Erler Antje, Bodenheimer Thomas, Baker Richard, Goodwin Nick, Spreeuwenberg Cor, Vrijhoef Hubertus J M, Nolte Ellen, Gerlach Ferdinand M
Institute of General Practice, Johann Wolfgang Goethe-University, Frankfurt/Main, Germany.
Z Evid Fortbild Qual Gesundhwes. 2011;105(8):571-80. doi: 10.1016/j.zefq.2011.09.029. Epub 2011 Oct 21.
All modern healthcare systems need to respond to the common challenges posed by an aging population combined with a growing number of patients with (complex) chronic conditions and rising patient expectations. Countries with 'stronger' primary care systems (e.g. the Netherlands and England) seem to be better prepared to address these challenges than countries with 'weaker' primary care (e.g. USA). The role of primary care in a health care system is strongly related to its organisation and funding, thus determining the starting point and the possibilities for change.
We selected the Netherlands, England, and USA as examples for the diversity of approaches to organise and finance health care. We analysed the main problems for primary care and reviewed strategies and practice models used to meet the challenges described above.
The Netherlands aim to strengthen prevention for chronic diseases, while England strives to improve the management of patients with multimorbidity, prevent hospital admissions to contain costs, and to satisfy the increased demand of patients for access to primary care. Both countries seek to reorganise care around the patient and place their needs at the centre. The USA has to provide sufficient workforce, organisation, and funding for primary care to ensure better access, prevention, and provision of chronic care for its population. Strategies to improve (trans-sectoral) cooperation and care coordination, a main issue in all three countries, include the implementation of standards of care and bundled payments for chronic diseases in the Netherlands, GP commissioning, federated and group practice models in England, and the introduction of the Patient-Centred Medical Home and accountable care organisations in the USA.
Organisation and financing of health care differ widely in the three countries. However, the necessity to improve coordination and integration of chronic disease care remains a common and core challenge.
所有现代医疗体系都需要应对人口老龄化、（复杂）慢性病患者数量不断增加以及患者期望不断提高所带来的共同挑战。拥有“更强”初级保健体系的国家（如荷兰和英国）似乎比初级保健“较弱”的国家（如美国）更有能力应对这些挑战。初级保健在医疗体系中的作用与其组织和资金密切相关，从而决定了变革的起点和可能性。
我们选择荷兰、英国和美国作为医疗保健组织和融资方式多样性的示例。我们分析了初级保健的主要问题，并审视了用于应对上述挑战的策略和实践模式。
荷兰旨在加强慢性病预防，而英国则努力改善多病共存患者的管理、防止住院以控制成本，并满足患者对获得初级保健服务不断增加的需求。两国都寻求围绕患者重新组织护理，并将患者需求置于中心位置。美国必须为初级保健提供充足的劳动力、组织架构和资金，以确保其民众能更好地获得初级保健服务、预防和慢性病护理。改善（跨部门）合作与护理协调的策略是所有三个国家的主要问题，其中包括在荷兰实施慢性病护理标准和捆绑支付，在英国推行全科医生委托、联合和团体执业模式，以及在美国引入以患者为中心的医疗之家和 accountable care organisations（可问责医疗组织）。
这三个国家的医疗保健组织和融资方式差异很大。然而，改善慢性病护理的协调与整合的必要性仍然是一个共同的核心挑战。
