美国医疗保健制度------管理式医疗护理[外文翻译].doc

本科毕业设计（论文） 外 文 翻 译原文原文The American Health Care System — Managed CareAmerica's private and public third-party payers, squeezed by health care costs that continue to soar at rates well above inflation, are persuaded that “managed care“ plans will produce demonstrable savings as compared with the current cost trends of traditional fee-for-service medicine. They are accelerating their efforts to promote plans that integrate the delivery and financing of care and that apply new constraints on encounters between physicians and patients. The key constraint for doctors is the limitation placed on the autonomy of their clinical decisions. The constraint for patients is the requirement that they see only physicians who are members of a plan's closed or partially open panel or who are selected as “preferred“ practitioners. In general, these doctors have agreed to deliver only “necessary“ medical services in return for prescribed fees.Most definitions characterize managed care as a system that integrates the financing and delivery of appropriate medical care by means of the following features: contracts with selected physicians and hospitals that furnish a comprehensive set of health care services to enrolled members, usually for a predetermined monthly premium; utilization and quality controls that contracting providers agree to accept; financial incentives for patients to use the providers and facilities associated with the plan; and the assumption of some financial risk by doctors, thus fundamentally altering their role from serving as agent for the patient's welfare to balancing the patient's needs against the need for cost control — or, as Mechanic put it succinctly, moving “from advocacy to allocation.“ Because these features circumscribe the freedom of physicians to practice medicine autonomously, they receive decidedly mixed reviews from doctors. Nevertheless, at least half of all practicing physicians have become involved in at least one managed care arrangement, and they have accepted the trade-off of lower fees for a guaranteed flow of patients. The reality is that this new model has rapidly emerged as a dominant one in the American health care system. At the same time as these new networks are developing, some existing large multispecialty group practices that previously treated patients only on a traditional fee-for-service basis are offering benefit packages directly to payers for a prepaid, fixed premium.Medical group practices that now operate such managed care plans, which may generate 30 to 40 percent of the practice's total patient revenues, include the Carle Clinic in Urbana, Illinois, the Dean Clinic in Madison, Wisconsin, the Geisinger Clinic in Danville, Pennsylvania, the Marshfield Clinic in Marshfield, Wisconsin, the Ochsner Clinic in New Orleans, the Palo Alto Clinic in Palo Alto, California, the Park—Nicollet Clinic in Minneapolis, the Scott and White Clinic in Temple, Texas, and the Virginia Mason Clinic in Seattle. The Cleveland Clinic and many other hospitals across the country have taken an important step in this direction by offering third parties fixed prices for “bundled“ sets of medical services — for example, a fee for all the services (provided by physicians, hospitals, and ancillary personnel) required to perform a coronary-artery bypass operation or a heart or kidney transplantation.The emergence of managed care is the subject of this report — my third on the American health care system. It represents the latest stage in a long struggle that has pitted the priorities of practicing physicians against management structures that have sought to gain firmer control over what doctors do. The traditional autonomy that physicians have enjoyed as ministers to the sick and as recipients of a state grant of monopoly power in medical practice — what Freidson calls “professional dominance“5 — is being threatened by these new arrangements. The new constraints, along with other economic and social pressures, are encouraging physicians to aggregate in larger professional groups that offer them greater protection against external assaults on their autonomy, as well as more regular working conditions. Most organizations that provide managed care are called either health maintenance organizations (HMOs) or preferred-provider organizations (PPOs). Within these categories, there are variations on the basic theme, reflecting the fact that the organization of managed care is evolving rapidly. Although still largely a regional phenomenon, far more prevalent on the East and West Coasts and in the Midwest, managed care is clearly a phenomenon that, in one form or another, is here to stay, despite the misgivings of many doctors.7 The states with the largest numbers of people enrolled in HMOs and the highest percentages of their population enrolled in such plans are California (33.4 percent), Massachusetts (30.9 percent), Minnesota (28.3 percent), Oregon (26.4 percent), Arizona (24.2 percent), Hawaii (2。