【争议】医院合并导致医疗费用增加？

威斯康辛大学公共与卫生学院David Rakel 博士

JAMA最近一期的话题（Who Benefits From Health System Change?）关注了医疗服务的价格和竞争。其中两篇文章特别提及了美国的社区医疗，两篇文章都提醒我们到底是否得到了为之买单的东西。如果我们是为健康买单，那么我们理应收获更多健康。如果我们在疾病护理方面投资过多，我们或许会怂恿更多的疾病发生。那么问题非常简单，如果我们希望我们的社会更健康，我们应该付出什么样的代价才能达成愿望？

Bruce Landon的观点是“向以患者为中心的医疗之家（PCMH）进行结构性支付” ，该报告指出，社区医疗体系在整体花费中仅占5%~7%。他提议，如果我们希望将我们的系统转向为健康，我们不仅需要在社区医疗和PCMH中投入更多，我们还需使我们的支付更加有战略性。为摒弃“头疼医头”的模式，我们要采取对该模式无鼓励作用的支付优先顺序，因为该模式通常造成更多大的浪费和较差的结果。

Landon在其文章中提出了一种“每月定员定量”的支付模式，这使得包含最亟需专业人员的跨学科团队得以建立，以满足社区的医疗需求。之后这些PCMH团队获得资金，鼓励了除面对面访视之外其他联络人群的方法实施。这些方法可包括电子邮件、电话、群组访视和行为矫正，而后者是健康的主要决定因素。他指出阻碍这一方法实施的主要问题是按诊疗服务付费的支付模式继续实施，以及简单地从收入最高的项目中获得报酬。

David Cutler也发表了一篇题为“谁在医疗体系改革中获益？”的文章。他在文中报道了医院合并的上升势头，并指出医院正在从非营利性逐渐转向营利性的状态。而这一改变的主要推动因素是稳定现金流。他表示，医院合并后医疗花费会增高。合并通常使得医院以及医院员工的财政经济状况更为稳定，但这或许并不能使社区的健康状况提高。Cutler还指出：“与非营利性医院相比，营利性医院更可能在盈利服务方面进行投资，而冷落非盈利性服务项目。”

这些因素使得我们陷入了购买与所得的两难之境，促使我们开始审视我们的医学道德目标。是利润驱动使命还是使命驱动利益？我们目前能够掌握的机会就是让医疗事业有价值。

 

The recent issue of JAMA is dedicated to the price of and competition in healthcare. Two articles are particularly relevant to primary care in America, and both remind us that we get what we pay for. If we pay for health, we will get more health. If disease care gets more investment, we will encourage more disease. The simple question is, if we want more health for our communities, how do we pay for what we want?

Bruce Landon in his viewpoint titled, “Structuring Payments to Patient-Centered Medical Homes” (PCMH)1 reports that the primary care system only accounts for 5% to 7% of overall spending. He proposes that, if we are going to shift our system toward health, we not only need to invest more in primary care and PCMHs, but we have to be more strategic in what we pay for. In order to get out of the find-it–fix-it model, we have to adopt payment priorities that don’t encourage more finding and fixing, an approach that is often associated with more waste and poor outcomes.

In his viewpoint article, Landon suggests a “per member–per month” payment model, which will allow for the creation of interdisciplinary teams that include the professionals who are needed most to address the health needs of a community. These PCMH teams will then have finances to encourage methods for touching lives beyond the face-to-face visit. These may include e-mail, phone calls, group visits, and behavior modifications that are the main determinants of health. The primary barrier he cites as preventing this approach is the continuation of the fee-for-service payment model and simply rewarding what makes the most money.

David Cutler also wrote a viewpoint titled, “Who Benefits from Health System Change?”2 He reports on a growing trend of hospital consolidation and moving from not-for-profit to for-profit status. The main impetus for this shift is to stabilize cash flow. He shows that, when hospitals consolidate, spending increases. Consolidation often results in more financial stability for hospitals and those employed by them but this may not translate to healthier communities. Cutler also points out that “… for-profit hospitals are more likely to invest in profitable services and to avoid unprofitable services than are not-for-profit hospitals.”

These factors leave us in a quandary relative to paying for what we want, and they encourage us to check on our moral purpose in medicine. Does margin drive mission or does mission drive margin? The opportunity we have is to make health profitable.

JAMA : The Journal of the American Medical Association

Who Benefits From Health System Change?

JAMA 2014 Oct 22;312(16)1639-1641, DM Cutler

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.

This abstract is available on the publisher's site.

Access this abstract now

Copyright © 2014 Elsevier Inc. All rights reserved.