Miller E A, Weissert W G, Chernew M
Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor 48109-2029, USA.
Am J Med Qual. 1998 Fall;13(3):127-40. doi: 10.1177/106286069801300304.
Although managed care seems to serve well the interests of non-elderly enrollees and their payers, elderly people face more risks. Chronic conditions, multiple problems, and more limited resources make them more vulnerable, whereas multiple payer sources make them more complicated to cover. This synthesis of managed care delivered in Medicare and Medicaid demonstration projects serving elderly beneficiaries shows that managed care plans either select or attract enrollees who suffer fewer frailties than those served in fee-for-service settings, exhibit reluctance to enter rural markets, provide a broad range of elderly-specific services, offer more comprehensive coverage and services, and result in greater perceived access problems, particularly for vulnerable subgroups. Plans operate more cheaply by using fewer resources, even after adjusting for case mix differences. Managed care enrollees tend to be more satisfied with financial and coverage aspects, whereas fee-for-service enrollees report higher satisfaction on other dimensions. In acute care settings, process of care findings were mixed, whereas clinical and self-reported outcome indicators were no better and in some instances worse in managed care. Long-term care enrollees, in the few studies reported, consistently faired worse in both the processes and outcomes of care. These findings suggest that further research on the effects of managed care in its rapidly changing incarnations is needed, particularly with respect to how to improve the quality of acute and long-term care delivered to elderly people and the proper role of government and other key actors in the health care system.
尽管管理式医疗似乎很好地满足了非老年参保者及其支付方的利益，但老年人面临更多风险。慢性病、多种问题以及资源更为有限使他们更加脆弱，而多个支付方来源则使他们的承保变得更加复杂。对为老年受益人群体提供服务的医疗保险和医疗补助示范项目中实施的管理式医疗进行的综合分析表明，管理式医疗计划要么选择要么吸引比按服务收费模式下服务的人群身体更健康的参保者，不愿进入农村市场，提供广泛的针对老年人的服务，提供更全面的保险范围和服务，并导致更多的可感知的就医问题，尤其是对弱势群体而言。即使在对病例组合差异进行调整之后，计划通过使用更少的资源来更廉价地运营。管理式医疗的参保者往往对财务和保险范围方面更满意，而按服务收费的参保者在其他方面报告的满意度更高。在急性护理环境中，护理过程的结果参差不齐，而在管理式医疗中，临床和自我报告的结果指标并没有更好，在某些情况下甚至更差。在少数已报道的研究中，长期护理的参保者在护理过程和结果方面一直表现更差。这些发现表明，需要对管理式医疗在其快速变化的形式中的影响进行进一步研究，特别是关于如何提高为老年人提供的急性和长期护理的质量，以及政府和医疗保健系统中其他关键行为者的适当作用。
