美国管理型医疗保健模式及其对我国医疗保健制度改革的启示

从美国管理型医疗保健的概念界定入手,介绍了管理型医疗保健的四种基本模式,从补偿机制、利用评审、质量保证三个角度阐述了它的运作方式,指出管理型医疗保健对我国医保改革的借鉴意义。     

管理型医疗保健与医学技术评估

管理型医疗保健具有严格的利用状况评估等６大特征，该保健中采取了医生补偿机制、医院补偿机制、通过签约和选择提供者及利用守门人、审核进行费用控制。为此，开展医学技术评估对实施管理型医疗保健有积极的作用。我国的医疗保健正在发展，管理型医疗保健和医疗技术评估必将逐步引入我国卫生事业改革中。     

我国管理型医疗的实现形式

我国医疗保险从“两江试点”开始至今已有10个年头，这种新的医疗保障制度在全国得到普遍建立。如何使新制度可持续发展是摆在广大医疗保险管理工作者和社会保障理论工作者面前的一项重要课题。可持续发展的关键是既能使患者享受优质的医疗服务，又能控制医疗费用的上涨。管理型医疗是提高医疗服务管理水平，控制医疗服务费用的最     

引入管理型医疗的必要性和可行性

本文通过较为系统的政策调研和查阅文献,分析了国外医疗保障制度模式的运行规律和特点,针对国内医疗保障制度中存在的医疗服务公平性差、医疗保障覆盖范围窄、医疗市场垄断等薄弱环节,系统地探讨了“管理型医疗”在我国医疗保障制度改革的借鉴意义,以及在我国的必要性和可行性。     

美国的管理型医疗保健及对我国卫生保健制度的启示

文章介绍了美国管理化卫生保健制度的概念、模式与特征,并对管理化医疗进行了评价,分析了管理型医疗保健对我国医疗保健制度的借鉴意义。     

管理型医疗与政府职责定位分析

管理型医疗就是处理医、患、保三方关系的一种规则，是全球范围的一种政策选择。建立和实行医疗保障制度、促进国民素质的提高是绝大多数国家的经济社会发展目标之一，但不同国家的政府在建立和实施医疗保障制度中的作用和责任是不同的。现阶段医疗保险的责任分担机制不符合市场经济的要求，也与各级政府财政的承受能力不匹配。从计划经济向市场经济转型，政府在医疗保险领域的职能和定位不断发生着调整和变化，政府逐渐从市场主体的位置上退下来．扮演更加超然的监管者角色。     

中国管理型医疗保险的制度结构选择

文章在界定管理型医疗保险概念的基础上．分析了现阶段中国管理型医疗保险的结构性特征．指出中国式管理型医疗保险形成的必要条件之一是建立以健康公平为价值取向，科学付费机制为基础的多层次全民社会医疗保险体系。     

实行预付制是我国医疗保健制度改革的方向

一、传统的医疗保健制度助长了卫生资源的浪费和医疗费用的过度上涨公费医疗和劳保医疗是我国社会福利保障制度的重要组成部分,它产生于实行“供给制”的五十年代。随着社会主义有计划商品经济的发展,这种以费用实报实销,费用支付与医疗行为脱节为特征的医疗保健制度,越来越暴露出其局限性。最为突出的是:它已成为卫生资源浪费和医疗费用过度上涨的主要原     

论新形势下军队老干部医疗保健工作

近20年来随着我国生活模式和生存环境的改变，慢性病及心血管疾病的发病、致残及病死率明显上升，严重的危害着中老年群体的健康及生活质量，并成为导致医疗费用不断上涨的主要因素之一，给国家、社会、家庭及个人带来非常复杂的问题。军队也不例外。如何进一步加强部队干部，尤其是中高级干部群体的医疗保健工作，提高其健康素质及生命质量，是当前摆在我们面前的一个重要课题。     

美国管理型医疗对我国社区健康教育的启示

社区健康教育是社区卫生服务"六位一体"功能的基础和前提,是整个社区社区卫生服务的先导.本文从目前社区健康教育发展动力不足、效果评估和管理监督薄弱等问题入手,借鉴美国管理型医疗的适宜经验,并对美国管理型医疗在我国社区健康教育中的应用进行探索.     

Managed Care Organizational Characteristics and Health Care Use among Children with Special Health Care Needs

Objective. To examine the relationship between features of managed care organizations (MCOs) and health care use patterns by children.
Data Sources. Telephone survey data from 2,223 parents of children with special health care needs, MCO-administrator interview data, and health care claims data.
Study Design. Cross-sectional survey data from families about the number of consequences of their children's conditions and from MCO administrators about their plans' organizational features were used. Indices reflecting the MCO characteristics were developed using data reduction techniques. Hierarchical models were developed to examine the relationship between child sociodemographic and health characteristics and the MCO indices labeled: Pediatrician Focused (PF) Index, Specialist Focused (SF) Index, and Fee-for-Service (FFS) Index, and outpatient use rates and charges, inpatient admissions, emergency room (ER) visits, and specialty consultations.
Data Collection/Extraction Methods. The telephone and MCO-administrator survey data were linked to the enrollment and claims files.
Principal Findings. The child's age, gender, and condition consequences were consistent predictor variables related to health care use and charges. The PF Index was associated with decreased outpatient use rates and charges and decreased inpatient admissions. The SF Index was associated with increased ER visits and decreased specialty consultations, while the FFS Index was associated with increased outpatient use rates and charges.
Conclusion. After controlling for sociodemographic and health characteristics, the PF, SF, and FFS indices were significantly associated with children's health care use patterns.     

Medicaid Managed Care and Health Care Access for Adult Beneficiaries with Disabilities

Objective. To evaluate the impact of Medicaid managed care organizations (MCO) on health care access for adults with disabilities (AWDs).
Data Sources. Mandatory and voluntary enrollment data for AWDs in Medicaid MCOs in each county were merged with the Medical Expenditure Panel Survey and the Area Resource File for 1996–2004.
Study Design. I use logit regression and two evaluation perspectives to compare access and preventive care for AWDs in Medicaid MCOs with FFS. From the state's perspective, I compare AWDs in counties with mandatory, voluntary, and no MCOs. From the enrollee's perspective, I compare AWDs who must enroll in an MCO or FFS to those who may choose between them.
Principal Findings. Mandatory MCO enrollees are 24.9 percent more likely to wait >30 minutes to see a provider, 32 percent more likely to report a problem accessing a specialist, and 10 percent less likely to receive a flu shot within the past year. These differences persist from the state evaluation perspective.
Conclusions. States should not expect a dramatic change in health care access when they implement Medicaid MCOs to deliver care to the adult disabled population. However, continued attention to specialty care access is warranted for mandatory MCO enrollees.     

Managed Care and Employer Premiums

This paper used 1993–1997 data from medium and large size employers to examine the effects of market wide managed care penetration on the premiums paid for employer sponsored health insurance. Regressions were run for weighted average single coverage premiums and for premiums on conventional, HMO, and PPO coverage. Four findings emerged from the analysis. First, increased managed care penetration had no statistically significant effect on weighted average employer premiums. Second, higher HMO penetration resulted in lower HMO premiums but higher conventional and PPO premiums. Third, higher PPO penetration had no statistically meaningful effects across plan types. Finally, the results depended critically on whether firms offered self-insured plans. Higher levels of HMO penetration led to smaller increases in conventional and PPO premiums for firms with self-insured plans, but also yielded smaller premium reductions from HMOs relative to those with purchased coverage.     

The United States Health Care System under Managed Care: How the Commodification of Health Care Distorts Ethics and Threatens Equity

Describing the U.S. health care system meansdescribing managed care under commercial forces.Managed care creates new moral tension forpractitioners, but more importantly, in its currentform it intensifies the commercialization of healthexpectations and interactions. The largely unregulatedmarketing of health services under managed care hasbeen a major factor in the increasing number ofuninsured citizens, while claims for cost reductionthrough managed care are equivocal. Risk-ratingpractices integral to the current medical marketplacethwart concerns for justice in allocation and createvulnerabilities for almost everyone. Thepolitical-moral concern of the early 1990s for a rightto health care is nowhere in sight.     

Medicaid Managed Care and Health Care for Children

Objective. Many states expanded their Medicaid managed care programs during the 1990s, causing concern about impacts on health care for affected populations. We investigate the relationship between Medicaid managed care enrollment and health care for children.
Data Sources and Measures. Repeated cross-sections of Medicaid-covered children under 18 years of age from the 1996/1997 and 1998/1999 Community Tracking Study Household Surveys ( n =2,602) matched to state-year CMS Medicaid managed care enrollment data. For each individual, we constructed measures of health care utilization (provider and emergency department visits, hospitalizations, surgeries); health care access (usual source of care, unmet medical needs, put-off needed care); and satisfaction (satisfaction overall, with doctor choice, and with last visit).
Study Design. Regression analysis of the relationship between within-state changes in Medicaid managed care enrollment rates and changes in mean utilization, access, and satisfaction measures for children covered by Medicaid, controlling for a range of potentially confounding factors.
Principal Findings. Increases in Medicaid health maintenance organization (HMO) enrollment are associated with less emergency room use, more outpatient visits, fewer hospitalizations, higher rates of reporting having put off care, and lower satisfaction with the most recent visit. Medicaid primary care case management (PCCM) plans are associated with increases in outpatient visits, but also with higher rates of reporting unmet medical needs, putting off care, and having no usual source of care.
Conclusions. Both Medicaid HMO and PCCM plans can have important impacts on health care utilization, access, and satisfaction. Some impacts may be positive (e.g., less ED use and more outpatient provider use), although concern about increasing challenges in access to care and satisfaction is also warranted.     

Healthcare Charges and Use in Commercially Insured Children Enrolled in Managed Care Health Plans in Washington State

Objective: To determine the relative importance of enrollee, physician, medical group, and healthcare plan characteristics as determinants of healthcare use and expenditures in commercially insured children <18 years of age enrolled in managed care health plans. We focused on the effects of age and benefit level, the two most important predictors of cost and utilization in our study of adults. Methods: This study included 67,432 commercially insured children who were between 1 and 18 years of age, and were cared for by 790 primary care physicians, who practiced in 60 medical care groups in Washington State. Plan enrollment and utilization data for 1994 were linked to a survey of medical care groups contracting with three managed care health plans. Benefit level for each enrollee was defined as low, medium, or high and was based on cost sharing by the health plan for hospitalization, outpatient care, and emergency department services. The three outcome measures included estimated total per member per year charges, number of ambulatory visits, and hospital days. Results: In multivariate analysis, enrollee age was the most important determinant of total charges, with younger children incurring higher charges and utilization. For children 5 years and younger, mean total per member per year charges were $617 in the low-benefit category and $878 in the high category (p < .0001). These differences were less apparent for children 6–12 years ($355 versus $420, p = .012), and were not statistically significant for children 13 years and older ($503 versus $552, p = .14). The annual number of visits increased with benefit level for children of all ages. Conclusions: Enrollee age and benefit level were the most important determinants of healthcare use and expenditures in children enrolled in managed care health plans.     

Providing Mental Health Services under Managed Care Arrangements: The Challenges

Every year, volunteers contribute billions of dollars worth of time to the healthcare industry. Despite their contributions, however, little is known about who these volunteers are, what they do, why they volunteer, as well as the costs and benefits they bring to institutions. This articfe examines these and other characteristics of the healthcare volunteer.     

对深化医疗卫生体制改革的思考和评价

随着社会主义市场经济的快速发展,我国各项社会事业的改革和发展也取得了显著进步。但始于20世纪80年代的医疗卫生体制改革,经过近30年的探索和发展,＂看病贵、看病难＂现象仍然存在,并且在一定的范围内表现得相当突出。因此,加强对医疗体制改革的分析研究,对于实现医疗服务领域健康有序发展,满足人民群众基本医疗保障需求,促进我国社会和谐发展具有重要意义。     

“Out of Our Crisis”: The Lack of Long-Term Relationships in the Provision of Managed Care

During the thirty-year period between 1965 and 1995, national healthcare expenditures rose significantly to a point where it became an untenable situation for any payer class: patient, employer, or government. Although managed care was offered as a conceptual framework for providing an opportunity for improving the health of the population while limiting the growth in expenditures, significant concern remained regarding the perceived quality of care and the underlying incentive structures. The author examines current healthcare incentive structures and proposes a structural model associated with long-term contracting to allow managed care to attain its intended objectives of enhanced quality and cost containment.