美國健康維護組織的近來發展趨勢

Recent Development trends in US Health Maintenance Organizations

林恆慶(Herng-Ching Lin) ； 陳楚杰(Chiu-Chieh Chen)

《護理雜誌》 50卷6期 (2003/12) Pp. 55-61

https://doi.org/10.6224/JN.50.6.55

摘要

促成健康維護組織在二十世紀末期蓬勃興盛的主因，即在於其抑制醫療費用上漲的能力，能力，然而在進入二十一世紀後，健康維護組織是否能繼續有效控制醫療費用並被醫療服務提供者及被保險人所接受，實在值得我們觀察研究。因此，本文首先擬介紹近幾年健康照護體系改革的啟示，以提供衛生專業人員及衛生政策制定者之參考。健康維設組織的最新發展趨勢有(1)廢除守門員制度；(2)大幅提高被保險人自付額；(3)醫療服務提供者解除與健康維護組織的特約；(4)對醫療服務提供者的給付開始大量採用論量計酬制度；(5)法案不利健康維設組織；(6)健康維護組繚得總投保人數開始下滑；(7)開始外包內部資訊系統；(8)提高健康維護組織的保費；(9)以營利為目的的健康維護組織數目大幅成長；(10)更重視預防醫學及(11)健康維護組織開始獲利等十一項最新發展趨勢。建議衛生主管相關單位重新思考論人計酬制度的可行性、提高被保險人部份負擔的費用、強化資訊系統的功能、將醫療給付與醫療品質相結合，以控制醫療費用及提高醫療品質，進而確保國民的健康。

關鍵字

健康維護組織 ； 守門員制度 ； 論人計酬制度

並列摘要

Cost containment is the major reason for the growth of health maintenance organizations (HMOs) at the end of the 20th century. However, at the turn of the 21st century, whether the HMOs can continue to control costs and to be accepted by providers remains unknown. The purposes of this article are to introduce the trends in HMOs' development and to propose recommendations applicable to health professionals in Taiwan. At the beginning of the 21st century, trends in HMOs' development include (1) discarding the gatekeeper system; (2) increases in the amounts of copayments and deductibles; (3) the end of the contracts between HMOs and providers; (4) the use of fee-for-service to replace capitation; (5) anti-HMO legislation; (6) reductions in the number of HMOss enrollment; (7) outsourcing of HMOs' information systems; (8) increases in the premiums of HMOs; (9) an increase in the number of for-profit HMOs; (10) emphasis on preventive medicine; and (11) HMOs' beginning to earn profits. The capitation and gatekeeper systems adopted by traditional HMOs have gradually been abandoned. HMOs are beginning to shift the responsibility for cost containment from providers to consumers. In addition, HMOs are committed to preventive medicine and the upgrading of their information systems. Although it is difficult to predict the trends in HMOs' development, the experience of the HMOs offers lessons for the health delivery system in Taiwan. It is recommended to reconsider the feasibility of capitation system, to shift the responsibility of cost containment from providers to consumers, to reinforce information systems, and to emphasize quality of medical care in Taiwan.

並列關鍵字

health maintenance organization ； capitation ； gatekeeper