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.docx

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.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

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

本科毕业论文外文翻译

外文题目:

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