美国医疗保健模式及其改革

由于倡导自由市场经济的文化和社会背景,美国是唯一没有实行全国统一的医疗保障制度的发达国家。本文对美国医疗保险制度、美国医院的管理运行机制、美国医疗保险付费方式的沿革进行了系统的介绍,并梳理了美国医疗保健管理模式的特点与问题,结合奥巴马政府医疗保健改革要点,对我国医疗保健体系改革提出了几点建议。     

The impact of private hospital insurance on the utilization of hospital care in Australia

We use the Australian National Health Survey to estimate the impact of private hospital insurance on the propensity for hospitalization as a private patient. We account for the potential endogeneity of supplementary private hospital insurance purchases and calculate moral hazard based on a difference-of-means estimator. We decompose the moral hazard estimate into a diversion component that is due to an insurance-induced substitution away from public patient care towards private patient care, and an expansion component that measures a pure insurance-induced increase in the propensity to seek private patient care. Our results suggest that on average, private hospital insurance causes a sizable and significant increase in the likelihood of hospital admission as a private patient. However, there is little evidence of an expansion effect; the treatment effect of private hospital insurance on private patient care is driven almost entirely by the substitution away from public patient care towards private patient care. We discuss the implications for policies that aim to expand supplementary private insurance coverage for the purpose of reducing excess demand on the public healthcare system.     

Modelling demand and supply influences on utilization: A flow demand model to predict hospital utilization at the small area level

This study outlines a model to predict hospital utilization at the small area level within a National Health Service (NHS) institutional context. The proposed approach departs from alternative analyses based on utilization flows of hospital care between a local population and a hospital. A flow demand model is outlined that relates flow demand to utilization flows; models the interaction between hospital supply and utilization of alternative hospitals; captures the process of demand for hospital care, with special attention given to the role of other health care sectors, to the organizational and institutional context of the hospital system and to geographic variations. The flow approach partly overcomes the problem of dealing with simultaneity of determination between supply and demand. A two-part econometric model suitable to estimate the flow demand model for prediction purposes is tested and applied to the Portuguese health care system. The results show the model to be robust and to provide key information for defining future hospital policies at the central level.     

How does the Price Regulation Policy Impact on Patient–Nurse Ratios and the Length of Hospital Stays in Japanese Hospitals?

This study examines how the 2000 and 2006 revisions of the fee‐for‐service system have affected patient–nurse ratios and the average length of hospital stays in Japan. The empirical results show that hospitals are quite responsive to changes in price policy. The fee revisions have certainly achieved the policy objectives of reducing patient–nurse ratios and the length of hospital stays. As a result, hospitals have responded by greatly increasing the number of expensive beds for acute care. However, this was not exactly predicted by the Japanese government, which has aimed to reallocate health‐care resources, such as beds, to subacute or long‐term care.     

The impact of hospice programs on U.S. hospitals

This study demonstrates that hospice programs are more likely in communities with favorable economic factors and higher Medicare populations. Large hospitals with high occupancy rates and more clinical services use the hospice as an alternative to inpatient care thereby improving hospital efficiency and profitability.     

完善市场营销策略提高医院核心竞争力

随着医药卫生体制改革的不断深入,医疗市场竞争日趋激烈,医院需要重视市场营销策略,强化经营理念。医院市场营销是市场经济条件下医院生存和发展的重要手段,只有通过不断完善市场营销策略,方能提高医院核心竞争力。     

Crossing the quality chasm: creating the ideal patient care experience

To create a health system that better meets patients' needs requires a fundamental redesign of our care delivery system and a new framework. Without a payment mechanism to reflect the value of care provided other than the face-to-face visit, adoption of advanced medical home principles will be challenging. The hand-off of the patient between providers and settings of care is a critical time for the patient and its effectiveness impacts patient care outcomes. The appropriate utilization of hospital and other health system resources is crucial, especially as hospitals, emergency departments, and other health care venues increasingly face capacity constraints and throughput challenges. It becomes the responsibility of the multidisciplinary team of providers to ensure that patients being discharged have an identified personal physician or team who will provide a medical home, and that the handoff to this medical home is thorough and well coordinated. An ideal patient care experience is one in which all systems and processes are geared to meet the needs of the patient: a safety-oriented system that provides standardized, evidence-based care supported by technology, but that recognizes and responds to individual needs.     

新会计制度下医院现金流量表的运用分析

为适应医疗体制改革的发展,卫生部、财政部于2010年12月印发了《医院财务制度》、《医院会计制度》、《基层医疗卫生机构财务制度》和《基层医疗卫生机构会计制度》,制度中新增的现金流量表进一步完善了医院财务报告体系。同时也使医院的财务报表体系与国际惯例和企业会计体系接轨。阐述了医院编制现金流量表的现实意义和如何对其进行分析运用。     

The diffusion of hospital technologies: some econometric evidence.

This paper examines the diffusion of five hospital technologies that have spread widely since 1950: the postoperative recovery room, the intensive care unit, the respiratory therapy department, diagnostic radioisotope facilities, and electroencephalograph. The regressions show that the logistic function describes the diffusion of hospital innovations as well as it does the diffusion of innovations in other industries, that the rates of diffusion for these technologies fall within the range established by work on other industries, and that the rates for technologies that were not yet widespread in the middle 1960s increased with the advent of Medicare and Medicaid.     

Dynamic factor demands for US cigarette manufacturing under rational expectations

Portugal was the first country with a national health system to incorporate diagnosis related group (DRG) case-mix adjustment in formulating hospital budgets on a nation-wide basis. Most of the case-mix payment-outcomes literature comes from the USA where the quality of data is superior to that of many other countries. The purpose of this article is to assess the initial impact of case-mix financing on the quality of inpatient care in Portuguese hospitals using a methodology that may be appropriate for health care systems whose information is not as complete as that of the USA. Estimating a count data model at the hospital level with inpatient mortality as a quality indicator, the authors find no evidence that case-mix based payment has had adverse consequences on inpatient mortality for the most frequent non-obstetric DRG during the three year time period under study.     

Patient as center of the health care universe: a closer look at patient-centered care

We need to consider how the health care system should revolve around the patient, rather than the patient rotating around the hospital. Considering a patient-centric point of view when implementing and optimizing the use of health information technology (HIT) provides new perspectives on the meaning of "integrated" health care. ot only do we need to give patients the opportunities to participate as true partners in their health care, we must convince them why this partnership makes sense. We should not be naive and believe all patients want this involvement in their care today and are ready to do all their health care transactions electronically. But considering and using these practices are important steps in the health care reform journey to improve quality and decrease cost. Many patients will benefit by our working with them to demystify the health care experience through patient-centric practices and the use of HIT.     

Cost effectiveness of a medical vigilance system to reduce patient falls

Patient falls are a serious problem in hospitals, resulting in substantial morbidity, mortality, length of stay, and costs. The results of a small trial of a patient vigilance system in a post-neurosurgery unit of a large acute care hospital are reported. The system includes two components: (a) passive sensor array placed under the patient in a hospital bed, and (b) a bedside unit that connects to the nurse call system already in place at the hospital. This trial demonstrated the overall effectiveness of the vigilance system in reducing the rate of patient falls. The cost-effectiveness analysis found that use of this system was associated with somewhat higher measured costs. It is likely that the system was cost-saving, due to unmeasured costs.     

Medical economic impact of tracheotomy patients on a hospital system

Abstract

Background:

Tracheotomy patients are a small portion of hospitalizations, but account for disproportionately high risk and costs. There are many complex decisions that go into the care of these patients, and practice variation is expected to be compounded in a health system. This study sought to characterize the medical economic impact of tracheotomy patients on the hospital system.

Methods:

A retrospective review of the health system’s hospital billing software was performed for 2013, and pertinent outcomes measures were tabulated.

Results:

There were 829 tracheotomies performed in the health system of seven hospitals, with total costs of $128,883,865. Average length of stay was 36.74 days for principal procedures, and 43.36 days for tracheotomy as secondary procedures. Mortality was ～18% overall, and re-admissions were 10.93% for primary, and 14.36% for secondary procedures. A fairly wide variation in each category among the different hospitals was observed.

Conclusions:

There are potentially many factors that impact variations of care and outcomes in patients with tracheotomy. Due to their large economic impact and risks for morbidity and mortality, a formalized care pathway is warranted. Goals of the pathway should include understanding medical decisions surrounding these complex patients, monitoring pertinent outcomes, reducing practice variation, and improving the efficiency of compassionate care.     

Change, consolidation, and competition in health care markets.

The health care industry is being transformed. Large firms are merging and acquiring other firms. Alliances and contractual relations between players in this market are shifting rapidly. Within the next few years, many markets are predicted to be dominated by a few large firms. Antitrust enforcement authorities like the Department of Justice and the Federal Trade Commission, as well as courts and legislators at both the federal and state levels, are struggling with the implications of these changes for the nature and consequences of competition in health care markets. In this paper we summarize the nature of the changes in the structure of the health care industry. We focus on the markets for health insurance, hospital services, and physician services. We then discuss the potential implications of the restructuring of the health care industry for competition, efficiency, and public policy. As will become apparent, this area offers a number of intriguing questions for inquisitive researchers.     

Hospital utilization in mixed public–private system: evidence from Australian hospital data

This article investigates whether patients who used a mixture of private and public hospital care have higher total hospital utilization than those who exclusively used either public or private hospital care. Using Australian hospital administrative data of heart disease patients, we found that those who used a mixture of private and public care had the highest total hospital utilization. Our findings are robust to how utilization is measured and endogeneity between utilization and hospital type choice.     

Intra-unit patient transports: time, motion, and cost impact on hospital efficiency

The costly and inefficient movement of patients within the hospital challenges health systems across the country as they strive to simultaneously contain rising costs and provide high-quality patient care. Solid evidence to support the improvement of hospital and patient care efficiency through the identification and suggested elimination of waste patterns within the transport process is presented.     

商业医疗保险中垄断型定点医院的动态激励机制设计

定点医院道德风险的控制问题以及对定点医院激励机制的设计问题是我国乃至全球医疗保险风险管控过程中的大难题.针对这一问题,利用委托代理理论的分析思路和数理方法,建立了一个以赔付率作为内生变量的动态激励机制模型;得出了一个具有可行性的激励合同;然后,通过引入另一个可观测变量在赔付率较高的情形下和在赔付率较合理的情形下分别对该合同做了改进;同时也给出了一套适宜于垄断型医疗服务市场的激励机制的设计方法.     

Predictors for total hospital and cardiology cost claims among patients with atrial fibrillation initiating dabigatran or acenocoumarol in The Netherlands

Aims: The prevalence of atrial fibrillation (AF) has increased over the past years due to aging of the population, and healthcare costs associated with AF reflect a significant financial burden. The aim of this study was to explore predictors for the real-world AF-related in-hospital costs in patients that recently initiated anticoagulation with acenocoumarol or dabigatran.

Methods: Predictors for claimed total hospital care costs and cardiology costs in AF patients were explored by using hospital financial claims data from propensity score matched patient groups in a large Dutch community hospital. This study analyzed the total dataset (n?=?766) and carried out a secondary analysis for all matched pairs of anticoagulation naïve AF patients (n?=?590) by ordinal regression.

Results: Dabigatran was a predictor for significantly lower cardiology and total hospital care costs (Odds Ratio [OR]?=?0.43, 95% confidence interval (CI)?=?0.33–0.57; and OR?=?0.60, 95% CI?=?0.46–0.79, respectively). Female gender was a predictor for lower total hospital care costs. Predictors for an increase in total hospital care costs were the occurrence of stroke or systemic embolism, major bleeding, and minor bleeding. The costs predictors were comparable when limiting the analysis to patients that were anticoagulation naïve. Age and CHA₂DS₂-VASc were not predictors for either cardiology or total hospital care costs in both analyses.

Conclusion: Dabigatran treatment was as a predictor for lower cardiology costs and lower total hospital care costs in AF patients that initiated oral anticoagulation.     

The Endogenous Sequential Probit model: An application to the demand for hospital utilization

This paper develops the Endogenous Sequential Probit model to analyze the effect of managed care on hospital utilization by adult married US population and finds that managed care gives disincentives to utilize hospital care relative to the standard indemnity plans.