Smith D B
Temple University, USA.
J Health Polit Policy Law. 1998 Feb;23(1):75-105. doi: 10.1215/03616878-23-1-75.
Large racial inequities in health care use continue to be reported, raising concerns about discrimination. Historically, the health system, with its professionally dominated, autonomous, voluntary organizational structure, has presented special challenges to civil rights efforts. De jure racial segregation in the United States gave way to a period of aggressive litigation and enforcement from 1954 until 1968 and then to the current period of relative inactivity. A combination of factors--declining federal resources and organizational capacity to address more subtle forms of discriminatory practices in health care settings, increasingly restrictive interpretations by the courts, and the lack of any systematic mechanisms for the statistical monitoring of providers--offers little assurance that discrimination does not continue to play a role in accounting for discrepancies in use. The current rapid transformation of health care into integrated delivery systems driven by risk-based financing presents both new opportunities and new threats. Adequate regulation, markets, and management for such systems impose new requirements for comparative systematic statistical assessment of performance. My conclusion illustrates ways that current "report card" approaches to monitoring performance of such systems could be used to monitor, correct, and build trust in equitable treatment.
医疗保健使用方面存在巨大的种族不平等现象，这一情况仍在不断被报道，引发了人们对歧视问题的担忧。从历史上看，医疗系统以其专业主导、自主且自愿的组织结构，给民权运动带来了特殊挑战。美国法律上的种族隔离在1954年至1968年间让位于一段积极诉讼和执法的时期，随后进入了当前相对不活跃的阶段。一系列因素——联邦资源减少、应对医疗保健环境中更微妙形式歧视行为的组织能力下降、法院日益严格的解释以及缺乏对医疗服务提供者进行统计监测的任何系统机制——几乎无法保证歧视在解释使用差异方面不再起作用。当前，在基于风险的融资推动下，医疗保健迅速转变为综合服务体系，这既带来了新机遇，也带来了新威胁。对此类体系进行充分监管、建立市场和管理机制，对基于比较的系统绩效统计评估提出了新要求。我的结论阐述了当前用于监测此类体系绩效的“成绩单”方法可如何用于监测、纠正和建立对公平待遇的信任。
