外文翻譯----美國(guó)醫(yī)療保健制度-管理式醫(yī)療護(hù)理

1、<p>　　本科畢業(yè)設(shè)計(jì)（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(guó)醫(yī)療保健制度------管理式醫(yī)療護(hù)理</p>

34、<p>　　美國(guó)的私人的和公共的第三方付款人，被以遠(yuǎn)超過(guò)通貨膨脹率且持續(xù)猛增的醫(yī)療保健費(fèi)用所擠壓，他們被勸告說(shuō)這個(gè)“管理式醫(yī)療護(hù)理”與現(xiàn)有的傳統(tǒng)一次一付的醫(yī)療費(fèi)的費(fèi)用趨勢(shì)相比會(huì)產(chǎn)生明顯的節(jié)約款項(xiàng)。他們正在加快努力來(lái)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(yīng)用新約束條件整合成一個(gè)整體。對(duì)于醫(yī)生的關(guān)鍵約束條件來(lái)說(shuō)是他們的臨床決策的自主權(quán)設(shè)置的限制。對(duì)于患者的限制是，他們只能看那些是封閉計(jì)劃或部分對(duì)外開(kāi)放專(zhuān)門(mén)小組的成員醫(yī)生或者

35、那些被選為“受喜愛(ài)”的醫(yī)生?？偟膩?lái)說(shuō)，這些醫(yī)生已經(jīng)同意只提供“必要的“醫(yī)療服務(wù)”來(lái)作為對(duì)規(guī)定費(fèi)用的回報(bào)。</p><p>　　大多數(shù)定義把管理式醫(yī)療護(hù)理描繪成一個(gè)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(gè)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(yù)定的獎(jiǎng)金會(huì)為注冊(cè)會(huì)員提供一套綜合的醫(yī)療護(hù)理服務(wù)；承包者同意接受應(yīng)用和質(zhì)量控制；讓病人使用與這個(gè)計(jì)劃相關(guān)聯(lián)的供應(yīng)商和設(shè)備的經(jīng)濟(jì)誘因；和醫(yī)生的一些財(cái)務(wù)風(fēng)險(xiǎn)的

36、承擔(dān)，這樣的話(huà)，他們的角色根本上從充當(dāng)患者福利的代理人變更為權(quán)衡病人相對(duì)于成本控制之間的需求--------或者，就像Mechanic簡(jiǎn)明扼要的說(shuō)，是從宣傳轉(zhuǎn)移到分配。</p><p>　　因?yàn)檫@些對(duì)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(píng)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(gè)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(gè)較低費(fèi)用的協(xié)定。事實(shí)上這個(gè)新模式已經(jīng)在美國(guó)

37、的醫(yī)療保障制度中快速地顯示出它的主導(dǎo)地位。與此同時(shí)，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(fèi)為基礎(chǔ)來(lái)對(duì)待患者的多專(zhuān)業(yè)類(lèi)的診所直接為那些有預(yù)付款和固定獎(jiǎng)金的支付人提供福利計(jì)劃。</p><p>　　現(xiàn)在運(yùn)作這種管理式醫(yī)療護(hù)理計(jì)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(guó)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(jià)格這個(gè)方向跨出了很重要一步——比如說(shuō)，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(dòng)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(bào)告的主題。傳統(tǒng)的模式中，醫(yī)生享有對(duì)病人的控制權(quán)，作為在醫(yī)療實(shí)踐中資助者的壟斷力量—Freidson所指的“專(zhuān)業(yè)優(yōu)勢(shì)” —現(xiàn)在正遭受改革的威脅。新的限制，以及其他經(jīng)濟(jì)和社會(huì)壓力，鼓勵(lì)醫(yī)生組合成規(guī)模更大的專(zhuān)業(yè)團(tuán)體，在自主權(quán)上為他們自身提供更大的保護(hù)，避免外來(lái)攻擊，以及更規(guī)律的工作環(huán)境。</p><p>　　大部分提供管制護(hù)理的組織被稱(chēng)為保健組織或者優(yōu)先提供者組織。在他們所涉及的項(xiàng)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(hù)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(méi)有擴(kuò)展到東西部海岸和中部。但是管制護(hù)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(yīng)計(jì)劃的人占州總?cè)藬?shù)最高百分比的幾個(gè)州分別是加利福尼亞（33.4%）、馬薩諸塞州（30.9%）、明尼蘇達(dá)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(jī)構(gòu)都不管意識(shí)形態(tài)領(lǐng)域的贊助者，而建議改革健康護(hù)理系統(tǒng)，促進(jìn)管制護(hù)理的擴(kuò)展。私營(yíng)企業(yè)——利益共同團(tuán)如果真的想?yún)⑴c健康護(hù)理改革，是完全可以促進(jìn)它的發(fā)展的——把管制護(hù)理當(dāng)作它現(xiàn)在最大的一個(gè)愿望，希望借此來(lái)控制成本并通過(guò)私人銷(xiāo)售和付款來(lái)控制對(duì)管制護(hù)理的主導(dǎo)權(quán)。最近，甚至是美國(guó)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(rèn)美國(guó)醫(yī)藥組織：“慢慢才認(rèn)識(shí)到并接受這些行為模式的合法地位和好處”。陶德承認(rèn)健康護(hù)理組織和美國(guó)其他的健康組織的成員對(duì)社會(huì)所作的積極貢獻(xiàn)。</p><p>　　隨著管制護(hù)理的進(jìn)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(gè)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(hù)理的中心。14個(gè)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(cái)務(wù)公司】，美國(guó)

43、快遞公司的附屬公司，曾經(jīng)發(fā)起投標(biāo)競(jìng)爭(zhēng)，指定健康機(jī)構(gòu)的一個(gè)財(cái)團(tuán)把他們125000員工和下屬輸送到該機(jī)構(gòu)中接受健康護(hù)理。這些財(cái)團(tuán)包括【梅奧診所，帕克尼科萊特醫(yī)療診所，團(tuán)體醫(yī)療，當(dāng)?shù)氐囊患襀MO】其他參加最終競(jìng)標(biāo)的是明尼蘇達(dá)的藍(lán)十字和藍(lán)盾計(jì)劃。雖然聯(lián)合企業(yè)的購(gòu)買(mǎi)力是健康護(hù)理財(cái)團(tuán)形成的最主要刺激因素，但是對(duì)于獎(jiǎng)勵(lì)提供高質(zhì)量健康護(hù)理的下屬的決定，聯(lián)盟里只有部分企業(yè)同意。財(cái)團(tuán)將通過(guò)一個(gè)新成立的機(jī)構(gòu)完善某行動(dòng)指南，該行動(dòng)目標(biāo)是減少方式多樣化和取消不必

44、要的護(hù)理。質(zhì)量評(píng)估主要依據(jù)整體的護(hù)理水平，如員工情況、病人的滿(mǎn)意度等，而不是通常情況下用于評(píng)價(jià)醫(yī)院等級(jí)的死亡率和并發(fā)率。</p><p>　　管理式醫(yī)療護(hù)理計(jì)劃類(lèi)型</p><p>　　管理式醫(yī)療護(hù)理項(xiàng)目看起來(lái)好像無(wú)止盡地變化，但是從本質(zhì)上來(lái)說(shuō)有兩種類(lèi)型的健康維護(hù)組織體：集團(tuán)或員工模式，在這種模式下各種醫(yī)生團(tuán)體簽合約來(lái)提供服務(wù)，還有一種獨(dú)立執(zhí)業(yè)協(xié)會(huì)，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(cè)進(jìn)一個(gè)健康計(jì)劃來(lái)治療病人。IPA模式在過(guò)去幾十年里是HMO變革中成長(zhǎng)最快的。在一個(gè)IPA里，一個(gè)健康計(jì)劃要和個(gè)體醫(yī)生或團(tuán)體以人均協(xié)議價(jià)簽訂合約來(lái)提供護(hù)理，這個(gè)價(jià)格可以是穩(wěn)定的定金，或者是一次一付的價(jià)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(fèi)為基礎(chǔ)為病人看病，同樣的，同時(shí)也可以與１個(gè)或者２個(gè)健康維護(hù)組織簽合同。</p><p>　　在一個(gè)集團(tuán)型的健康維護(hù)組織中，醫(yī)生們經(jīng)常聚集在獨(dú)立的

46、醫(yī)療團(tuán)體里（就像在凱撒–Permanente醫(yī)療護(hù)理項(xiàng)目提供服務(wù)的12個(gè)這樣的團(tuán)體）。在一個(gè)員工模式計(jì)劃中，醫(yī)生是雇員而且沒(méi)有被組織進(jìn)單獨(dú)的醫(yī)療團(tuán)體中去。盡管如此，即使在員工型健康維護(hù)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(qiáng)是顯而易見(jiàn)的，去年11月，當(dāng)醫(yī)生職員們?cè)诓ㄋ诡D參加的哈佛社區(qū)健康計(jì)劃時(shí)就強(qiáng)迫了他們長(zhǎng)期的首席執(zhí)行官辭職，因?yàn)樗麄兛棺h他的管理模式。最終的對(duì)抗是被新頒布的尋求把收入與病人拜訪(fǎng)數(shù)量限額掛鉤的生產(chǎn)

47、力標(biāo)準(zhǔn)而激起的。</p><p>　　鑒于越來(lái)越多的細(xì)節(jié)管理有償服務(wù)由第三方實(shí)踐，集團(tuán)型的健康維護(hù)組織模式具有兩個(gè)重要特點(diǎn)：第一，醫(yī)生在醫(yī)療實(shí)踐中有在規(guī)定費(fèi)用基礎(chǔ)上提供全面護(hù)理的責(zé)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(qǐng)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(lái)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(bào)，集團(tuán)型的健康維護(hù)組織通

48、過(guò)仔細(xì)選擇醫(yī)生的數(shù)量和登記在冊(cè)的患者嚴(yán)密控制護(hù)理的種類(lèi)和患者數(shù)量，初級(jí)保健醫(yī)生充當(dāng)看門(mén)人。保健組織從而確保獲得足夠的初級(jí)保健和維持其全面運(yùn)轉(zhuǎn)的專(zhuān)家門(mén)診時(shí)間表。</p><p>　　醫(yī)生們勉強(qiáng)擔(dān)任這個(gè)守門(mén)的角色因?yàn)樗鼊?chuàng)造了與病人和專(zhuān)家的潛在沖突。盡管如此，在HMO中初級(jí)護(hù)理醫(yī)生的關(guān)鍵作用是把他們放在比在原來(lái)傳統(tǒng)系統(tǒng)中的情況下與專(zhuān)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(hù)理計(jì)劃發(fā)現(xiàn)招募初級(jí)護(hù)理醫(yī)生變得越

49、來(lái)越難，因?yàn)橛?xùn)練項(xiàng)目持續(xù)強(qiáng)調(diào)醫(yī)學(xué)專(zhuān)業(yè)，而不管在HMO市場(chǎng)中對(duì)于對(duì)面手的強(qiáng)烈需求。</p><p>　　其他形式的管理式醫(yī)療護(hù)理包括PPO還有最新的管理式醫(yī)療護(hù)理變異——點(diǎn)服務(wù)計(jì)劃。在這種計(jì)劃下面，PPO與那些同意通過(guò)提供醫(yī)療服務(wù)然后按照打折的費(fèi)用清單來(lái)收費(fèi)的醫(yī)生專(zhuān)門(mén)小組或醫(yī)生網(wǎng)絡(luò)簽訂合約。那些注冊(cè)者們會(huì)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(xiǎn)公司就是由雇主組合在首選列表上的醫(yī)生的話(huà)，但是這