In 1965 Congress, through amendments to the Social Security Act, established the Medicare and Medicaid programs and mandated that hospitals participating in those programs be reimbursed for the “reasonable cost” of providing inpatient services to Medicare and Medicaid patients. In this Article, the Chairman of the Massachusetts Rate Setting Commission contends that HEW—which, like Congress, was anxious to stimulate the voluntary participation of hospitals in the Medicare and Medicaid programs—interpreted “reasonable cost” with excessive liberality toward participating hospitals and created a fiscally burdensome and inflationary reimbursement system lacking principles of efficiency and planning. The author then describes a series of attempts—varying in scope and success—to reformulate “reasonable cost,” as applied to Medicare and Medicaid reimbursement, in a manner more consistent with the author's concept of sound public policy. The culmination of these attempts to date, he states, was Public Law 92-603 (Social Security Amendments of 1972), which introduced to the reimbursement system the concepts of (1) tough evaluation of the reasonableness of hospital costs, with emphasis on efficiency, utilization, and planning; (2) shifting de facto power over reimbursement rates away from the hospitals and into the hands of the agencies that purchase their services; and (3) increased public scrutiny of hospital operations. The author contends that this law, and the philosophy which underlies it, represents a healthy balancing of the needs of hospitals and the needs of the public; that the trend toward cost control and public control which the law embodies has been substantially furthered in those states which have statutorily established hospital budget or charge review programs; and that such trend will continue and profoundly affect any national health insurance plan enacted in the future.

中文翻译：

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医疗保险和医疗补助下住院医院服务的“合理成本”报销：公共控制的出现

1965 年，国会通过对《社会保障法》的修订，建立了医疗保险和医疗补助计划，并要求对参与这些计划的医院向医疗保险和医疗补助患者提供住院服务的“合理费用”进行报销。在这篇文章中，马萨诸塞州费率制定委员会主席认为，与国会一样，HEW 急于刺激医院自愿参与医疗保险和医疗补助计划，以对参与医院的过度宽松解释为“合理成本”，并创造了一个缺乏效率和计划原则的财政负担和通货膨胀的报销制度。然后，作者描述了一系列尝试——范围和成功率各不相同——重新制定“合理的成本，”适用于医疗保险和医疗补助报销，以更符合作者健全公共政策概念的方式。他指出，迄今为止，这些尝试的高潮是第 92-603 号公法（1972 年社会保障修正案），该法向报销系统引入了以下概念：（1）对医院费用的合理性进行严格评估，强调效率、利用和规划；(2) 换档事实上将报销率从医院转移到购买其服务的机构手中的权力；(3) 加强公众对医院运营的监督。作者认为，该法律及其背后的理念代表了医院需求和公众需求的健康平衡；法律所体现的成本控制和公共控制的趋势在那些已经法定建立医院预算或收费审查计划的州得到了实质性的推动；并且这种趋势将继续并深刻影响未来制定的任何国民健康保险计划。