Dowie J
Health Econ. 1998 Mar;7(2):93-103. doi: 10.1002/(sici)1099-1050(199803)7:2<93::aid-hec313>3.0.co;2-2.
Health economists concerned about the efficiency and equity of health care provision have focused their attention and evaluations on programmes and interventions at a population or group level. Clinicians, including those seeking to improve the quality of care by making it more evidence-based, see their task as using their clinical judgment to make the best use of the resources available to them as a result of policy decisions The existence of significant incoherence between the two (or more) levels is increasingly recognized, but clinical guidelines, the only current response, are analytically inadequate to the task of reducing it. 'Clinical Guidance Trees', on the other hand, not only have the potential to bridge the policy-clinical gap but also provide the means by which public funds can be allocated to individual patients on the basis of a societally determined willingness to pay per incremental unit of benefit. This paper aims to stimulate debate about a system in which all public funds are allocated on the basis of patient specific cost-effectiveness analyses, conducted on the basis of sociopolitically determined parameters (including equity weightings), but individualized 'quality of life' measures. The system, seeking to maximize 'equificiency', would do away with the increasingly unsustainable division between public and private sector provision and remove many expensive layers of health care decision making. While it would have many problems (including strategic behaviour various by parties), these need to be considered in the light of the problems of all alternative systems, including those of the status quo.
关注医疗保健提供效率和公平性的卫生经济学家，已将他们的注意力和评估集中在人群或群体层面的项目和干预措施上。临床医生，包括那些试图通过使医疗更具循证性来提高医疗质量的医生，认为他们的任务是运用临床判断力，充分利用政策决策所提供给他们的资源。人们越来越认识到这两个（或更多）层面之间存在显著的不一致，但目前唯一的应对措施——临床指南，在分析上不足以完成减少这种不一致的任务。另一方面，“临床指导树”不仅有可能弥合政策与临床之间的差距，还提供了一种手段，可根据社会确定的每单位增量效益支付意愿，将公共资金分配给个体患者。本文旨在激发关于一种系统的讨论，在该系统中，所有公共资金都基于针对特定患者的成本效益分析进行分配，这种分析是根据社会政治确定的参数（包括公平权重）以及个性化的“生活质量”衡量标准来进行的。该系统旨在实现“公平效率”最大化，将消除公共部门和私营部门提供服务之间日益不可持续的划分，并去除医疗保健决策中许多昂贵的层级。虽然它会有许多问题（包括各方的策略行为差异），但需要根据所有替代系统（包括现状系统）的问题来考虑这些问题。
