Gold M
Mathematica Policy Research, Washington, DC 20024, USA.
Health Serv Res. 1998 Aug;33(3 Pt 2):625-52; discussion 681-4.
OBJECTIVE/PURPOSE: To stimulate discussion within the research and policy community about the value of and issues surrounding different ways to describe access to care in a health system reconfigured by the growth of managed care, competition, and other marketplace changes.
The concept of access has evolved over time to address shifting health policy concerns like the growing interest in looking beyond utilization as a measure of access to a better consideration, too, of the effectiveness of services used as judged by costs and outcomes. Yet current frameworks used to look at access are person-based and do not capture the complexity of the healthcare system and the complex structures involved in managed care organizations that combine delivery and financing and vary substantially within and across markets. In addition, many at times competing or conflicting policy goals on access exist. There also is an increasingly diverse and widening set of uses that include benchmarking against national goals, measuring performance of accountable entities, and providing consumer information.
Traditional access frameworks are invaluable in encouraging focus on historical measures of access, like insurance coverage and other barriers to system entry. But much greater attention needs to be paid to adapting current access frameworks so that they also better support the ability to understand how processes inherent in diverse health delivery and financing arrangements influence access to services within a system and what this means for how well individuals negotiate healthcare systems and the effects on care outcomes. The increasing demands on access measures and the growing diversity of users also point to a need for collaboration to better pool insights, share experiences, and honestly confront trade-offs or disagreements to progress in addressing these issues.
目标/目的：激发研究和政策界就不同方式描述医疗保健可及性的价值及相关问题展开讨论，这些方式涉及因管理式医疗的发展、竞争及其他市场变化而重新配置的卫生系统。
可及性概念随时间演变，以应对不断变化的卫生政策关注点，比如越来越倾向于超越将利用率作为可及性衡量标准，转而更好地考虑以成本和结果评判的所使用服务的有效性。然而，当前用于审视可及性的框架是以个人为基础的，没有涵盖医疗保健系统的复杂性以及管理式医疗组织中涉及的复杂结构，这些组织将服务提供与融资相结合，且在市场内部和市场之间差异很大。此外，在可及性方面存在许多相互竞争或冲突的政策目标。还存在越来越多样化且不断扩大的一系列用途，包括对照国家目标进行基准测试、衡量责任实体的绩效以及提供消费者信息。
传统的可及性框架在鼓励关注可及性的历史衡量标准（如保险覆盖范围和其他进入系统的障碍）方面具有重要价值。但需要更加关注调整当前的可及性框架，以便它们也能更好地支持理解不同卫生服务提供和融资安排中固有的流程如何影响系统内服务的可及性，以及这对个人在医疗保健系统中的协商能力意味着什么，对护理结果有何影响。对可及性衡量标准的需求不断增加以及用户的日益多样化也表明需要开展合作，以更好地汇集见解、分享经验，并诚实地面对权衡或分歧，从而在解决这些问题上取得进展。
