Robinson J C, Casalino L P
School of Public Health, University of California, Berkeley 94720, USA.
N Engl J Med. 1995 Dec 21;333(25):1684-7. doi: 10.1056/NEJM199512213332506.
In California, it is common for health maintenance organizations (HMOs) to contract with large medical groups that are paid through capitation and are responsible for managing a full spectrum of medical services.
We studied six large medical groups in California--Bristol Park Medical, Friendly Hills HealthCare Network, HealthCare Partners Medical Group, Mullikin Medical Centers, Palo Alto Medical Foundation, and San Jose Medical Group--that are paid through capitation and that are growing as a result of contracts with managed-care organizations. We conducted interviews and obtained data on factors such as patient enrollment, capitation and other revenue, numbers of days spent by enrollees in the hospital, and numbers of visits to physicians per enrollee.
Between 1990 and 1994, the number of HMO enrollees whose care was paid for through capitation in the six medical groups increased by 91 percent, from 398,359 to 759,474. In 1994, the mean number of hospital days per 1000 HMO enrollees ranged from 120 to 149 for non-Medicare patients and from 643 to 936 days for Medicare patients. By comparison, in 1993 the mean numbers of hospital days per 1000 HMO enrollees not covered by Medicare were 232 for California and 297 for the United States; for HMO enrollees covered by Medicare, the numbers were 1337 for California and 1698 for the United States. In 1994, the average annual number of visits to physicians for HMO patients in the six groups not covered by Medicare ranged from 3.1 to 3.9; for Medicare patients, it ranged from 7.2 to 9.3; these rates were slightly lower than statewide and national rates. Four of the groups have sold their assets (such as facilities, supplies, equipment, and patients' charts) to outside investors; the physicians remain employed by physician-owned professional corporations.
Medical groups paid through capitation offer a model for the status of physicians in managed-care systems that differs from the employee status offered by staff-model HMOs and the subcontractor status offered by HMOs that negotiate directly with individual physicians. Despite their growth, such medical groups in California face substantial challenges, such as obtaining the financial assets necessary to sustain rapid growth.
在加利福尼亚州，健康维护组织（HMO）与大型医疗集团签订合同很常见，这些医疗集团通过按人头付费获得报酬，并负责管理全方位的医疗服务。
我们研究了加利福尼亚州的六个大型医疗集团——布里斯托尔公园医疗集团、友好山医疗保健网络、医疗保健合作伙伴医疗集团、穆利金医疗中心、帕洛阿尔托医疗基金会和圣何塞医疗集团——它们通过按人头付费获得报酬，并因与管理式医疗组织签订合同而不断发展。我们进行了访谈，并获取了有关患者注册、按人头付费及其他收入、参保者住院天数以及每位参保者看医生次数等因素的数据。
1990年至1994年间，这六个医疗集团中通过按人头付费获得医疗服务的HMO参保者数量增加了91%，从398,359人增至759,474人。1994年，每1000名非医疗保险患者的平均住院天数在120至149天之间，医疗保险患者则在643至936天之间。相比之下，1993年，加利福尼亚州每1000名未参保医疗保险的HMO参保者的平均住院天数为232天，美国为297天；对于参保医疗保险的HMO参保者，加利福尼亚州为1337天，美国为1698天。1994年，这六个集团中未参保医疗保险的HMO患者每年看医生的平均次数在3.1至3.9次之间；医疗保险患者则在7.2至9.3次之间；这些比率略低于全州和全国水平。其中四个集团已将其资产（如设施、物资、设备和患者病历）出售给外部投资者；医生仍受雇于医生所有的专业公司。
通过按人头付费获得报酬的医疗集团提供了一种管理式医疗系统中医生地位的模式，这不同于员工模式HMO提供的员工地位以及与个体医生直接谈判的HMO提供的分包商地位。尽管这些医疗集团在不断发展，但加利福尼亚州的此类医疗集团仍面临重大挑战，如获取维持快速增长所需的金融资产。
