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zoom RSS マサチューセッツ州 包括支払い方式採用へ/米国医療事情

<<   作成日時 : 2009/07/21 20:05   >>

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 マサチューセッツではほとんどの住民を健康保険カバーしたが医療費の増大を遅めることには失敗したため、州の委員会は木曜日、医療制度改革の第2段階として支払い方法の再構造化を推奨した。
 推奨方法を州議会と知事が採用すれば、マサチューセッツが、個々の診療や検査に対する代金として支払うことを止める最初の州となる。その代わりとして、「包括支払い」という、毎月または年間の均一料金で補償されるネットワークの中で、患者の健康状態に責任を持つシステムとなる。既存の「診療出来高支払い」システムでは必要以上の治療を進めてしまうように医師を誘導することが批判されている。包括払いでは患者を健康に保つことで報酬が得られ、治療コストが包括支払いより少なければ医療業者は利益を得ることになる。
 決済システムの変更に関してはワシントンでの医療改革議論でも中心となっている。一貫して高品質の予防医療を提供する医師に報酬を提供することに中心が置かれ、出来高払いの廃止はあまり議論されていない。
 マサチューセッツ州の役員と議員は州のおかれた状況により政治的な挑戦に迫られている。委員会は5年以内に実施を勧めている。最も高コストの州となっており、対策なしでは2020年には1人あたり医療費が倍増するだろうという。
画像 州は伝統的に多額の医療費支出を行ってきた。人口あたりの医師数はどの州よりも多く、多くはボストンの著明な学究的病院の専門医である。またこの病院は保険業者からの高率な返還レートを得ている。
 Commonwealth Careという州助成保険プログラムが州財政を圧迫している。昨年、雇用者に保険提供しない企業への罰金を上げ、タバコ税を上げて不足を補ったが、今年は経済危機により登録者が増大し、合法移民への補償を切るなどして2億5000万ドルの削減にを迫られている。
 水曜日に市の中心的なセーフティネット病院の一つであるBoston Medical Center が、州を相手に訴訟を起こし、貧困層の治療に対する支払いカットが不公平であると訴えた。
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皆保険モデル マサチューセッツの現状/米国医療事情
http://kurie.at.webry.info/200905/article_53.html
高騰する医療費問題に直面するマサチューセッツ/米国医療事情
http://kurie.at.webry.info/200903/article_21.html
マサチューセッツ州 無保険者が1年で半減/米国医療事情
http://kurie.at.webry.info/200806/article_4.html
皆保険により逼迫するマサチューセッツの医療/米国医療事情
http://kurie.at.webry.info/200804/article_9.html
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Mass. Panel Backs Radical Shift in Health Payment
http://www.nytimes.com/2009/07/17/health/policy/17masshealth.html

By KEVIN SACK
Published: July 16, 2009

BOSTON ― A high-level state commission recommended Thursday that Massachusetts radically restructure the way doctors and hospitals are paid, kicking off the second phase of a health care overhaul that has succeeded in covering nearly every resident but done little to slow the relentless growth of health costs.

The recommendations, if taken up by the Legislature and Gov. Deval Patrick, would make Massachusetts the first state to end the practice of paying physicians, hospitals and other health care providers for each office visit, laboratory test or procedure. Instead, providers would group themselves into networks that would be responsible for a patient’s well being and would be compensated with a flat monthly or annual fee known as a “global payment.”

The existing “fee-for-service” system has been roundly criticized for offering incentives that encourage doctors to provide more treatment than is necessary, a significant contributor to the high cost of health care. Global payments, it is thought, would reward health care providers for keeping their patients well rather than for merely treating their ailments. If the cost of treating a patient is less than the global payment, the provider networks ― called accountable care organizations in the proposal ― would keep the difference as profit.

Discussions about changing the payment system also have been central to the national health care debate in Washington. Those discussions have focused primarily on providing financial rewards to doctors who consistently offer high-quality preventive care, and less on demolishing the fee-for-service system.

Although state officials and lawmakers in Massachusetts said it would be a political challenge to enact the proposals, they also said the state’s circumstances demanded it. The commission recommended that its plan be implemented over a five-year period.

“We are among the highest cost states and without intervention our projections are that spending on a per-person basis could double by 2020,” said Sarah Iselin, commissioner of the state division of health care finance and quality, and a co-chairwoman of the health care payment commission.

Senator Richard T. Moore, co-chairman of a joint legislative committee on health care financing, said he expected to hold hearings on the recommendations this fall. Representative Harriett Stanley, the committee’s other co-chair, said she did not expect consideration of a bill until well into 2010.

“It’s going to be a very long haul, but it’s a trip worth taking,” she said.

The commission, which was created by the Legislature last year, and directed by two top policy advisors to the governor, included leaders of the state’s medical, hospital and insurer associations, and they joined in Thursday’s unanimous vote for the recommendations. As in 2006, when state leaders negotiated a plan to cover almost all of the state’s residents, it was deemed politically vital to keep such stakeholders at the payment reform table.

But while the doctors’ and hospitals’ representatives said their groups endorsed the general principles behind changing the payment system, they made it clear that their continuing support would depend on details that were deferred by the commission.

Chief among them is how a new payment system would account for variations among doctors and hospitals in the health conditions and socioeconomic status of their patients. The commission recommended that payments would have to be adjusted to recognize the insurance risks posed by the sickest patients, but said it would leave the details to an independent board that would be formed to oversee the process.

“Hospitals want to be part of this historic endeavor,” said Lynn Nicholas, president of the Massachusetts Hospital Association. But she added that “the success of moving to a global payment system is not a foregone conclusion” and expressed concerns about how risks would be adjusted and how start-up costs would be covered.

The president of the state medical society, Dr. Mario E. Motta, also urged caution. “A big transition like this has never been done on such a broad scale, so it must be done very carefully, deliberately and thoughtfully,” he said.

The commission’s report stressed the importance of changing not only the way that doctors and hospitals are paid by private insurers, but also by the two large public insurance plans ― Medicare and Medicaid. That would require permission from the federal government.

The commission issued its recommendations three years after the state enacted one of the most sweeping restructurings of health care in the country’s history. By requiring nearly all residents to have health insurance, and providing subsidies to those earning up to $66,150 for a family of four, the state has succeeded in covering 97 percent of its residents.

That is by far highest rate of any state, and elements of the plan have been emulated by President Obama and congressional Democrats in their proposals to restructure the national health care system.

But to maintain a fragile coalition of doctors, hospitals, insurers, consumers and businesses, Massachusetts’ political leaders deliberately deferred any serious discussion about how to control health costs. They have continued to rise at what state leaders acknowledge is an unsustainable rate, between 6 and 9 percent a year, well above the national average.

The state has a tradition of heavy spending on health care. It has more doctors per capita than any state, many of them specialists at Boston’s expensive academic medical centers. The state’s most prominent hospitals have been able to negotiate high reimbursement rates from insurers, and a new state law requires comprehensive insurance benefits, which drives up costs.

Although the state’s subsidized insurance program, Commonwealth Care, has managed to keep a lid on premium increases, it is already straining the state’s budget. Last year, it filled a shortfall in the program by assessing insurers and hospitals, raising the penalty on businesses that do not cover their workers, increasing premiums and co-payments, and raising the state tobacco tax.

This year, the program is facing $250 million in reductions, including cutting off coverage for legal immigrants, because the economy has both drained revenues and boosted enrollment. And on Wednesday, one of this city’s main safety net hospitals, Boston Medical Center, challenged the state in a lawsuit for what it contends are unfairly damaging cuts in payments for treating poor patients.

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