Shapiro D W
Department of Medicine, University of California, School of Medicine, San Francisco.
West J Med. 1994 May;160(5):434-9.
All managed competition proposals for health system reform must confront several key issues. The premiums paid to health care purchasing cooperatives will need to be subsidized for those who cannot pay full fare; the amount and sources of the subsidies are controversial political issues. The payments passed on by purchasing cooperatives to health plans must be risk adjusted to account for differences in the health care needs of their enrolled populations. This is essential to create a level playing field for competition and to eliminate incentives for plans to use risk assessment for attracting enrollees. The data and methods needed for risk adjustment, however, are not adequate at present. The Clinton Administration's plan to limit expenditure increases raises a host of thorny issues. Maintaining quality of care will require health plan quality report cards to be supplemented by external quality assurance systems. Assuring quality will be particularly problematic for traditional indemnity plans. The structure and governance of the system, administration simplification, and other issues need to be addressed. The size and voluntariness of the purchasing cooperatives greatly influence all of these considerations. Physicians should inform their political representatives on how these issues should be resolved as compromise bills are drafted by the United States Congress this year.
所有关于卫生系统改革的管理式竞争提案都必须面对几个关键问题。对于那些无力支付全额费用的人，支付给医疗保健采购合作社的保费将需要得到补贴；补贴的数额和来源是有争议的政治问题。采购合作社支付给健康计划的款项必须进行风险调整，以考虑其参保人群医疗保健需求的差异。这对于创造公平的竞争环境以及消除健康计划利用风险评估来吸引参保人的动机至关重要。然而，目前风险调整所需的数据和方法并不充足。克林顿政府限制支出增长的计划引发了一系列棘手问题。维持医疗质量将需要通过外部质量保证系统来补充健康计划质量报告卡。对于传统的赔偿计划而言，确保质量将尤其成问题。该系统的结构和治理、管理简化以及其他问题都需要加以解决。采购合作社的规模和自愿性在很大程度上影响着所有这些考量因素。在今年美国国会起草妥协法案时，医生们应告知其政治代表这些问题应如何解决。
