外文翻譯----美國醫(yī)療保健制度-管理式醫(yī)療護理

1、<p>　　本科畢業(yè)設(shè)計（論文）</p><p>　　外 文 翻 譯</p><p><b>　　原文</b></p><p>　　The American Health Care System — Managed Care</p><p>　　America's private and publ

2、ic 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 c

3、ost 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 a

4、nd patients. The key constraint for doctors </p><p>　　Most definitions characterize managed care as a system that integrates the financing and delivery of appropriate medical care by means of the following f

5、eatures: 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 c

6、ontracting providers agree to accept; financial incentives for patients to use the providers and facilities associated with the</p><p>　　Because these features circumscribe the freedom of physicians to pract

7、ice 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

8、 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 network</p>

9、<p>　　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 Clin

10、ic 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—Nicolle

11、t Clinic in Minneapolis, the Scott and White Clinic in Temple, Texas, and the</p><p>　　The emergence of managed care is the subject of this report — my third on the American health care system. It represents

12、 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 physi

13、cians have enjoyed as ministers to the sick and as recipients of a state grant of monopoly power in medical practice — what Freidson calls "professional dominan</p><p>　　Most organizations that provide

14、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 organizati

15、on 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,

16、is here to stay, despite the</p><p>　　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 bu

17、siness — 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 dominan

18、ce of the health system by private providers and payers. Recently, even the American Medical Association, in th</p><p>　　As proposals for managed care evolve, new alliances are formed among major stakeholder

19、s 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 Corpo

20、ration, 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 instituti</p><p>　　Typ

21、es of Managed Care Plans</p><p>　　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

22、, 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

23、decade. In an IPA, a health plan contracts with individual practitioners or groups to provide care at a neg</p><p>　　In a group-model HMO, physicians usually aggregate in independent medical groups (like the

24、 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-mode

25、l 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 Bosto</p><p>　　Given t

26、he 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 comprehensiv

27、e 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 relatio

28、ns with physicians, are employing doctors as medical </p><p>　　Many plans incorporate financial incentives into their agreements with physicians in an attempt to influence the frequency with which primary ca

29、re 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

30、 specialists. Nevertheless, the key role of primary care doctors in HMOs places them in positions of greater authority in relation to sp</p><p>　　Other forms of managed care include the PPO and the latest va

31、riant 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. Enroll

32、ees 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 car&

33、lt;/p><p>　　Source: John K. Iglehart.The American Health Care System — Managed Care[J]. N Engl J Med ,1992（09）</p><p><b>　　譯文：</b></p><p>　　美國醫(yī)療保健制度------管理式醫(yī)療護理</p>

34、<p>　　美國的私人的和公共的第三方付款人，被以遠超過通貨膨脹率且持續(xù)猛增的醫(yī)療保健費用所擠壓，他們被勸告說這個“管理式醫(yī)療護理”與現(xiàn)有的傳統(tǒng)一次一付的醫(yī)療費的費用趨勢相比會產(chǎn)生明顯的節(jié)約款項。他們正在加快努力來促成將醫(yī)療支付與融資和在醫(yī)生與患者之間的接觸應用新約束條件整合成一個整體。對于醫(yī)生的關(guān)鍵約束條件來說是他們的臨床決策的自主權(quán)設(shè)置的限制。對于患者的限制是，他們只能看那些是封閉計劃或部分對外開放專門小組的成員醫(yī)生或者

35、那些被選為“受喜愛”的醫(yī)生?？偟膩碚f，這些醫(yī)生已經(jīng)同意只提供“必要的“醫(yī)療服務(wù)”來作為對規(guī)定費用的回報。</p><p>　　大多數(shù)定義把管理式醫(yī)療護理描繪成一個將融資和提供有下列特征的醫(yī)療處理方式相融合的這么一個系統(tǒng)：簽約的被選擇的醫(yī)生和醫(yī)院，他們通常為了每月預定的獎金會為注冊會員提供一套綜合的醫(yī)療護理服務(wù)；承包者同意接受應用和質(zhì)量控制；讓病人使用與這個計劃相關(guān)聯(lián)的供應商和設(shè)備的經(jīng)濟誘因；和醫(yī)生的一些財務(wù)風險的

36、承擔，這樣的話，他們的角色根本上從充當患者福利的代理人變更為權(quán)衡病人相對于成本控制之間的需求--------或者，就像Mechanic簡明扼要的說，是從宣傳轉(zhuǎn)移到分配。</p><p>　　因為這些對醫(yī)生自主行醫(yī)自由限定的特征，他們明確地從醫(yī)生那邊收到了褒貶不一的評論。盡管如此，至少還有一半的執(zhí)業(yè)醫(yī)生已經(jīng)參與到至少一個管理式醫(yī)療協(xié)議，他們已經(jīng)接受給有一定流量保證的患者一個較低費用的協(xié)定。事實上這個新模式已經(jīng)在美國

37、的醫(yī)療保障制度中快速地顯示出它的主導地位。與此同時，隨著這些新網(wǎng)絡(luò)的發(fā)展，一些現(xiàn)存的以前只以一次一付醫(yī)療費為基礎(chǔ)來對待患者的多專業(yè)類的診所直接為那些有預付款和固定獎金的支付人提供福利計劃。</p><p>　　現(xiàn)在運作這種管理式醫(yī)療護理計劃的醫(yī)療組織診所，他們可以產(chǎn)生30%到40%的所有的病人業(yè)務(wù)收入，包括在伊利諾斯州厄巴納市的卡爾診所，威斯康辛州麥迪遜市的迪安診所，賓夕法尼亞州丹維爾的蓋辛格診所，威斯康辛州馬什

38、菲爾德的馬什菲爾德診所，新奧爾良市的Ochsner診所，加利福尼亞州帕洛阿爾托的帕洛阿爾托診所，明尼阿波利斯市的尼克萊公園診所，德克薩斯州坦普爾斯科特與懷特診所，還有西雅圖市的維吉尼亞 梅森診所?？死蛱m診所還有其他許多全國的醫(yī)院已經(jīng)朝著為“捆綁式”醫(yī)療服務(wù)提供第三方固定價格這個方向跨出了很重要一步——比如說，一筆包括所有服務(wù)（由醫(yī)生，醫(yī)院和附屬人員提供）要求履行冠狀動脈繞道手術(shù)或者心臟或腎臟移植。</p><p&g

39、t;　　管理式醫(yī)療的出現(xiàn)是本報告的主題。傳統(tǒng)的模式中，醫(yī)生享有對病人的控制權(quán)，作為在醫(yī)療實踐中資助者的壟斷力量—Freidson所指的“專業(yè)優(yōu)勢” —現(xiàn)在正遭受改革的威脅。新的限制，以及其他經(jīng)濟和社會壓力，鼓勵醫(yī)生組合成規(guī)模更大的專業(yè)團體，在自主權(quán)上為他們自身提供更大的保護，避免外來攻擊，以及更規(guī)律的工作環(huán)境。</p><p>　　大部分提供管制護理的組織被稱為保健組織或者優(yōu)先提供者組織。在他們所涉及的項目范圍內(nèi)

40、，有各種相關(guān)的多樣化服務(wù)，這反映了管制護理組織正在快速發(fā)展。雖然大致上還只是區(qū)域性的的現(xiàn)象，還沒有擴展到東西部海岸和中部。但是管制護理，不管醫(yī)生的質(zhì)疑，已經(jīng)以這樣或那樣的形式出現(xiàn)了。已經(jīng)加入保健組織的人數(shù)最多和加入相應計劃的人占州總?cè)藬?shù)最高百分比的幾個州分別是加利福尼亞（33.4%）、馬薩諸塞州（30.9%）、明尼蘇達州（28.3%）、俄勒岡州（26.4%）、亞利桑那州（24.2%）、夏威夷（22.9%）、威斯康辛州（22.5%）、馬里

41、蘭島（22.3%）、科羅拉多州（21.9%）、康涅狄格州（20.7%）。</p><p>　　大部分立法機構(gòu)都不管意識形態(tài)領(lǐng)域的贊助者，而建議改革健康護理系統(tǒng)，促進管制護理的擴展。私營企業(yè)——利益共同團如果真的想?yún)⑴c健康護理改革，是完全可以促進它的發(fā)展的——把管制護理當作它現(xiàn)在最大的一個愿望，希望借此來控制成本并通過私人銷售和付款來控制對管制護理的主導權(quán)。最近，甚至是美國醫(yī)藥組織，也在六月由執(zhí)行副主席陶德博士以演

42、講的形式承認美國醫(yī)藥組織：“慢慢才認識到并接受這些行為模式的合法地位和好處”。陶德承認健康護理組織和美國其他的健康組織的成員對社會所作的積極貢獻。</p><p>　　隨著管制護理的進一步發(fā)展，大的利益相關(guān)者為了追求更大的利益而結(jié)成聯(lián)盟。最近，其中有一個最有意思的發(fā)展于6月30日發(fā)生在明尼阿波利斯市——管制護理的中心。14個明尼阿波利斯市的公司，包括【戴頓哈德遜公司，通用公司，諾韋斯特公司，IDS財務(wù)公司】，美國

43、快遞公司的附屬公司，曾經(jīng)發(fā)起投標競爭，指定健康機構(gòu)的一個財團把他們125000員工和下屬輸送到該機構(gòu)中接受健康護理。這些財團包括【梅奧診所，帕克尼科萊特醫(yī)療診所，團體醫(yī)療，當?shù)氐囊患襀MO】其他參加最終競標的是明尼蘇達的藍十字和藍盾計劃。雖然聯(lián)合企業(yè)的購買力是健康護理財團形成的最主要刺激因素，但是對于獎勵提供高質(zhì)量健康護理的下屬的決定，聯(lián)盟里只有部分企業(yè)同意。財團將通過一個新成立的機構(gòu)完善某行動指南，該行動目標是減少方式多樣化和取消不必

44、要的護理。質(zhì)量評估主要依據(jù)整體的護理水平，如員工情況、病人的滿意度等，而不是通常情況下用于評價醫(yī)院等級的死亡率和并發(fā)率。</p><p>　　管理式醫(yī)療護理計劃類型</p><p>　　管理式醫(yī)療護理項目看起來好像無止盡地變化，但是從本質(zhì)上來說有兩種類型的健康維護組織體：集團或員工模式，在這種模式下各種醫(yī)生團體簽合約來提供服務(wù)，還有一種獨立執(zhí)業(yè)協(xié)會，在這種模式下醫(yī)生們留在他們自己的辦公室里

45、，但是同意注冊進一個健康計劃來治療病人。IPA模式在過去幾十年里是HMO變革中成長最快的。在一個IPA里，一個健康計劃要和個體醫(yī)生或團體以人均協(xié)議價簽訂合約來提供護理，這個價格可以是穩(wěn)定的定金，或者是一次一付的價格。醫(yī)生們可以維持他們自己的辦公室，可以繼續(xù)以一次一付醫(yī)療費為基礎(chǔ)為病人看病，同樣的，同時也可以與１個或者２個健康維護組織簽合同。</p><p>　　在一個集團型的健康維護組織中，醫(yī)生們經(jīng)常聚集在獨立的

46、醫(yī)療團體里（就像在凱撒–Permanente醫(yī)療護理項目提供服務(wù)的12個這樣的團體）。在一個員工模式計劃中，醫(yī)生是雇員而且沒有被組織進單獨的醫(yī)療團體中去。盡管如此，即使在員工型健康維護組織中，醫(yī)生們是管理層必須考慮的一股力量。醫(yī)生們能形成的力量有多強是顯而易見的，去年11月，當醫(yī)生職員們在波斯頓參加的哈佛社區(qū)健康計劃時就強迫了他們長期的首席執(zhí)行官辭職，因為他們抗議他的管理模式。最終的對抗是被新頒布的尋求把收入與病人拜訪數(shù)量限額掛鉤的生產(chǎn)

47、力標準而激起的。</p><p>　　鑒于越來越多的細節(jié)管理有償服務(wù)由第三方實踐，集團型的健康維護組織模式具有兩個重要特點：第一，醫(yī)生在醫(yī)療實踐中有在規(guī)定費用基礎(chǔ)上提供全面護理的責任，任何監(jiān)督工作由同行組織，而不是外在的管理人員。許多成功的IPA，尋求與醫(yī)生建立更具建設(shè)性的和永久的關(guān)系，聘請醫(yī)生作為醫(yī)務(wù)主任行使同行間審查的職能，希望以此來緩沖從業(yè)人員與管理層的關(guān)系。第二，作為這種自由的回報，集團型的健康維護組織通

48、過仔細選擇醫(yī)生的數(shù)量和登記在冊的患者嚴密控制護理的種類和患者數(shù)量，初級保健醫(yī)生充當看門人。保健組織從而確保獲得足夠的初級保健和維持其全面運轉(zhuǎn)的專家門診時間表。</p><p>　　醫(yī)生們勉強擔任這個守門的角色因為它創(chuàng)造了與病人和專家的潛在沖突。盡管如此，在HMO中初級護理醫(yī)生的關(guān)鍵作用是把他們放在比在原來傳統(tǒng)系統(tǒng)中的情況下與專家有關(guān)的更大職權(quán)的位子上。具有諷刺意味的是，管理式醫(yī)療護理計劃發(fā)現(xiàn)招募初級護理醫(yī)生變得越

49、來越難，因為訓練項目持續(xù)強調(diào)醫(yī)學專業(yè)，而不管在HMO市場中對于對面手的強烈需求。</p><p>　　其他形式的管理式醫(yī)療護理包括PPO還有最新的管理式醫(yī)療護理變異——點服務(wù)計劃。在這種計劃下面，PPO與那些同意通過提供醫(yī)療服務(wù)然后按照打折的費用清單來收費的醫(yī)生專門小組或醫(yī)生網(wǎng)絡(luò)簽訂合約。那些注冊者們會被提供更好的覆蓋范圍的醫(yī)療服務(wù)，如果他們同意看那些通常不是由保險公司就是由雇主組合在首選列表上的醫(yī)生的話，但是這