在美国的医疗制度改制中整合公共健康和个人护理外文翻译文档格式.docx

在美国的医疗制度改制中整合公共健康和个人护理外文翻译文档格式.docx

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IntegratingPublicHealthandPersonalCareinaReformed

USHealthCareSystem

出处:

AmericanJournalofPublicHealth

作者:

Chernichovsky,Dov,Leibowitz,ArleenARigotti,NancyA.

原文：

IntegratingPublicHealthandPersonalCareinaReformedUSHealthCareSystem

THEUNITEDSTATESHASTHEmosttechnologicallyintensivemedicalpracticeintheworld.Italsospendsmorethananyothernationonmedicalcare,buthealthoutcomesintheUnitedStatesareinferiortothoseinmostotherdevelopednations.Thisinefficiency—spendingmorewithpoorerresults—stemspartlyfromfailuretoprovideeffectiveaccesstomedicalcaretoasubstantialshareofthepopulation.LackofaccessleadstowiderdisparitiesinhealthintheUnitedStatesthanareexperiencedbythepopulationsofotherdevelopednations.Thefragmenteddeliverysystemalsoleadstocostshifting（insurers'

attemptstotransfercoststootherpayers）,administrativewaste,andanimbalancebetweenspendingonmedicalcareandspendingonpopulationhealthinitiatives.

ThereisgeneralagreementthattheUShealthcaresystemshouldbemoreefficientaswellasmoreequitable.Mostcomprehensiveproposalsforreformingthesystemrecognizetheneedforuniversalcoveragethatisindependentofemploymentstatus,disabilitystatus,orage,althoughsomewouldcontinuetorelyonemployerstocollecthealthinsurancepayments.Althoughuniversalinsuranceisimportant,itisnottheonlyurgentissue.Areformedsystemshouldintegratepersonalpreventiveandtherapeuticcarewithpublichealthandshouldincludepopulation-widehealthinitiatives.CoordinatingpersonalmedicalcarewithpopulationhealthwillrequireamorestructuredsystemthanhaseverexistedintheUnitedStates.

Wearguethatareformedhealthcaresystemnotonlyshouldprovidehealthinsurancecoverageforallbutshouldalsobeorganizedandfundedtotakeadvantageofnewknowledgeaboutmedicalandnonmedicaldeterminantsofhealth.Thishealthtrustsystem（HTS）would

（1）assessthecostofhealthinsuranceequitably,

（2）promoteefficiencybyreducingfragmentationandrelyingoncompetitivemarkets,（3）allowcoordinationofspendingonpopulationhealthandpersonalmedicalcare,（4）accommodateheterogeneouspreferences,and（5）buildonexistingAmericanhealthinsuranceandproviderinstitutions,informedbyinternationalexperience.

UNDERINVESTMENTINPUBLICHEALTH

UnderinvestmentinpreventivecareandpopulationhealthpersistsintheUnitedStatesdespitethegrowingevidencethatsuchinvestmentshavegreatpotentialtoimprovehealth.Highratesofreturnhavebeendemonstratedforcommunity-levelinterventionstoreducethehigh-riskbehaviorsthatpromotechronicdiseases,whichaccountfortwothirdsofalldeathsintheUnitedStatesandahigherpercentageofdeathsamongthemostdisadvantagedgroups.Thesechronicdiseasesareoftenassociatedwithhigh-risklifestyleconsumptionchoices（smoking,drinking,andpoordiet）,whichmaybemoreeffectivelyavertedbypolicyinterventionsinthecommunityandearlyinthelifecoursethanalteredbylaterinterventionswithinthemedicalcaresector.Forexample,2structuralinterventionsinCalifornia—levyingacigarettetaxandbanningindoorsmokinginpublicplaces—resultedindramaticdeclinesinsmoking,followedbydeclinesintheratesoflungcancerandheartdiseaseinthestate.Disadvantagedpopulations,whichbearthegreatestburdenofchronicdisease,standtobenefitmostfrompublicandpopulationhealthinterventions.

ThecurrentfinancingstructureandorganizationofcareintheUnitedStatesprovidestrongincentivestotreatillnessafteritoccursratherthantoinvestinprevention.Healthinsurancepoliciesalsoencourageasuboptimalmixofservices,relyingonexpensive,andoftenredundant,technology,withinadequatecoverageforpreventivecare.Thefragmentedhealthcarefinancingsystemalsowastesresourcesthroughcostshiftingandexcessiveadministrativcosts.

Tocreateamoreeffectiveandefficienthealthcaresystem,theUnitedStatesshouldcapitalizeoncurrenthealthreformeffortsthataimtomakeaccesstocareuniversalandcontainitscostswithinanintegratedhealthsystem.Thiswillrequireredesigningthesystemtoallocateresourcestotherapeuticcareandtopopulationhealthinabalancethatmorecloselyreflectstheirabilitiestopromotehealthandtherebyincreasesthehealthreturnsgeneratedbyhealthexpenditures.

ARCHITECTUREOFANINTEGRATEDHEALTHSYSTEM

Inadditiontoprovidinguniversalaccessandequitablefunding,areformedhealthsystemshouldstriveto

（1）increaseefficiencybyformulatingcoherentpolicywithappropriateincentives,information,andsupportinginfrastructure;

（2）fostercoordinationofpublic,population,andprivatehealthcareatthelocallevel;

（3）imposefinancialdiscipline,orcostcontainment;

and（4）encouragechoicefor,andresponsivenessto,clients.

Weproposeahealthsystemconsistingofanationalindependentbody,anationalhealthtrust（NHT）,whichwouldcoordinateregional-orstate-basedaffiliates-regionalhealthtrusts（RHTs）—andwhichwouldformacoherentnationalstructuretoensureorderlyandefficientoperation.

ADVANTAGESANDSAFEGUARDSINAHEALTHTRUSTSYSTEM

MostofthepoliticaldiscussionofhealthcarereformintheUnitedStateshascenteredonthecrisisinhealthcarecostsandtherelatedlackofaccesstoqualitymedicalcare.Theseimportantissuesare,however,partofalargerproblem:

thecurrentinabilityoftheUnitedStatestocareforthehealthforitspopulationefficientlybecauseitlacksacoherentsystemforfinancingandprovidingmedicalcareaswellasamechanismforallocatingresourcesbothtomedicalcareforindividualsandtopublicandpopulationhealthinitiatives.Ourproposalwouldcreatealogical,nestedorganizationthatwouldbuildonthefoundationsofthecurrentUShealthcaresystem.

Ourproposedstructurewouldhaveseveralfundamentaladvantages.Itcouldensurethathealthspendingwouldbetargetedtoitsmostproductiveusesandthatdecisionmakerscouldtakeamoreappropriatelong-termperspectiveonthehealthofAmericansbyinvestingnowinpreventionandhealthpromotion,whilealsoprovidingmedicalcareequitablytoallAmericans.Suchasystemwouldreducebillingcostsandadministrativewastebyeliminatingmedicalunderwriting,duplicatecoverage,andcostshifting.Inaddition,therebalancingofpersonalandpopulationhealthinitiativesandthedevelopmentanddisseminationofinformationontheconstituentsofcost-effectivehealthcarewouldacttocontrolcosts.

Universality

TheproposedHTSpromiseseveryAmericanaportable,basicpackageofcorebenefits,independentofemploymentstatus,whichwouldcomprisepersonalandpopulationservicesforpreventionandtreatment.ThisHTSwouldmainstreamthecareoflow-incomepersonscurrentlyenrolledincategoricalprogramsforpeoplewithparticularcharacteristics,suchasMedicaidforthedisabled,theStateChildren'

sInsuranceProgramforchildren,orRyanWhiteCareActprogramsfortreatmentofHIV/AIDS.UnderanHTS,avoucherwouldsupportenrollmentofthecategoricallyeligibleinanyplanofferedintheirarea,therebyexpandingtheirchoiceofproviders.Plans'

incentivestofavorlow-riskapplicantswouldbemitigatedbyreceiptofarisk-adjustedcapitationpaymentthatwouldbeindependentoftheenrolleecontribution.

Universalitydoesnotimplyuniformcare,eitherincontentorinform.InanHTS,individualswouldhaveagreaterchoiceofprovidersthaniscurrentlyavailabletomostAmericans.Althougheveryonewouldbeguaranteedthesamecorebenefits,individualscouldsatisfydiversepreferencesbysupplementingthecorebenefitswiththeirpersonalfunds,withinthesamehealthsystem,muchasFEHBPenrolleescurrentlydo.Althoughthisarrangementmayraisethespecterofa2-tieredsystem,supplementationhasnotbeenamajorissueintheFEHBP.Someindividualsnowhavebenefitsthatexceedthecorebenefitsthatcanbeprovideduniversally.Allowingthemtosupplementthecorebenefitpackageandkeeptheircurrenthealthinsuranceiftheypreferitmaybenecessaryforpoliticalacceptability.

TheorganizationofhealthcoverageintheNetherlandsprovidesaprototypeforthetypeofsystemweadvocate.Dutchresidentsreceivearisk-adjustedvoucherforabasicbenefitpackage,purchasedfromcompetinginsurers.Theycansupplementthecorebenefitsthroughtheirownresourcesorfundingfromtheiremployer.TheNetherlandscombatsrisksegmentationbycompensatingplanswithhighlydevelopedrisk-adjustedcapitationpayments.

Governance

AnHTSwouldfinanceuniversalcoveragethroughmandatedcontributionsbutwouldrelyonprivateproviderstosupplymedicalcare.Itwouldnotresemblesocializedmedicine.Thefederalgovernmentwouldinfactremaindistantfromtheorganizationandmanagementofthesystem,letalonethemanagementandprovisionofcare.However,toensurethatplansassumeafiduciaryroleonbehalfofthepublic,theNHTandRHTswouldhavetocarefullymonitorthathealthplansareprovidingappropriatecareandnotengaginginriskselection.

ThebasicnatureofUShealthcareprovisionwouldremainintact,andallAmericansenrolledinaninsuranceplanofanytypecouldcontinuetoreceivecareinthesamemannertheyreceiveittoday,althoughfundingsourceswouldchange.Theproposedplanwouldrelyheavilyonprivate,nongovernmentalentitiestoinsurethecorebenefitsaswellastooffersupplementalinsurance.Specializedgovernment-runprogramssuchasMedicareandMedicaidcouldremaininplaceandfunctionashealthplans,a