Mühlbacher Axel C, Amelung Volker E, Juhnke Christin
Health Economics and Healthcare Management, Hochschule Neubrandenburg, Neubrandenburg, DE.
Institute of Epidemiology, Social Medicine and Health System Research, Hannover Medical School, Hannover, DE.
Int J Integr Care. 2018 Jan 12;18(1):2. doi: 10.5334/ijic.3615.
Integrated care systems as well as accountable care organisations (ACOs) in the US and similar concepts in other countries are advocated as an effective method of improving the performance of healthcare systems. These systems outline a payment and care delivery model that intends to tie provider reimbursements to predefined quality metrics. By this the total costs of care shall be reduced. When designing healthcare options contractors are faced with a variety of financial options. The costs of market utilisation are highly relevant for the conception of healthcare contracts; furthermore contract-specific investments are an obstacle to the efficient operation of ACOs.
A comprehensive literature review on methods of designing contracts in Integrated Care was conducted. This article is the second in a row of three that are all published in this issue and contribute to a specific issue in designing healthcare contracts. The first dealt with the organisation of contracts and information asymmetries, while part 3 concludes with the question of risk management and evaluation. The specific research question of this second article focusses on the financial options and reimbursement schemes that are available to define healthcare contracts.
A healthcare contract is a relational contract, which determines the level of reimbursement, the scope of services and the quality between service providers and payers, taking account of the risks relating to population and performance. A relational contract is an agreement based upon assumption of a longer timeframe. A major obstacle to the practical implementation of healthcare contracts is the prognosis of the inflows and outflows due to the actuarial risks of the insured population. Financing conditions and reimbursement arrangements that are based on a prospectively determined fixed price, have a significant drawback: it is very difficult to take the differences in health status and the utilisation of distinct insured clientele (panel) into account.
The first two articles of this series on contract design have shown that complete contracts in healthcare are unrealistic. Healthcare reimbursement contracts are incomplete contracts with a high degree of uncertainty. In incomplete contracts specific contractual regulations are not made for any eventuality. For this reason it is important that the parties agree on the prevention of endogenous risks (asymmetric information after the conclusion of the contract) and on the procedure in the case of unforeseen circumstances (the risks of random, parameter risk and change risks to the healthcare program).
美国的综合医疗系统以及责任医疗组织（ACO）和其他国家的类似概念被视为提高医疗系统绩效的有效方法。这些系统概述了一种支付和医疗服务提供模式，旨在将提供者的报销与预先定义的质量指标挂钩，从而降低医疗总成本。在设计医疗保健方案时，承包商面临多种财务选择。市场利用成本与医疗保健合同的构思高度相关；此外，特定合同的投资是ACO高效运作的障碍。
对综合医疗中合同设计方法进行了全面的文献综述。本文是本期发表的三篇系列文章中的第二篇，这三篇文章都围绕医疗保健合同设计中的一个特定问题展开。第一篇涉及合同组织和信息不对称，而第三部分以风险管理和评估问题作为结论。第二篇文章的具体研究问题聚焦于可用于定义医疗保健合同的财务选择和报销方案。
医疗保健合同是一种关系合同，它在考虑到与人群和绩效相关风险的情况下，确定服务提供者和支付者之间的报销水平、服务范围和质量。关系合同是基于较长时间框架假设的协议。医疗保健合同实际实施的一个主要障碍是由于被保险人群的精算风险而对流入和流出进行预测。基于预先确定的固定价格的融资条件和报销安排有一个重大缺陷：很难考虑到健康状况的差异以及不同被保险客户群体（小组）的使用情况。
本系列关于合同设计的前两篇文章表明，医疗保健中的完全合同是不现实的。医疗保健报销合同是具有高度不确定性的不完全合同。在不完全合同中，没有针对任何可能情况制定具体的合同规定。因此，重要的是各方就预防内生风险（合同签订后的信息不对称）以及在不可预见情况下的程序（医疗保健计划的随机风险、参数风险和变化风险）达成一致。
