Curtiss F R
Am J Hosp Pharm. 1984 Aug;41(8):1548-57.
Reimbursement mechanisms for home health-care products and services are discussed in detail. The two major categories of the home health-care industry--(1) skilled nursing, homemaker, and other services, and (2) equipment, supplies, and other products (including drugs)--are reimbursed by third-party payers differently. While prospective pricing of inpatient care encourages the growth of home-care services, government administrators are concerned about potential spending growth at a time of ballooning deficits, and private health insurers are uncertain about coverage criteria. Nuances of Medicare coverage criteria and private insurance reimbursement for home health-care services are described. Medicaid coverage of drugs and biologicals for home patients is also described. The Health Care Financing Administration (HCFA) is expected to clarify and restrict Medicare coverage and payment of home-care products, equipment, and supplies. Medical justification will probably become more specific with greater attention to patient diagnoses and prognosis of patient therapies. Per-case payment methods will be refined to encompass home care. The government and private insurance programs will move toward capitation payment methods under which institutions will have even greater incentives to develop sophisticated home-care programs to substitute for institutional care.
本文详细讨论了家庭保健产品和服务的报销机制。家庭保健行业主要分为两大类：（1）专业护理、家政及其他服务；（2）设备、用品及其他产品（包括药品），第三方支付方对这两类的报销方式有所不同。虽然住院护理的前瞻性定价促进了家庭护理服务的发展，但在赤字不断膨胀之际，政府管理人员担心潜在的支出增长，而私人健康保险公司对承保标准也不确定。文中描述了医疗保险承保标准的细微差别以及家庭保健服务的私人保险报销情况。还介绍了医疗补助对家庭患者药品和生物制品的承保情况。预计医疗保健财务管理局（HCFA）将对医疗保险对家庭护理产品、设备和用品的承保范围及支付进行澄清和限制。随着对患者诊断和治疗预后的关注度提高，医疗理由可能会变得更加具体。按病例支付方式将得到完善，以涵盖家庭护理。政府和私人保险计划将朝着按人头支付方式发展，在此方式下，机构将更有动力开发复杂的家庭护理计划以替代机构护理。
