Hochstein M, Halfon N, Inkelas M
Department of Pediatrics, School of Medicine, University of California, Los Angeles (UCLA), USA.
J Urban Health. 1998 Dec;75(4):751-71. doi: 10.1007/BF02344505.
The value of innovation must be measured against the costs, financial and political, associated with changing the current employer-based insurance system and the Medicaid, Title V, Title XXI/SCHIP, and other federal and state programs that supplement it. Although imperfect, this system still provides most children with insurance, and in the near term, it will need to continue to do so. Administrators, child advocates, and politicians understand how it works and how to make it work for many children. Yet, no close observer of the children's health “nonsystem” can escape the uneasy awareness that uninsurance, access barriers, and inadequate benefit packages and a lack of attention to developmental monitoring and services continue to constitute serious problems, particularly for lower-income children. However, many of the very trends and forces that complicate and are undermining the current children's health care system may suggest the potential shape of solutions. For example, the desire of payers to control costs and the consequent growth of large integrated managed-care organizations that focus primarily on cost control issues also has created new opportunities to improve quality. The key to quality improvement seems to be the improved measurement and evaluation techniques that more-integrated organizations can potentially bring to bear on developmental health. Another key to a more developmental approach to health is the creation of community oversight mechanisms, possibly in the form of outcomes trusts or health insurance purchasing cooperatives, that allocate funding for services based on a larger vision of developmental health outcomes. To do this, communities will first need to develop a vision of developmental health and then to begin to create the outcomes trusts that can coordinate the full range of services needed to promote developmental health. As communities develop a shared vision of developmental and contextual health promotion, the contemporary emergence of integrated managed-care organizations may ultimately prove to have been a necessary precursor to more-comprehensive “three-dimensionally” integrated systems of developmental health care for all children.
创新的价值必须根据与改变当前基于雇主的保险系统以及医疗补助、第五章、第二十一章/儿童健康保险计划（SCHIP）和其他补充该系统的联邦及州计划相关的财务和政治成本来衡量。尽管该系统并不完美，但它仍然为大多数儿童提供了保险，并且在短期内，它仍需继续这样做。管理人员、儿童权益倡导者和政治家都了解该系统的运作方式以及如何使其为许多儿童发挥作用。然而，任何密切观察儿童健康“非系统”的人都无法回避这样一种不安的认识，即无保险、获取障碍、福利套餐不足以及对发育监测和服务缺乏关注，仍然是严重问题，尤其是对低收入儿童而言。然而，许多使当前儿童医疗保健系统复杂化并正在破坏该系统的趋势和力量，可能暗示了解决方案的潜在形式。例如，支付方控制成本的愿望以及随之而来的主要专注于成本控制问题的大型综合管理式医疗组织的增长，也创造了提高质量的新机会。质量改进的关键似乎在于改进的测量和评估技术，更综合的组织有可能将这些技术应用于发育健康领域。采取更具发育性的健康方法的另一个关键是建立社区监督机制，可能以结果信托或健康保险购买合作社的形式，根据对发育健康结果的更广泛愿景来分配服务资金。要做到这一点，社区首先需要制定发育健康愿景，然后开始创建能够协调促进发育健康所需的全方位服务的结果信托。随着社区形成关于发育和情境健康促进的共同愿景，综合管理式医疗组织的当代出现最终可能被证明是为所有儿童建立更全面的“三维”综合发育医疗保健系统的必要先驱。
