Reid R J, Hurtado M P, Starfield B
Johns Hopkins School of Hygiene and Public Health, Baltimore, MD 21205, USA.
Curr Opin Pediatr. 1996 Apr;8(2):164-70. doi: 10.1097/00008480-199604000-00015.
In an effort to provide medical care that is both more effective and less costly, the new variants of managed care organizations have instituted a variety of incentives and administrative controls that impact on the types and quantity of care provided to patients. Evidence suggests that the early forms of managed care, namely prepaid group practices, showed particular promise in improving the primary care delivered to children, ie, care that is accessible, person-focused in the long term, comprehensive, coordinated, and oriented toward achieving better outcomes. However, recent evidence concerning the quality of care delivered to children in the newer variants of managed care is mixed and scant; the newer organizational forms may not facilitate and may even have a negative impact on the attainment of primary care. Managed care can have a positive effect on first contact care, because it contractually defines a primary care provider and reduces use of the emergency room as a source of care. It may, however, have mixed effects on other aspects of access and use, depending on the plan's particular characteristics. Longitudinality is threatened by the disruption of prior relationships with out-of-plan providers and by the instability of both enrollees and providers in managed care plans. Children's benefits in managed care arrangements tend to include more preventive services, but access to specialty services has generally been found to be more restrictive. Coordination of care is not inherent to managed care, and many plans are no more likely to foster communication than are traditional indemnity plans. Evidence for the superior clinical quality afforded to children by new variants of managed care is lacking. Because managed care arrangements are proliferating rapidly, better studies are needed to prove or refute the contention that managed care has a significant positive effect on quality of care.
为了提供更有效且成本更低的医疗服务，管理式医疗组织的新变体制定了各种激励措施和行政控制手段，这些措施会影响向患者提供的医疗服务的类型和数量。有证据表明，早期形式的管理式医疗，即预付费团体医疗模式，在改善儿童初级医疗服务方面显示出特别的前景，也就是说，这种医疗服务具有可及性、长期以患者为中心、全面、协调且旨在实现更好的治疗效果。然而，近期有关管理式医疗新变体中儿童医疗服务质量的证据好坏参半且十分匮乏；新的组织形式可能不利于甚至对初级医疗服务的获得产生负面影响。管理式医疗对首次就诊医疗可能有积极影响，因为它通过合同确定了初级医疗服务提供者，并减少了将急诊室作为医疗服务来源的使用。然而，根据该计划的具体特点，它对医疗服务可及性和使用的其他方面可能会产生好坏参半的影响。连续性受到与计划外提供者先前关系的中断以及管理式医疗计划中参保者和提供者双方不稳定的威胁。管理式医疗安排中儿童的福利往往包括更多的预防服务，但一般发现获得专科服务的机会更受限制。医疗服务的协调并非管理式医疗所固有，而且许多计划在促进沟通方面并不比传统的赔偿计划更具优势。缺乏证据表明管理式医疗新变体为儿童提供了更高的临床质量。由于管理式医疗安排正在迅速扩散，需要更好的研究来证实或反驳管理式医疗对医疗服务质量有重大积极影响这一论点。
