論管理式醫療的利弊得失

The Pros and Cons of Managed Care

1973年，美國國會通過了健康維護組織法（HMO Act of 1973），　除了授權聯邦政府需要提供經費或是代款來幫助健康維護組織（Health Maintenance Organizations，HMOs）的發展，也規定25位員工以上的雇主在提供員工傳統的保險以外，必須還要提供管理式醫療的選擇。由於聯邦政府的支持，1980年以後，健康維護組織大行其道，網保人口逐年增加，至2000年時，管理式醫療已有超過1億的納保人口。管理式醫療已被視為當今美國醫療保險的主流，亦是最能夠控制醫療成本及確保品質的利器。雖然管理式醫療支配了二十世紀末期的美國健康照護體系，但是以論人計酬制度、轉移病人至較便宜的醫療場所、病人入院前許可、利用率審核、高頻率使用者個案管理等為實行要素下的管理式醫療制度真的值得我們台灣仿效學習嗎？是否被公認為最能控制醫療費用及確保醫療品質的管理式醫療，亦能成為台灣解決醫療資源浪費與醫療品質日益低下等難題的萬靈丹？本文係藉由台灣之健保市場、政府型態、醫療服務提供者與民眾就醫習慣四方面加以探討台灣推行管理式醫療可能面臨的利弊得失。

The US Congress passed the HMO Act of 1973 to encourage the formation and development of managed care organizations（MCOs）. Under this act, the US government should provide financial assistance or loan to help the establishment of MCOs. The act also issued that the companies with over 25 emloyees have to offer managed care insurance as well as traditional insurance plans. During the 1980s, managed care has become the most popular insurance system in the US. The number of people enrolled in the managed care reached 100 million in 2000. The managed care has been regarded as one of the best mechanisms to cost containment and to ensure quality of health care in the US. The managed care has dominated US health delivery system during the end of 20th century. However, is the managed care that uses capitation, transferal patients to the cheaper settings, pre-admission authorization, utilization review, and case management appropriate for the health delivery system in Taiwan? Can the managed care help the health delivery system in Taiwan control escalating costs and assure quality of medical care? The purpose of this paper is to explore the pros and cons of the managed care from the perspectives health market, government, providers, and consumers.