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Word文档格式.docx
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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Word文档格式.docx
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IntegratingPublicHealthandPersonalCareinaReformedUSHealthCareSystem
出处:
AmericanJournalofPublicHealth
作者:
Chernichovsky,Dov,Leibowitz,ArleenARigotti,NancyA
原文:
IntegratingPublicHealthandPersonalCareinaReformedUSHealthCareSystem
THEUNITEDSTATESHASTHEmosttechnologicallyintensivemedicalpracticeintheworld.Italsospendsmorethananyothernationonmedicalcare,buthealthoutcomesintheUnitedStatesareinferiortothoseinmostotherdevelopednations.Thisinefficiency?
spendingmorewithpoorerresults?
stemspartlyfromfailuretoprovideeffectiveaccesstomedicalcaretoasubstantialshareofthepopulation.LackofaccessleadstowiderdisparitiesinhealthintheUnitedStatesthanareexperiencedbythepopulationsofotherdevelopednations.Thefragmenteddeliverysystemalsoleadstocostshiftinginsurers'
attemptstotransfercoststootherpayers,administrativewaste,andanimbalancebetweenspendingonmedicalcareandspendingonpopulationhealthinitiatives.
ThereisgeneralagreementthattheUShealthcaresystemshouldbemoreefficientaswellasmoreequitable.Mostcomprehensiveproposalsforreformingthesystemrecognizetheneedforuniversalcoveragethatisindependentofemploymentstatus,disabilitystatus,orage,althoughsomewouldcontinuetorelyonemployerstocollecthealthinsurancepayments.Althoughuniversalinsuranceisimportant,itisnottheonlyurgentissue.Areformedsystemshouldintegratepersonalpreventiveandtherapeuticcarewithpublichealthandshouldincludepopulation-widehealthinitiatives.CoordinatingpersonalmedicalcarewithpopulationhealthwillrequireamorestructuredsystemthanhaseverexistedintheUnitedStates.
Wearguethatareformedhealthcaresystemnotonlyshouldprovidehealthinsurancecoverageforallbutshouldalsobeorganizedandfundedtotakeadvantageofnewknowledgeaboutmedicalandnonmedicaldeterminantsofhealth.ThishealthtrustsystemHTSwould1assessthecostofhealthinsuranceequitably,2promoteefficiencybyreducingfragmentationandrelyingoncompetitivemarkets,3allowcoordinationofspendingonpopulationhealthandpersonalmedicalcare,4accommodateheterogeneouspreferences,and5buildonexistingAmericanhealthinsuranceandproviderinstitutions,informedbyinternationalexperience.
UNDERINVESTMENTINPUBLICHEALTH
UnderinvestmentinpreventivecareandpopulationhealthpersistsintheUnitedStatesdespitethegrowingevidencethatsuchinvestmentshavegreatpotentialtoimprovehealth.Highratesofreturnhavebeendemonstratedforcommunity-levelinterventionstoreducethehigh-riskbehaviorsthatpromotechronicdiseases,whichaccountfortwothirdsofalldeathsintheUnitedStatesandahigherpercentageofdeathsamongthemostdisadvantagedgroups.Thesechronicdiseasesareoftenassociatedwithhigh-risklifestyleconsumptionchoicessmoking,drinking,andpoordiet,whichmaybemoreeffectivelyavertedbypolicyinterventionsinthecommunityandearlyinthelifecoursethanalteredbylaterinterventionswithinthemedicalcaresector.Forexample,2structuralinterventionsinCalifornia?
levyingacigarettetaxandbanningindoorsmokinginpublicplaces?
resultedindramaticdeclinesinsmoking,followedbydeclinesintheratesoflungcancerandheartdiseaseinthestate.Disadvantagedpopulations,whichbearthegreatestburdenofchronicdisease,standtobenefitmostfrompublicandpopulationhealthinterventions.
ThecurrentfinancingstructureandorganizationofcareintheUnitedStatesprovidestrongincentivestotreatillnessafteritoccursratherthantoinvestinprevention.Healthinsurancepoliciesalsoencourageasuboptimalmixofservices,relyingonexpensive,andoftenredundant,technology,withinadequatecoverageforpreventivecare.Thefragmentedhealthcarefinancingsystemalsowastesresourcesthroughcostshiftingandexcessiveadministrativcosts.
Tocreateamoreeffectiveandefficienthealthcaresystem,theUnitedStatesshouldcapitalizeoncurrenthealthreformeffortsthataimtomakeaccesstocareuniversalandcontainitscostswithinanintegratedhealthsystem.Thiswillrequireredesigningthesystemtoallocateresourcestotherapeuticcareandtopopulationhealthinabalancethatmorecloselyreflectstheirabilitiestopromotehealthandtherebyincreasesthehealthreturnsgeneratedbyhealthexpenditures.
ARCHITECTUREOFANINTEGRATEDHEALTHSYSTEM
Inadditiontoprovidinguniversalaccessandequitablefunding,areformedhealthsystemshouldstriveto1increaseefficiencybyformulatingcoherentpolicywithappropriateincentives,information,andsupportinginfrastructure;
2fostercoordinationofpublic,population,andprivatehealthcareatthelocallevel;
3imposefinancialdiscipline,orcostcontainment;
and4encouragechoicefor,andresponsivenessto,clients.
Weproposeahealthsystemconsistingofanationalindependentbody,anationalhealthtrustNHT,whichwouldcoordinateregional-orstate-basedaffiliates-regionalhealthtrustsRHTs?
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,atl
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- 关 键 词:
- 美国 医疗 制度 改制 整合 公共 健康 个人 护理 外文 翻译
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