Enthoven A C
Stanford University, Graduate School of Business, CA 94305.
Soc Sci Med. 1994 Nov;39(10):1413-24. doi: 10.1016/0277-9536(94)90236-4.
The ideal market structure would give each medical care organization effective incentives to produce maximum value for money for enrolled subscribers. It should be based on integrated financing and delivery systems--partnerships that link doctors, hospitals and insurers--with per capita prepayment, with providers at risk for cost of care and cost of poor quality, publicly accountable for quality and per capita costs. The ideal market structure must be managed by active intelligent collective purchasing agents, called sponsors, that contract with health care systems and set the rules of competition. Sponsors structure and manage the enrollment process; they create price-elastic demand; they manage risk selection; and they create and administer equitable rules of coverage. Microeconomic theory tells us what sponsors should do to get the market incentives right. There is no comparable political theory to tell us how their boards of directors should be constituted. The paper offers a list of undesirable political arrangements to be avoided and some desirable features of sponsor constitutions.
理想的市场结构应促使每个医疗保健机构积极为参保用户创造最大性价比。它应以综合融资与服务提供体系为基础——即医生、医院和保险公司之间的合作伙伴关系——实行人均预付制，让医疗服务提供者承担医疗成本和低质量医疗成本的风险，并对医疗质量和人均成本负责。理想的市场结构必须由积极、明智的集体采购代理机构（称为主办方）来管理，这些机构与医疗保健系统签订合同并制定竞争规则。主办方构建并管理参保流程；创造价格弹性需求；管理风险选择；制定并执行公平的承保规则。微观经济理论告诉我们主办方应如何做才能确保市场激励机制正确运行。但没有类似的政治理论来指导我们应如何组建其董事会。本文列出了一些应避免的不良政治安排以及主办方章程中一些理想的特征。
