美國發展管理式照護的經驗與啟示

Managed Care: US Experiences and Lessons for Taiwan

江東亮(Tung-Liang Chiang) ； 胡德偉(Teh-Wei Hu)

《中華公共衛生雜誌》 19卷5期 (2000/10) Pp. 340-355

https://doi.org/10.6288/CJPH2000-19-05-05

摘要

美國發展管理式照護與其醫療費用不斷上漲息息相關。管理式照護的特色在利用種種管理技術將保險財務風險與健康服務提供相互結合，基本上分為兩大類，即健康維護組織(HMO)和擇優特約組織(PPO)。綜合實證研究結果，可以發現：不僅管理式照護的醫療費用顯著低於傳統論量計酬之健康保險，而且管理式照護市場佔率越高，則醫療費用的成長率越低，唯管理式照護的臨床醫療品質是否亞於傳統健康保險並無定論。本文以美國發展管理模式照護經驗為借鏡，建議全民健保改制必須重視深化醫療提供者的財務風險分擔並以增進國民健康為首要目標，同時亦必須注意配套措施的健全以及保障人人有適當醫療保健服務。

關鍵字

管理式照護 ； 醫療費用控制 ； 醫療品質 ； 醫療改革

並列摘要

The evolution of managed care in the United States has been attributed to the repidly increas-ing of health care costs. Characterized as a collection of systems that integrate the financing and delivery of health care services, managed care organizations might be grouped into two major groups:health mantenance organizaton (HMO) and preferred provider organization (PPO). A liter-atural review of empirical studies indicates not onlt that managed care has lower health care costs than traditional fee-for-service health insurance, but also that higher market share of managed care is associated with a lower growth rate of health care costs. Further, there has no conclusive evidence that traditional fee-for-service health insurance provides either consistently better or consistently worse clinical quality of care than managed care. Based on US experiences on man-aged care, we recommend that the National Health Insurance reform in Taiwan should pay more attention to increasing the finacial-risk sharing of health care provider and put pursuing population health as the formost priority. Besides, the infrastructure for reforming the National Health Insur-ance should be well developed and the premise of health care for all should be undersocored.

並列關鍵字

managed care ； health cost control ； quality of care ； health care reforms