Broomberg J, De Beer C, Price M R
Department of Community Health, University of the Witwatersrand, Johannesburg.
S Afr Med J. 1990 Aug 4;78(3):139-42; discussion 142-3.
The private health sector is experiencing a crisis of spiralling costs, with average annual cost increases of between 13% and 32% over the decade 1978-1988. This trend is partly explained by the high utilisation rates that result from the combination of the 'fee-for-service' system and the 'third-party' payment structure of the sector. Medical schemes have responded by promoting the idea of 'flexible packages', and have won the right to 'risk-rate' prospective members. It is argued that these measures will undermine the principle of equity in health care, and will not solve the problems of the private sector. Instead, a more significant restructuring of the sector is likely to emerge. This may take the form of 'managed care' structures, along the lines of the health maintenance organisation model from the USA. The principles, advantages and problems of 'managed care' structures are described. These are shown to be potentially more rational and efficient than the current structure of the private sector. Although some resistance to 'managed care' structures can be expected, the convergence of interests of large employers and trade unions in containing health care costs suggests that their emergence is a likely development.
私立医疗部门正面临成本不断飙升的危机，在1978年至1988年这十年间，年均成本增长幅度在13%至32%之间。这种趋势部分归因于“按服务收费”体系与该部门“第三方”支付结构相结合所导致的高利用率。医疗计划的应对方式是推广“灵活套餐”理念，并赢得了对潜在成员进行“风险评级”的权利。有人认为，这些措施将损害医疗保健的公平原则，并且无法解决私立部门的问题。相反，该部门可能会出现更重大的结构调整。这可能采取“管理式医疗”结构的形式，类似于美国的健康维护组织模式。文中描述了“管理式医疗”结构的原则、优势和问题。结果表明，这些结构可能比私立部门目前的结构更合理、更高效。尽管预计会有人抵制“管理式医疗”结构，但大型雇主和工会在控制医疗保健成本方面利益趋同，这表明这种结构的出现是一种可能的发展趋势。
