymakers risk enacting misguided policies unless they understand the details of these arrangements.
对健康维护组织（HMOs）与初级保健医生之间某些合同安排的担忧，促使政策制定者考虑限制这些安排；一项法律已经通过。然而，这些安排很复杂，其影响既不明显也未得到充分理解。本文首先提出一种概念性方法来理解HMOs与初级保健医生之间的关系，并讨论它们如何影响财务风险和管理控制的归属。然后，通过研究260个HMOs（占HMOs总参保人数的50%以上）的调查回复，深化对两个关键维度（三层HMOs和风险池）的理解。评估结果得出结论，三层HMOs中的初级保健医生免受HMOs制定的一些财务激励和合同安排的影响，使用风险池的原因可能更多是由于同伴效应或与其他激励措施的相互作用，而不是风险池对个体医生的直接财务影响。这些概念和观察结果与该国及其他地方的其他类型医疗保健系统相关。除非政策制定者了解这些安排的细节，否则他们有可能制定出错误的政策。
