美国管理型商业医疗运行模式和管控实现路径探析
Analysis on the Operation Mode and Control Path of Managed Commercial Medical Care in the United States

目前我国医疗保险市场正不断探索管理型商业健康险的本土化发展模式，《“健康中国2030”规划纲要》明确提出要促进商业保险公司与社会医疗及专业护理机构合作，发展健康管理组织(Health Maintenance Organization, HMO)等新兴管理型医疗组织形式。管理型医疗(Managed Care)作为美国医疗保险市场份额最大、市场化程度最高、覆盖面最广的一类私营计划，在医疗成本控制和服务质量管理上独树一帜。本文介绍了美国管理型商业健康险的内涵和特点，简要梳理了管理型医疗的发展背景，分析了商业健康险市场HMO、PPO和POS三种主要管理型医疗的运行模式，并从经济管控和程序管控两种路径探究了美国管理型商业健康险的有效管控的实现过程，最后对管理型医疗进行客观评述和启示总结。
At present, China’s medical insurance market is constantly exploring the localization development mode of managed commercial health insurance. The “Healthy China 2030” planning outline clearly proposes to continuously promote the cooperation between commercial insurance companies and medical, nursing and other institutions, and develop new managed medical organization forms such as health maintenance organization (HMO). Managed care, as a private plan with the largest market share, the highest degree of marketization and the widest coverage of medical insurance in the United States, is unique in medical cost control and service quality management. This paper introduces the connotation and characteristics of managed commercial health insurance in the United States, briefly sorts out the development background of managed medical care, analyzes the operation modes of HMO, PPO and POS in the commercial health insurance market, and explores the realization process of effective control of managed commercial health insurance in the United States from the two paths of economic control and procedural control. Finally, it makes an objective review and Enlightenment summary of managed medical care.