Block L E
Division of Health Management and Policy, School of Public Health, University of Minnesota, Minneapolis 55455-0381, USA.
Public Health Rev. 1997;25(3-4):193-244.
While under attack in the United States, managed care/competition is being viewed by a number of European and other countries as a remedy in their struggle to control rising health care costs. While many fundamentals of American managed care have their roots in the British health system, significant differences exist between the two systems. While managed care, which can be loosely defined as any system of delivering health services in which care is delivered by a specified network of providers who agree to comply with the care approaches established through a case management process, has had a 100-year history in the United States, it wasn't until the mid-1970's that it began to gain national recognition. All health maintenance organizations (HMOs) are managed care organizations (MCOs) but not all MCOs are HMOs. The two other categories of MCOs are, preferred provider organizations (PPOs) and point of service plans (POS). Currently, three-quarters of Americans with health insurance are enrolled in managed care plans and there are 160 million Americans enrolled in such plans. A major on-going debate occurring in the United States is in regard to the comparative quality of care provided by MCOs and traditional fee-for-service plans. The study results to date have been equivocal. Another controversial managed care issue is the use of gag clauses in contracts between the MCOs and their providers. These clauses limit providers from being totally open and honest with patients about, for example, alternative treatment possibilities or the details of provider reimbursement. Since the failure of U.S. health care reform in 1994, there has been a more focused turn to the marketplace to provide the impetus for reducing costs. As a result, health care plans and providers have become more like traditional businesses which must focus on the bottom line to survive. In a marketplace where purchasers of care look for low bidders, it should be remembered that the level and quality of care a society receives is usually commensurate with the level of resources that it is willing to expend.
尽管在美国受到抨击，但管理式医疗/竞争却被一些欧洲国家和其他国家视为控制不断上涨的医疗保健成本的一种补救措施。虽然美国管理式医疗的许多基本要素都源于英国医疗体系，但这两种体系之间存在显著差异。管理式医疗可以宽泛地定义为任何一种提供医疗服务的体系，在这种体系中，医疗服务由一个特定的提供者网络提供，这些提供者同意遵守通过病例管理流程确立的医疗方法。管理式医疗在美国已有100年历史，但直到20世纪70年代中期才开始获得全国认可。所有健康维护组织（HMO）都是管理式医疗组织（MCO），但并非所有MCO都是HMO。MCO的另外两类是优选提供者组织（PPO）和服务点计划（POS）。目前，四分之三拥有医疗保险的美国人参加了管理式医疗计划，有1.6亿美国人参加了此类计划。美国正在进行的一场主要辩论涉及MCO和传统按服务收费计划所提供医疗服务的相对质量。迄今为止的研究结果尚无定论。另一个有争议的管理式医疗问题是MCO与其提供者之间合同中使用的限制条款。这些条款限制提供者对患者完全坦诚相告，比如替代治疗可能性或提供者报销细节。自1994年美国医疗改革失败以来，人们更加专注于转向市场以提供降低成本的动力。结果，医疗保健计划和提供者变得更像传统企业，必须关注盈亏底线才能生存。在一个医疗服务购买者寻找出价低者的市场中，应该记住，一个社会所获得的医疗服务水平和质量通常与其愿意投入的资源水平相称。
