管理式照護制度的介紹──HMO與PPO

THE INTRODUCTION OF MANAGED CARE－HMO AND PPO

管理式照護（Managed Care）是一個提供醫療照護的成本、品質及可近性的醫療系統。能兼顧這三者並在這三者間取得一平衡點，是一個照護系統所追求的目標。本文即在介紹美國的醫療管理，尤其是著重在Health Maintenance Organization（HMO）與Preferred Provider Organization（PPO）二種最主要型態的介紹。由於台灣的全民健保已在民國八十四年三月開始實施，至今已超過兩年，對於全民健保未來的走向及作法，仍有許多不同的建議及看法，因此作者將藉由美國管理式照護的觀念介紹，對台灣的全民健保與醫療制度提供若干建議。這些建議包括運用管理式照護的方法來改善醫療品質、應用論人計酬制(Capitation)以增進預防性健康、運用利用審查(Utilization Review)等方式來控制醫療成本。

Managed Health care is a system of health care delivery that tries to manage the cost of health care，the quality of that health care，and access to that care. This study is specifically focused on the introduction of two types of the managed care organizations-health maintenance organization（HMO）and preferred provider orgainization（PPO）. Futhermore, Taiwan has implemented the National Health Insurance since March 1, 1995. The authors apply the concept of managed care and provide some suggestions to National Health Insurance and to health care system for Taiwan. Suggestions include using managed care methods to improve health care quality, and using capitation to increase preventive health, and using utilization to control health care cost.