Golembesky H E
APM, Inc, San Francisco, CA, USA.
Pediatrics. 1995 Oct;96(4 Pt 2):866-72.
In the evolving health care delivery paradigm, physicians manage overall health status rather than illness, and providers rather than insurance companies bear the risk. Consequently, interest in prevention--long of prime interest to pediatricians--is increasing among all providers. The ethical practice of medicine in a managed care environment involves providing care at a level that avoids high cost with poor outcomes. High cost with poor outcomes can be the result of either undertreatment or overtreatment. Purchasers of health care today are clear about what they want--low cost, convenient access for their employees, medically appropriate, documented treatment, and patient satisfaction--and they are clear about how they intend to get what they want. Different areas of the country are at different stages in the evolution of managed care. Physicians who practice in markets that are still in early stages must plan ahead, taking the lead in shaping the changes that are occurring and preparing their practices for managed care. Otherwise, someone less concerned about quality of care will shape them. Solo or small group practices will survive, but those that survive will not be independent. The necessary affiliation with larger entities does not mean that clinical autonomy and freedom must be sacrificed.
在不断演变的医疗服务模式中，医生管理的是整体健康状况而非疾病，承担风险的是医疗服务提供者而非保险公司。因此，对预防的关注——长期以来一直是儿科医生的首要关注点——在所有医疗服务提供者中都在增加。在管理式医疗环境中，符合伦理的医疗实践包括提供能避免高成本且疗效不佳的医疗服务。高成本且疗效不佳可能是治疗不足或过度治疗的结果。如今，医疗保健的购买者清楚自己想要什么——低成本、员工就医便捷、医疗上合理且有记录的治疗，以及患者满意度——而且他们清楚打算如何实现自己的目标。美国不同地区处于管理式医疗发展的不同阶段。在仍处于早期阶段的市场中执业的医生必须提前规划，带头塑造正在发生的变革，并让自己的诊所为管理式医疗做好准备。否则，一些不太关心医疗质量的人会对其进行塑造。个体诊所或小型诊所会存活下来，但存活下来的将不再独立。与更大实体的必要联合并不意味着必须牺牲临床自主权和自由。
