Curtiss F R
Am J Hosp Pharm. 1986 Jan;43(1):121-31.
Factors affecting growth of the home health-care (HHC) industry are identified, basic principles of HHC product and service reimbursement are reviewed, and third-party payer coverage criteria and payment methods for HHC products and services are discussed. Reimbursement for HHC services has suffered from the absence of a financing mechanism for long-term care. Providers of HHC services are burdened by the laborious process of obtaining favorable coverage determinations for short-term-care patients when home care substitutes for institutional care. When home care is covered benefit, there is often a complex mix of confusing coverage rules, coverage criteria that differ among public and private payers, and interpretations of coverage criteria that differ among local carrier personnel. Private financing obstacles and federal budget deficits will deter the development of an adequate financing mechanism for HHC. The growth of health-maintenance organizations and competitive medical plans will help to reduce reimbursement complexity. Long-term changes in HHC financing may become less important if capitation payment is successful.
确定了影响家庭保健（HHC）行业增长的因素，回顾了HHC产品和服务报销的基本原则，并讨论了第三方付款人对HHC产品和服务的承保标准及支付方式。HHC服务的报销因缺乏长期护理融资机制而受到影响。当家庭护理替代机构护理时，HHC服务提供者要为短期护理患者获得有利的承保判定这一繁琐过程所累。当家庭护理作为承保福利时，通常存在令人困惑的承保规则复杂组合、公共和私人付款人之间不同的承保标准以及当地承运人工作人员对承保标准的不同解释。私人融资障碍和联邦预算赤字将阻碍为HHC建立适当的融资机制。健康维护组织和竞争性医疗计划的发展将有助于降低报销的复杂性。如果按人头付费成功，HHC融资的长期变化可能就没那么重要了。
