Schlesinger M, Gray B, Bradley E
Yale University School of Medicine, USA.
J Health Polit Policy Law. 1996 Winter;21(4):697-751. doi: 10.1215/03616878-21-4-697.
As American medicine has been transformed by the growth of managed care, so too have questions about the appropriate role of nonprofit ownership in the health care system. The standards for community benefit that are increasingly applied to nonprofit hospitals are, at best, only partially relevant to expectations for nonprofit managed care plans. Can we expect nonprofit ownership to substantially affect the behavior of an increasingly competitive managed care industry dealing with insured populations? Drawing from historical interpretations of tax exemption in health care and from the theoretical literature on the implications of ownership for organizational behavior, we identify five forms of community benefit that might be associated with nonprofit forms of managed care. Using data from a national survey of firms providing third-party utilization review services in 1993, we test for ownership-related differences in these five dimensions. Nonprofit utilization review firms generally provide more public goods, such as information dissemination, and are more "community oriented" than proprietary firms, but they are not distinguishable from their for-profit counterparts in addressing the implications of medical quality or the cost of the review process. However, a subgroup of nonprofit review organizations with medical origins are more likely to address quality issues than are either for-profit firms or other nonprofit agencies. Evidence on responses to information asymmetries is mixed but suggests that some ownership related differences exist. The term "charitable" is thus capable of a definition far broader than merely the relief of the poor. While it is true that in the past Congress and the federal courts have conditioned the hospital's charitable status on the level of free or below cost care that it provided for indigents, there is no authority for the conclusion that the determination of "charitable" status was always so limited. Such an inflexible construction fails to recognize the changing economic, social and technological precepts and values of contemporary society. -Circuit Court of Appeals, District of Columbia, Eastern Kentucky Welfare Rights Organization v. Simon (1974).
随着管理式医疗的发展改变了美国医学，关于非营利所有制在医疗保健系统中适当角色的问题也同样如此。越来越多地应用于非营利医院的社区福利标准，充其量只是部分适用于对非营利管理式医疗计划的期望。我们能指望非营利所有制对日益竞争的、面向参保人群的管理式医疗行业的行为产生重大影响吗？借鉴对医疗保健领域税收豁免的历史解读以及关于所有制对组织行为影响的理论文献，我们确定了可能与非营利形式的管理式医疗相关的五种社区福利形式。利用1993年对提供第三方利用审查服务的公司进行的全国性调查数据，我们测试了这五个维度中与所有制相关的差异。非营利利用审查公司通常提供更多公共产品，如信息传播，并且比营利性公司更“以社区为导向”，但在解决医疗质量影响或审查过程成本方面，它们与营利性同行没有区别。然而，有医疗背景的非营利审查组织子群体比营利性公司或其他非营利机构更有可能解决质量问题。关于对信息不对称反应的证据好坏参半，但表明存在一些与所有制相关的差异。因此，“慈善”一词的定义可能远比仅仅救济穷人要宽泛得多。诚然，过去国会和联邦法院将医院的慈善地位与其为贫困人口提供的免费或低于成本的护理水平挂钩，但没有依据得出“慈善”地位的认定总是如此有限的结论。这种僵化的解释未能认识到当代社会不断变化的经济､社会和技术准则及价值观。——哥伦比亚特区巡回上诉法院，东肯塔基福利权利组织诉西蒙案（1974年）
