Busse Reinhard
Fachgebiet Management im Gesundheitswesen, Technische Universität Berlin.
Z Evid Fortbild Qual Gesundhwes. 2009;103(10):608-15; discussion 619-20. doi: 10.1016/j.zefq.2009.10.011.
That "more competition in healthcare primarily produces more needs-based equity, better quality, higher efficiency, reduced costs and less bureaucracy" is a familiar claim. But is it correct? Three types of competition can be identified within a triangle: (1) competition among third-party-payers for insured individuals/customers, (2) competition among providers for patients, and (3) competition among third-party payers for contracts with providers--and vice versa. German and international evidence for these three types of competition demonstrates that many expectations--e.g., that patients can be steered based on quality information--are wishful thinking. Instead of market and competition, regulation is needed (e.g., in the form of an effective risk-based allocation mechanism) to ensure high-quality care for those 5% of the population incurring 50% of the healthcare expenditures (i.e., the seriously ill patients), while at the same time competition based on selective contracts does not pay off for the majority of the population due to high transaction costs.
“医疗保健领域更多的竞争主要会带来更多基于需求的公平性、更高的质量、更高的效率、更低的成本以及更少的官僚作风”，这是一个常见的说法。但这正确吗？在一个三角关系中可以识别出三种竞争类型：（1）第三方支付者之间为参保个人/客户展开的竞争，（2）医疗服务提供者之间为患者展开的竞争，以及（3）第三方支付者之间为与医疗服务提供者签订合同而展开的竞争——反之亦然。德国和国际上关于这三种竞争类型的证据表明，许多期望——例如，患者可以根据质量信息被引导——只是一厢情愿的想法。为了确保那5%产生50%医疗保健支出的人群（即重症患者）能得到高质量的护理，需要的是监管（例如，以有效的基于风险的分配机制的形式），而与此同时，由于交易成本高昂，基于选择性合同的竞争对大多数人来说并不划算。
