Schulman K A, Rubenstein L E, Seils D M, Harris M, Hadley J, Escarce J J
Clinical Economics Research Unit, Georgetown University Medical Center, Washington, DC 20007, USA.
Jt Comm J Qual Improv. 1997 Feb;23(2):117-27. doi: 10.1016/s1070-3241(16)30304-2.
Few studies have examined the provision of tertiary care services by managed care organizations (MCOs). Moreover, little is known about the role of quality assessment and quality assurance mechanisms in the contracting process. Site visits were conducted in 1995 in three geographic areas to describe and evaluate the contracting processes for tertiary care services, especially neonatal intensive care and coronary artery bypass graft surgery, of health maintenance organizations (HMOs).
Three market areas in the United States, each with differing levels of "maturity", as primarily defined in terms of managed care penetration, were selected for study. Interviews were conducted with HMO and hospital managers about the processes for identifying potential tertiary care hospitals and mechanisms for quality assessment and quality improvement (QI) that are considered in the contracting process.
The most sophisticated contracting arrangements were found in the most mature market-where HMOs select hospitals for tertiary care services based on both the price and quality of services, with quality assessed through both objective and subjective data. Yet in all three markets, quality assessment was the least well-developed component of tertiary care contracting. Even in the mature market, we found inconsistent use of even validated quality or outcomes measures in hospital contracting.
The potential of MCOs to increase quality depends on their ability to identify high-quality hospitals and their willingness to direct enrollees to those hospitals. Yet inconsistent evidence was found that mechanisms for evaluating and rewarding quality are being fully adopted in the three markets studied.
很少有研究考察管理式医疗组织（MCO）提供三级医疗服务的情况。此外，对于质量评估和质量保证机制在签约过程中的作用知之甚少。1995年对三个地理区域进行了实地考察，以描述和评估健康维护组织（HMO）三级医疗服务的签约过程，特别是新生儿重症监护和冠状动脉搭桥手术。
选择美国三个市场区域进行研究，每个区域的“成熟度”水平不同，主要根据管理式医疗的渗透率来定义。就确定潜在三级医疗医院的过程以及签约过程中考虑的质量评估和质量改进（QI）机制，对HMO和医院管理人员进行了访谈。
在最成熟的市场中发现了最复杂的签约安排——HMO根据服务价格和质量选择三级医疗服务医院，通过客观和主观数据评估质量。然而在所有三个市场中，质量评估都是三级医疗签约中最不完善的部分。即使在成熟市场，我们也发现医院签约中对经过验证的质量或结果指标的使用并不一致。
MCO提高质量的潜力取决于其识别高质量医院的能力以及将参保人引导至这些医院的意愿。然而，在所研究的三个市场中，发现评估和奖励质量的机制并未得到充分采用，证据并不一致。
