Scutchfield F D, Lee J, Patton D
Center for Health Services Research, Policy and Management, University of Kentucky Medical Center, Lexington 40536-0003, USA.
J Public Health Med. 1997 Sep;19(3):251-4. doi: 10.1093/oxfordjournals.pubmed.a024626.
Medical care in the United States continues to consume an increasing amount of the Gross Domestic Product. To control the rising costs of health care many industries have turned to a controlled form of financing and delivery of health care--often referred to as managed care. Many types of managed care exist, including preferred provider organizations (PPO), exclusive provider organization (EPO), and health maintenance organizations (HMO). HMOs involve prepaid premiums, limited panels of providers and assumption of financial risk on the part of the providers. A variety of HMOs are currently operating in the United States. Managed care involves taking risks by those who administer it. Some methods of controlling patient and physician behaviour by taking risks are capitation, risk pools and withholds. With capitation the physician is paid a 'per member per month' fee regardless of whether the patient uses the service. Risk pools are concerned with who shares the risk; for example, the primary physician shares the financial risk with specialists. Withholds involve a fee-for-service with a portion withheld which may be returned to the provider if he/she is parsimonious. A concern expressed about HMOs is the possibility of restricted services. Moreover, hospital expenses make up a large portion of the total health care dollar. In 1995 the average length of stay for a Medicare patient was 6.1 days as opposed to 3.9 days for the non-Medicare patient. Indeed, HMOs were the leaders in the development of same-day surgery and out-patient treatment. Increasingly, in the United States, public and social insurance plans are turning to managed care as a method to control health care expenditure. Some government insurance plans, such as Medicare and Medicaid, also increasingly offer managed health options. The trend, for now, in the United States increases enrollment in managed care plans. Although this is occurring at a rapid pace, managed care will probably not be the final solution to provision of medical care in the United States.
美国的医疗保健支出在国内生产总值中所占的比例持续上升。为了控制不断上涨的医疗成本，许多行业已转向一种可控的医疗保健融资和提供形式——通常被称为管理式医疗。管理式医疗有多种类型，包括优选提供者组织（PPO）、独家提供者组织（EPO）和健康维护组织（HMO）。健康维护组织涉及预付保费、有限的提供者名单以及提供者承担财务风险。目前有多种健康维护组织在美国运营。管理式医疗要求管理者承担风险。一些通过承担风险来控制患者和医生行为的方法包括按人头付费、风险分担池和扣留款。按人头付费是指无论患者是否使用服务，都向医生支付“每人每月”的费用。风险分担池关注的是谁来分担风险；例如，初级保健医生与专科医生分担财务风险。扣留款涉及按服务收费，但会扣留一部分费用，如果提供者节约使用，这部分费用可能会返还给他们。人们对健康维护组织表示担忧的一点是可能会限制服务。此外，医院费用在医疗保健总支出中占很大一部分。1995年，医疗保险患者的平均住院天数为6.1天，而非医疗保险患者为3.9天。事实上，健康维护组织是当日手术和门诊治疗发展的引领者。在美国，公共和社会保险计划越来越多地转向管理式医疗作为控制医疗保健支出的一种方法。一些政府保险计划，如医疗保险和医疗补助，也越来越多地提供管理式健康选项。目前，美国的趋势是增加管理式医疗计划的参保人数。尽管这一趋势发展迅速，但管理式医疗可能不会是美国提供医疗保健的最终解决方案。
