Kronick R, Goodman D C, Wennberg J, Wagner E
Department of Community and Family Medicine, University of California-San Diego, La Jolla 92093.
N Engl J Med. 1993 Jan 14;328(2):148-52. doi: 10.1056/nejm199301143280225.
The theory of managed competition holds that the quality and economy of health care delivery will improve if independent provider groups compete for consumers. In sparsely populated areas where relatively few providers are required, however, it is not feasible to divide the provider community into competing groups. We examined the demographic features of health markets in the United States to see what proportion of the population lives in areas that might successfully support managed competition.
The ratios of physicians to enrollees in large staff-model health maintenance organizations were determined as an indicator of the staffing needs of an efficient health plan. These ratios were used to estimate the populations necessary to support health organizations with various ranges of specialty services. Metropolitan areas with populations large enough to support managed competition were identified.
We estimated that a health care services market with a population of 1.2 million could support three fully independent plans. A population of 360,000 could support three plans that independently provided most acute care hospital services, but the plans would need to share hospital facilities and contract for tertiary services. A population of 180,000 could support three plans that provided primary care and many basic specialty services but that shared inpatient cardiology and urology services. Health markets with populations greater than 180,000 would include 71 percent of the U.S. population; those with populations greater than 360,000, 63 percent; and those with populations greater than 1.2 million, 42 percent.
Reform of the U.S. health care system through expansion of managed competition is feasible in medium-sized or large metropolitan areas. Smaller metropolitan areas and rural areas would require alternative forms of organization and regulation of health care providers in order to improve quality and economy.
管理竞争理论认为，如果独立的医疗服务提供方群体为消费者展开竞争，医疗服务的质量和经济性将会提高。然而，在人口稀少、所需医疗服务提供方相对较少的地区，将医疗服务提供方群体划分为相互竞争的团体是不可行的。我们研究了美国医疗市场的人口特征，以了解有多大比例的人口居住在可能成功支持管理竞争的地区。
确定大型员工模式健康维护组织中医生与参保人的比例，作为高效健康计划人员配置需求的指标。这些比例用于估算支持提供各类专科服务的健康组织所需的人口数量。确定了人口规模足以支持管理竞争的大都市地区。
我们估计，拥有120万人口的医疗服务市场能够支持三个完全独立的计划。36万人口的市场能够支持三个独立提供大多数急症医院服务的计划，但这些计划需要共享医院设施并签订三级服务合同。18万人口的市场能够支持三个提供初级保健和许多基本专科服务但共享住院心脏病学和泌尿学服务的计划。人口超过18万的医疗市场将涵盖71%的美国人口；人口超过36万的市场涵盖63%；人口超过120万的市场涵盖42%。
通过扩大管理竞争来改革美国医疗体系在中型或大型大都市地区是可行的。较小的大都市地区和农村地区需要采取其他形式的医疗服务提供方组织和监管方式，以提高质量和经济性。
