Donabedian A
Am J Public Health. 1976 Apr;66(4):345-50. doi: 10.2105/ajph.66.4.345.
Health insurance, by reducing net price to the consumer and increasing the opportunities for revenue to the provider, has profound effects, among other things, on the volume, content and distribution of services, their prices, and the capacity of providers to produce them. The magnitude and nature of these effects depend, partly, on the design of insurance benefits and, partly, on the nature of the health care system, particularly its current and potential capacity and the methods it uses to pay providers. Those who believe that the unique aim of insurance is to protect against unpredictable expenses attempt to suppress these effects, mainly by imposing financial disincentives to utilization which, in turn, reduce protection for those who need it most. Those who wish to reform the system have a broader range of objectives which include protective efficacy, cost control, quantitative adequacy, qualitative adequacy, efficiency of production, efficiency of allocation, equity, and redistribution of capacity. An analysis of the effects of insurance in the light of these objectives reveals favorable as well as unfavorable consequences. The provision of comprehensive benefits generates the necessity for a fundamental change in the organization of health services, if the advantages are to be fully realized and the disadvantages minimized.
医疗保险通过降低消费者的净价格并增加提供者的收入机会，除其他方面外，还对服务的数量、内容和分配、服务价格以及提供者提供服务的能力产生深远影响。这些影响的程度和性质部分取决于保险福利的设计，部分取决于医疗保健系统的性质，特别是其当前和潜在的能力以及支付提供者费用的方式。那些认为保险的唯一目的是防范不可预测费用的人试图抑制这些影响，主要是通过对医疗服务利用施加经济抑制措施，而这反过来又减少了对最需要保险的人的保障。那些希望改革该系统的人有更广泛的目标，包括保障效力、成本控制、数量充足性、质量充足性、生产效率、分配效率、公平性以及能力的再分配。根据这些目标对保险的影响进行分析，会揭示出有利和不利的后果。如果要充分实现优势并将劣势最小化，提供全面的福利就需要对医疗服务的组织进行根本性变革。
