[DOC]-外文翻译----美国医疗保健制度-管理式医疗护理-其他专业

[DOC]-外文翻译----美国医疗保健制度-管理式医疗护理-其他专业 本科毕业(论文) 外 文 翻 译 原文 The American Health Care System — Managed Care America's private and public third-party payers, squeezed by health care costs that continue to soar at rates well above inflation, are persuaded that "managed care" plans will produce demonstrable savings as compared with the current cost trends of traditional fee-for-service medicine. They are accelerating their efforts to promote plans that integrate the delivery and financing of care and that apply new constraints on encounters between physicians and patients. The key constraint for doctors is the limitation placed on the autonomy of their clinical decisions. The constraint for patients is the requirement that they see only physicians who are members of a plan's closed or partially open panel or who are selected as "preferred" practitioners. In general, these doctors have agreed to deliver only "necessary" medical services in return for prescribed fees. Most definitions characterize managed care as a system that integrates the financing and delivery of appropriate medical care by means of the following features: contracts with selected physicians and hospitals that furnish a comprehensive set of health care services to enrolled members, usually for a predetermined monthly premium; utilization and quality controls that contracting providers agree to accept; financial incentives for patients to use the providers and facilities associated with the plan; and the assumption of some financial risk by doctors, thus fundamentally altering their role from serving as agent for the patient's welfare to balancing the patient's needs against the need for cost control — or, as Mechanic put it succinctly, moving "from advocacy to allocation." Because these features circumscribe the freedom of physicians to practice medicine autonomously, they receive decidedly mixed reviews from doctors. Nevertheless, at least half of all practicing physicians have become involved in at least one managed care arrangement, and they have accepted the trade-off of lower fees for a guaranteed flow of patients. The reality is that this new model has rapidly emerged as a dominant one in the American health care system. At the same time as these new networks are developing, some existing large multispecialty group practices that previously treated patients only on a traditional fee-for-service basis are offering benefit packages directly to payers for a prepaid, fixed premium. Medical group practices that now operate such managed care plans, which may generate 30 to 40 percent of the practice's total patient revenues, include the Carle Clinic in Urbana, Illinois, the Dean Clinic in Madison, Wisconsin, the Geisinger Clinic in Danville, Pennsylvania, the Marshfield Clinic in Marshfield, Wisconsin, the Ochsner Clinic in New Orleans, the Palo Alto Clinic in Palo Alto, California, the Park—Nicollet Clinic in Minneapolis, the Scott and White Clinic in Temple, Texas, and the Virginia Mason Clinic in Seattle. The Cleveland Clinic and many other hospitals across the country have taken an important step in this direction by offering third parties fixed prices for "bundled" sets of medical services — for example, a fee for all the services (provided by physicians, hospitals, and ancillary personnel) required to perform a coronary-artery bypass operation or a heart or kidney transplantation. The emergence of managed care is the subject of this report — my third on the American health care system. It represents the latest stage in a long struggle that has pitted the priorities of practicing physicians against management structures that have sought to gain firmer control over what doctors do. The traditional autonomy that physicians have enjoyed as ministers to the sick and as recipients of a state grant of monopoly power in medical practice — what Freidson calls "professional dominance"5 — is being threatened by these new arrangements. The new constraints, along with other economic and social pressures, are encouraging physicians to aggregate in larger professional groups that offer them greater protection against external assaults on their autonomy, as well as more regular working conditions. Most organizations that provide managed care are called either health maintenance organizations (HMOs) or preferred-provider organizations (PPOs). Within these categories, there are variations on the basic theme, reflecting the fact that the organization of managed care is evolving rapidly. Although still largely a regional phenomenon, far more prevalent on the East and West Coasts and in the Midwest, managed care is clearly a phenomenon that, in one form or another, is here to stay, despite the misgivings of many doctors.7 The states with the largest numbers of people enrolled in HMOs and the highest percentages of their population enrolled in such plans are California (33.4 percent), Massachusetts (30.9 percent), Minnesota (28.3 percent), Oregon (26.4 percent), Arizona (24.2 percent), Hawaii (22.9 percent), Wisconsin (22.5 percent), Maryland (22.3 percent), Colorado (21.9 percent), and Connecticut (20.7 percent). Most of the legislative proposals to reform the health care system, regardless of the ideological stripe of their sponsors, promote expansion of managed care. Private business — the community of interests that, if it ever really extended itself on behalf of health care reform, could propel it forward — views managed care as its best current hope to control costs and preserve the dominance of the health system by private providers and payers. Recently, even the American Medical Association, in the form of a speech delivered on June 8 by executive vice-president Dr. James S. Todd, conceded that it has been "slow in recognizing and accepting the legitimacy, the benefits, of these modes of practice"; Todd acknowledged the positive contributions made by HMOs and other members of the Group Health Association of America. As proposals for managed care evolve, new alliances are formed among major stakeholders seeking competitive advantage. One of the most interesting recent developments was announced on June 30 in Minneapolis, long a center of managed care. Fourteen Minneapolis-based companies, including Dayton Hudson Corporation, General Mills, Norwest Corporation, and the IDS Financial Corporation, a subsidiary of American Express, which had sponsored a bidding competition, named a consortium of health institutions to which they will channel their more than 125,000 employees and dependents for their medical care. The consortium includes the Mayo Clinic, the Park—Nicollet Medical Clinic, and Group Health, a local HMO. The other finalist was Minnesota's Blue Cross and Blue Shield plan. Although the purchasing power of the coalition of businesses served as the major catalyst for the formation of the health care consortium, the collaboration hinged in part on a new effort to reward providers for the quality of the care they render. The consortium, through a newly established institute, will develop guidelines for practice aimed at reducing variation in practice patterns and eliminating unneeded care. The assessments of quality will be based largely on the overall health status of enrolled members and on patient satisfaction, rather than on rates of death and complications, which are normally used to rank hospitals. Types of Managed Care Plans Managed care programs seem endlessly varied, but there are essentially two types of HMO: the group or staff model, in which groups of physicians contract to provide services, and the independent practice association (IPA), in which doctors remain in their own offices but agree to treat patients enrolled in a health plan. The IPA model was the fastest-growing of the HMO variants in the past decade. In an IPA, a health plan contracts with individual practitioners or groups to provide care at a negotiated rate per capita, for a flat retainer, or for a negotiated fee-for-service rate. The physicians maintain their own offices and continue to see patients on a fee-for-service basis, as well, while contracting with one or more HMOs. In a group-model HMO, physicians usually aggregate in independent medical groups (like the 12 such groups that provide services within the Kaiser–Permanente Medical Care Program). In a staff-model plan, physicians are employees and are not organized in separate medical groups. Nevertheless, even in staff-model HMOs, doctors are a force with which management must reckon. How strong a force physicians can be was evident last November when staff doctors at the Harvard Community Health Plan in Boston forced the resignation of their long-standing chief executive officer in protest over his management style. The final confrontation was provoked by the promulgation of new productivity standards that sought to peg income to quotas for numbers of patient visits. Given the increasing management of the details of fee-for-service practice by third parties, group- and staff-model HMOs feature two important characteristics: First, physicians accept the responsibility to provide comprehensive care for a fixed fee in exchange for autonomy in the practice of medicine; any oversight is carried out by peers, not external managers. Many of the most successful IPAs, seeking more constructive and permanent relations with physicians, are employing doctors as medical directors to perform the peer-review function, thus hoping to buffer the practitioners' relation with management. Second, in return for this freedom, group- and staff-model HMOs tightly control the kind and amount of care received by enrolled patients by carefully selecting the numbers and types of doctors in their panels in relation to the needs of the population served. Primary care doctors act as gatekeepers — generalists who serve as the entry point to a plan. Each enrolled member can be referred to specialists only by his or her primary care doctor. HMOs thereby ensure adequate access to primary care and maintain full patient schedules for their specialists. Many plans incorporate financial incentives into their agreements with physicians in an attempt to influence the frequency with which primary care doctors refer patients, order tests or procedures, and admit patients to the hospital. Physicians often assume this gatekeeping role with some reluctance because of the potential conflicts it creates with patients and specialists. Nevertheless, the key role of primary care doctors in HMOs places them in positions of greater authority in relation to specialists than is the case in the traditional system. Ironically, managed care plans find it increasingly difficult to recruit primary care doctors because training programs continue to emphasize the medical specialties, despite the strong need for generalists in the HMO market. Other forms of managed care include the PPO and the latest variant of managed care — the point-of-service plan. Under such a plan, a PPO contracts with networks or panels of physicians who agree to provide medical services and be paid according to a discounted fee schedule. Enrollees are offered better coverage if they agree to see physicians on the preferred list, which is generally assembled by either insurers or employers, but the plan makes no provision to couple a patient with a primary care doctor as gatekeeper. A point-of-service plan does encourage such a coupling by offering employees incentives (usually more benefits or lower copayments) to channel their care through a primary care doctor to other selected practitioners. This option, offered to employees by a growing number of Fortune 500 companies, including AT&T, Marriott, Chevron, and Sears Roebuck, strengthens the role of the primary care physician. An enrollee has the freedom to seek care from a physician not affiliated with the plan, but he or she pays substantially more out of pocket for such care. Source: John K. Iglehart.The American Health Care System — Managed ()Care[J]. N Engl J Med ,199209 译文: 美国医疗保健制度------管理式医疗护理 美国的私人的和公共的第三方付款人，被以远超过通货膨胀率且持续猛增的医疗保健费用所挤压，他们被劝告说这个“管理式医疗护理”与现有的传统一次一付的医疗费的费用趋势相比会产生明显的节约款项。他们正在加快努力来促成将医疗支付与融资和在医生与患者之间的接触应用新约束条件整合成一个整体。对于医生的关键约束条件来说是他们的临床决策的自主权设置的限制。对于患者的限制是，他们只能看那些是封闭或部分对外开放专门小组的成员医生或者那些被选为“受喜爱”的医生。总的来说，这些医生已经同意只提供“必要的“医疗服务”来作为对规定费用的回报。 大多数定义把管理式医疗护理描绘成一个将融资和提供有下列特征的医疗处理方式相融合的这么一个系统:签约的被选择的医生和医院，他们通常为了每月预定的奖金会为注册会员提供一套综合的医疗护理服务;承包者同意接受应用和质量控制;让病人使用与这个计划相关联的供应商和设备的经济诱因;和医生的一些财务风险的承担，这样的话，他们的角色根本上从充当患者福利的代理人变更为权衡病人相对于成本控制之间的需求--------或者，就像Mechanic简明扼要的说，是从宣传转移到分配。 因为这些对医生自主行医自由限定的特征，他们明确地从医生那边收到了褒贬不一的评论。尽管如此，至少还有一半的执业医生已经参与到至少一个管理式医疗，他们已经接受给有一定流量保证的患者一个较低费用的协定。事实上这个新模式已经在美国的医疗保障制度中快速地显示出它的主导地位。与此同时，随着这些新网络的发展，一些现存的以前只以一次一付医疗费为基础来对待患者的多专业类的诊所直接为那些有预付款和固定奖金的支付人提供福利计划。 现在运作这种管理式医疗护理计划的医疗组织诊所，他们可以产生30%到40%的所有的病人业务收入，包括在伊利诺斯州厄巴纳市的卡尔诊所，威斯康辛州麦迪逊市的迪安诊所，宾夕法尼亚州丹维尔的盖辛格诊所，威斯康辛州马什菲尔德的马什菲尔德诊所，新奥尔良市的Ochsner诊所，加利福尼亚州帕洛阿尔托的帕洛阿尔托诊所，明尼阿波利斯市的尼克莱公园诊所，德克萨斯州坦普尔斯科特与怀特诊所，还有西雅图市的维吉尼亚 梅森诊所。克利夫兰诊所还有其他许 多全国的医院已经朝着为“捆绑式”医疗服务提供第三方固定价格这个方向跨出了很重要一步——比如说，一笔包括所有服务(由医生，医院和附属人员提供)要求履行冠状动脉绕道手术或者心脏或肾脏移植。 管理式医疗的出现是本报告的主题。传统的模式中，医生享有对病人的控制权，作为在医疗实践中资助者的垄断力量—Freidson所指的“专业优势” —现在正遭受改革的威胁。新的限制，以及其他经济和社会压力，鼓励医生组合成规模更大的专业团体，在自主权上为他们自身提供更大的保护，避免外来攻击，以及更规律的工作环境。 大部分提供管制护理的组织被称为保健组织或者优先提供者组织。在他们所涉及的项目范围内，有各种相关的多样化服务，这反映了管制护理组织正在快速发展。虽然大致上还只是区域性的的现象，还没有扩展到东西部海岸和中部。但是管制护理，不管医生的质疑，已经以这样或那样的形式出现了。已经加入保健组织的人数最多和加入相应计划的人占州总人数最高百分比的几个州分别是加利福尼亚(33.4%)、马萨诸塞州(30.9%)、明尼苏达州(28.3%)、俄勒冈州(26.4%)、亚利桑那州(24.2%)、夏威夷(22.9%)、威斯康辛州(22.5%)、马里兰岛(22.3%)、科罗拉多州(21.9%)、康涅狄格州(20.7%)。 大部分立法机构都不管意识形态领域的赞助者，而建议改革健康护理系统，促进管制护理的扩展。私营企业——利益共同团如果真的想参与健康护理改革，是完全可以促进它的发展的——把管制护理当作它现在最大的一个愿望，希望借此来控制成本并通过私人销售和付款来控制对管制护理的主导权。最近，甚至是美国医药组织，也在六月由执行副主席陶德博士以演讲的形式承认美国医药组织:“慢慢才认识到并接受这些行为模式的合法地位和好处”。陶德承认健康护理组织和美国其他的健康组织的成员对社会所作的积极贡献。 随着管制护理的进一步发展，大的利益相关者为了追求更大的利益而结成联盟。最近，其中有一个最有意思的发展于月日发生在明尼阿波利斯市—630 —管制护理的中心。个明尼阿波利斯市的公司，包括【戴顿哈德逊公司，通14 用公司，诺韦斯特公司，财务公司】，美国快递公司的附属公司，曾经发起IDS 投标竞争，指定健康机构的一个财团把他们员工和下属输送到该机构中125000 接受健康护理。这些财团包括【梅奥诊所，帕克尼科莱特医疗诊所，团体医疗， 当地的一家】其他参加最终竞标的是明尼苏达的蓝十字和蓝盾计划。虽然HMO 联合企业的购买力是健康护理财团形成的最主要刺激因素，但是对于奖励提供高质量健康护理的下属的决定，联盟里只有部分企业同意。财团将通过一个新成立的机构完善某行动指南，该行动目标是减少方式多样化和取消不必要的护理。质量评估主要依据整体的护理水平，如员工情况、病人的满意度等，而不是通常情 况下用于评价医院等级的死亡率和并发率。 管理式医疗护理计划类型 管理式医疗护理项目看起来好像无止尽地变化，但是从本质上来说有两种类型的健康维护组织体:集团或员工模式，在这种模式下各种医生团体签合约来提供服务，还有一种独立执业协会，在这种模式下医生们留在他们自己的办公室里，但是同意注册进一个健康计划来治疗病人。IPA模式在过去几十年里是HMO变革中成长最快的。在一个IPA里，一个健康计划要和个体医生或团体以人均协议价签订合约来提供护理，这个价格可以是稳定的定金，或者是一次一付的价格。医生们可以维持他们自己的办公室，可以继续以一次一付医疗费为基础为病人看病，同样的，同时也可以与,个或者,个健康维护组织签。 在一个集团型的健康维护组织中，医生们经常聚集在独立的医疗团体里(就像在凯撒–Permanente医疗护理项目提供服务的12个这样的团体)。在一个员工模式计划中，医生是雇员而且没有被组织进单独的医疗团体中去。尽管如此，即使在员工型健康维护组织中，医生们是管理层必须考虑的一股力量。医生们能形成的力量有多强是显而易见的，去年11月，当医生职员们在波斯顿参加的哈佛社区健康计划时就强迫了他们长期的首席执行官辞职，因为他们抗议他的管理模式。最终的对抗是被新颁布的寻求把收入与病人拜访数量限额挂钩的生产力标准而激起的。 鉴于越来越多的细节管理有偿服务由第三方实践，集团型的健康维护组织模式具有两个重要特点:第一，医生在医疗实践中有在规定费用基础上提供全面护理的责任，任何监督工作由同行组织，而不是外在的管理人员。许多成功的IPA，寻求与医生建立更具建设性的和永久的关系，聘请医生作为医务主任行使同行间审查的职能，希望以此来缓冲从业人员与管理层的关系。第二，作为这种 自由的回报，集团型的健康维护组织通过仔细选择医生的数量和登记在册的患者严密控制护理的种类和患者数量，初级保健医生充当看门人。保健组织从而确保获得足够的初级保健和维持其全面运转的专家门诊时间。 医生们勉强担任这个守门的角色因为它创造了与病人和专家的潜在冲突。尽管如此，在HMO中初级护理医生的关键作用是把他们放在比在原来传统系统中的情况下与专家有关的更大职权的位子上。具有讽刺意味的是，管理式医疗护理计划发现招募初级护理医生变得越来越难，因为训练项目持续强调医学专业，而不管在HMO市场中对于对面手的强烈需求。 其他形式的管理式医疗护理包括PPO还有最新的管理式医疗护理变异——点服务计划。在这种计划下面，PPO与那些同意通过提供医疗服务然后按照打折的费用清单来收费的医生专门小组或医生网络签订合约。那些注册者们会被提供更好的覆盖范围的医疗服务，如果他们同意看那些通常不是由保险公司就是由雇主组合在首选列表上的医生的话，但是这个计划没有规定像守门人一样把病人和医生联系起来。注册者也可以从看那些不附属于这个计划中的医生去看病，但是他或者她大致上要花更多的钱。 出处:[美]约翰 K 伊格尔哈特，《美国医疗保健制度------管理式医疗护理》，新英格兰医学杂志,1992(09).