Clark R E, Dorwart R A, Epstein S S
Department of Community and Family Medicine, Dartmouth Medical School, Hanover, NH 03755-3862.
Milbank Q. 1994;72(4):653-78.
There were clear differences in our study between the management strategies employed by public agencies and those favored by private agencies. These differences, however, appeared to reflect the realities of financing rather than any fundamental differences in their orientation toward public service. There was no clear evidence that particular management practices affected an agency's performance on measures of financial access or acceptance of referrals from public hospitals. Government regulation and pressure from advocacy groups probably helped to maintain private agencies' focus on these and other public goals. From a public policy perspective, choosing a provider solely on the basis of ownership status is, at best, a naive approach to providing public mental health treatment. Not only is there great variation in process and practices within both private and public groups, but external factors such as competition from private practitioners may also exert a stronger influence on agency behavior than does ownership status. Because most current proposals for health care reform rely heavily on increased competition among providers to achieve their goals, the importance of ownership status as a predictor of conduct or performance may be further diminished. The emphasis on competition could increase differences between urban agencies and those in rural areas where there is less competition and, therefore, require different contracting approaches. As we move toward a health care system based on competition, administrators and policy makers will be forced to abandon their reliance on stereotypical public/private agency behavior as guides for policy decisions. Instead, they will have to consider more carefully the effects of political and market influences as well as agency characteristics when choosing community mental health providers.
在我们的研究中，公共机构采用的管理策略与私人机构青睐的管理策略存在明显差异。然而，这些差异似乎反映了融资的现实情况，而非它们在公共服务导向方面存在任何根本差异。没有明确证据表明特定的管理做法会影响机构在财务可及性指标或接受公立医院转诊方面的表现。政府监管和倡导团体的压力可能有助于使私人机构专注于这些及其他公共目标。从公共政策的角度来看，仅根据所有权状况选择提供者，充其量只是一种提供公共心理健康治疗的幼稚方法。不仅私人团体和公共团体内部的流程和做法存在很大差异，而且私人从业者的竞争等外部因素对机构行为的影响可能比所有权状况更大。由于当前大多数医疗改革提案严重依赖增加提供者之间的竞争来实现目标，所有权状况作为行为或绩效预测指标的重要性可能会进一步降低。对竞争的强调可能会加大城市机构与农村地区机构之间的差异，农村地区竞争较少，因此需要不同的签约方式。随着我们朝着基于竞争的医疗体系迈进，管理人员和政策制定者将不得不放弃依赖刻板的公共/私人机构行为作为政策决策的指导。相反，在选择社区心理健康提供者时，他们将不得不更仔细地考虑政治和市场影响以及机构特征的作用。
