Glaser W A
Graduate School of Management and Urban Policy, New School for Social Research, New York, NY 10011.
Milbank Q. 1993;71(1):97-127.
Every organized payment system must contain its costs in order to keep within revenue without denying benefits. Fixed expenditure caps requiring the provider to operate within its annual financial grant can be imposed on organizations like hospitals, but are fiercely resisted by the medical profession. All financial arrangements with doctors are negotiated, including systems of fixed expenditure caps and more flexible expenditure targets. If the doctors accept the principle of caps and cooperate in achieving them, they do so only as part of a negotiated settlement to avoid a worse outcome. Government's power is minimized, even when government is the payer. Caps on the physicians' sector are unusual. Instead, we see the spread of flexible targeting systems, wherein cost overruns are compensated for by lower expenditure targets the following year. Medical associations in all countries resisted even these restraints for years, but eventually accepted them, provided that target setting, judgments of overruns, utilization control, and all other features are part of a joint negotiating system. Targeting systems are often complicated because they preserve the semiprivate character of statutory health insurance and they are the result of negotiated compromises. To succeed in controlling costs, they require the cooperation of the medical association and of the rank-and-file doctors--but they can succeed. The United States has enacted a small-scale targeting system for Medicare physician payments alone. It cannot become the method for universal health insurance, which must heed lessons from abroad. Only an all-payer system can cover an entire population and contain the costs of the system. A few government officials cannot dictate and implement expenditure goals, but a system of consultation is required for setting and carrying out targets. Impartial officials can regulate hospitals according to the guidelines produced by the consultations, but the record of the medical profession in the countries reviewed here is that they insist on negotiating the final rules and rates. Americans have become bewitched by the mirage of econometric formulas automatically governing a sector, but the real problem is to devise and operate a harmonious decision-making system.
每个有组织的支付系统都必须控制成本，以便在不削减福利的情况下保持收支平衡。可以对医院等机构实施固定支出上限，要求其在年度财政拨款范围内运营，但这遭到了医学界的强烈抵制。与医生的所有财务安排都是通过协商达成的，包括固定支出上限制度和更灵活的支出目标。如果医生接受上限原则并合作实现这些目标，那也只是作为协商解决方案的一部分，以避免更糟糕的结果。即使政府是付款方，政府的权力也会被最小化。对医生部门实施上限并不常见。相反，我们看到了灵活目标设定系统的推广，即成本超支将通过次年降低支出目标来弥补。多年来，所有国家的医学协会都抵制这些限制措施，但最终还是接受了，前提是目标设定、超支判断、使用控制以及所有其他特征都是联合谈判系统的一部分。目标设定系统往往很复杂，因为它们保留了法定医疗保险的半私人性质，而且是协商妥协的结果。为了成功控制成本，它们需要医学协会和普通医生的合作——但它们能够成功。美国仅为医疗保险医生支付制定了一个小规模的目标设定系统。它无法成为全民医疗保险的方法，全民医疗保险必须吸取国外的经验教训。只有全付款方系统才能覆盖全体人口并控制系统成本。少数政府官员无法强行规定和实施支出目标，而是需要一个协商系统来设定和执行目标。公正的官员可以根据协商产生的指导方针来监管医院，但从这里所审查国家的医学界记录来看，他们坚持要就最终规则和费率进行谈判。美国人被自动管理一个部门的计量经济学公式的幻象迷惑了，但真正的问题是设计并运行一个和谐的决策系统。
