University of Virginia, Charlottesville, USA.
Health Aff (Millwood). 2011 Jan;30(1):32-40. doi: 10.1377/hlthaff.2010.0782.
Under the Affordable Care Act, the new Center for Medicare and Medicaid Innovation will guide a number of experimental programs in health care payment and delivery. Among the most ambitious of the reform models is the accountable care organization (ACO), which will offer providers economic rewards if they can reduce Medicare's cost growth in their communities. However, the dismal history of provider-led attempts to manage costs suggests that this program is unlikely to accomplish its objectives. What's more, if ACOs foster more market concentration among providers, they have the potential to shift costs onto private insurers. This paper proposes a more flexible payment model for providers and private insurers that would divide health care services into three categories: long-term, low-intensity primary care; unscheduled care, including unscheduled emergency services; and major clinical interventions that usually involve hospitalization or organized outpatient care. Each category of care would be paid for differently, with each containing different elements of financial risk for the providers. Health plans would then be encouraged to provide logistical and analytic support to providers in managing health costs in these categories.
在《平价医疗法案》下，新的医疗保险和医疗补助创新中心将指导医疗保健支付和提供方面的多项实验性计划。在最具雄心的改革模式中，有一个责任医疗组织（ACO），如果提供者能够降低他们所在社区的医疗保险成本增长，他们将获得经济奖励。然而，提供者主导的降低成本的尝试的惨淡历史表明，该计划不太可能实现其目标。更重要的是，如果 ACO 促进了提供者之间的更多市场集中，它们有可能将成本转嫁给私人保险公司。本文为提供者和私人保险公司提出了一种更灵活的支付模式，将医疗服务分为三类：长期、低强度的初级保健；非计划性护理，包括非计划性急诊服务；以及通常涉及住院或有组织的门诊护理的主要临床干预。每一类护理的支付方式都不同，其中包含提供者的不同财务风险因素。然后，鼓励健康计划为提供者在管理这些类别的医疗成本方面提供后勤和分析支持。
