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PubMedDate not supplied

From cooperation to competition in national health systems--and back?: impact on professional ethics and quality of care.

Ethical behaviour in health workers is the jewel in the crown of health services. Health system policies need to nurture a professional service ethic. The primary health care policy envisioned a national health system led by the public sector and based on a philosophy of cooperation. A common theme of 'health sector reform' in OECD countries, introduced in the context of neoliberalism, has been the use of 'managed competition' to increase efficiency. Some countries that flirted with health system competition have returned to cooperation. Market relationships tend to be oppositional and to stimulate self-seeking behaviour. Health system relationships should encourage patient and community centred behaviour. The World Bank and bilateral donors have exported health sector reform theories from the north to the south, involving privatization and marketization policies. This is despite the lack of evidence on their desirability or feasibility of implementing them. Private health care has increased in many developing countries, more as a result of economic crisis and liberalization than specific health sector reforms. Much of this private practice is unlicensed and unregulated, and informal privatization has had a damaging effect on health worker ethics. The lead policy should be reconstruction of the public health system, involving decentralization, democratization and improved management. Commonsense contracting of an existing private sector is different from a policy of proactive privatization and marketization. Underlying the two approaches is whether health care should be viewed as a human right best served by socialized provision or a private good requiring governments only to correct market failures and ensure basic care for the poor. It is a matter of politics, not economics.

Cooperative Behavior↗
PubMed1995

Washington State Health Services Act: implementing comprehensive health care reform.

In 1993, Washington State enacted the Health Services Act of 1993 (HSA) to guarantee universal access to health care through an employer mandate, with caps on premiums as the primary cost-control mechanism. The HSA represents the Nation's first formal experiment with managed competition. This article reports the results of a case study of the HSA's implementation. The study concludes that the Washington State initiative can be replicated in other States, but that implementation is complex, requires sustained public education, and requires cooperation from the Federal Government through program waivers. A major implementation challenge is to facilitate competition and minimize regulation.

Competitive Medical Plans↗
PubMed2001

On the "efficiency" of managed care plans.

The claim that managed care plans are more efficient than fee-for-service plans has been made so often that it has reached the status of folklore, but the evidence is inconclusive. The claim is usually based on one or both of the following errors: (1) lower medical care costs mean lower total costs (medical plus administrative costs) and (2) lower HMO premiums mean HMOs are more efficient than fee-for-service plans. The first assertion ignores evidence indicating that managed care has driven up administrative costs for both insurers and providers. The second ignores evidence that managed care plans have numerous methods of shifting costs that are unavailable or less available to fee-for-service plans. The lull in health care inflation during the mid-1990s is often cited as evidence that managed care is efficient. But the lull may have been caused not by the spread of managed care but by the near-simultaneous occurrence of four events: a downturn in the insurance underwriting cycle, the 1990-1991 recession, endorsement of managed competition by numerous politicians, and the merger fever triggered by those endorsements.

Cost Allocation↗
PubMed2006

The effects of managed care and competition on community-based clinical research.

BACKGROUND: The National Institutes of Health is developing practice-based clinical research networks (PBRNs) to expedite the pace of scientific discovery and improve care quality. Anecdotal evidence suggests managed care penetration and provider competition negatively affect PBRN clinical research. OBJECTIVE: The objective of this study is to examine the effects of environmental factors on clinical research performance in the National Cancer Institute's Community Clinical Oncology Program (CCOP). RESEARCH DESIGN: This study examined 49 CCOPs in 34 states using longitudinal (1991-2001) generalized least-squares regression including fixed effects, using secondary data from the National Cancer Institute, Group Health Association of America, InterStudy, American Hospital Association, Area Resource Files, and the Current Population Survey. MEASURES: Performance was measured as CCOP-level accrual in treatment trials, cancer prevention and control (CP/C) trials, and all trials combined. HMO penetration served as a proxy for managed care penetration. Competition measures included both hospital competition and physician competition. RESULTS: Managed care penetration was positively associated with accrual in areas of low to moderate penetration and negative in the areas of high penetration. Compared with areas with 5% penetration, areas with 15% penetration had 21% more treatment accrual and 66% more CP/C accrual. Compared with areas with 40% penetration, areas with 50% penetration had 11% lower treatment accrual and 3% lower CP/C accrual. CP/C accrual was more positively affected than treatment accrual. Greater hospital competition was associated with a decline in trial enrollment. CONCLUSIONS: The healthcare environment appears to have a significant effect on accrual into community-based cancer treatment and CP/C clinical trials. Findings for treatment and CP/C accrual suggest each type of accrual is distinct and requires different strategies and administrative methods.

Clinical Trials as Topic↗
PubMed2002

Application of pharmacoeconomics to formulary decision making in managed care organizations.

OBJECTIVE: To discuss the apparent value of incorporating pharmacoeconomic studies into pharmacy and therapeutic committee decision making; current internal and external barriers to the use of pharmacoeconomic studies; and possible solutions to the problems. STUDY DESIGN: Literature review. RESULTS: The formulary system assists healthcare providers in the evaluation, appraisal, and selection of drugs. Unfortunately, managed care organizations usually evaluate drugs exclusively on clinical efficacy, safety, and daily acquisition cost without considering overall cost effectiveness. Factors that have been impeding the use of pharmacoeconomic data include departmental budgetary constraints, tardy publications, limited reliability of available studies, and a lack of knowledge required to evaluate such studies. CONCLUSIONS: To remain competitive, managed care organizations need to incorporate pharmacoeconomic consideration into their formulary decision-making process. Performing an institutionwide economic evaluation; conducting pharmacoeconomic studies earlier, perhaps along with clinical trials; using decision analysis; developing standardized guidelines; and increasing education can help overcome current barriers.

Budgets↗
PubMedDate not supplied

Perspective from a hotbed of managed care.

An environmental assessment of the current healthcare market in the United States shows four stages of evolution: (1) the unstructured stage, (2) the loose framework, (3) consolidation, and (4) managed competition. Recognition of these stages should help in the development of strategies for the future. After determining the existing stage of the health-care market in a particular geographic area, clinical endocrinologists can compose a vision statement, develop goals and objectives, and formulate strategies to achieve the established goals. For example, one strategy is to join a managed-care plan. Some practical business advice about assuming risk (responsibility) for various health-care services is provided, and the concept of disease-specific capitation is discussed. Health-care reform is likely to proceed regardless of what the federal government does. In the managed-care environment, the most successful physician participants will be those who are thoroughly informed.

Journal Article↗
PubMed1992

Empowering the demand side: from regulation to purchasing.

The primary justification for private insurance is the hypothesis that competition among private insurers will lead to an environment in which physicians and hospitals will continually strive to improve the quality and economy of the care they provide, and to be responsive to the preferences of the consumers they serve. However, to date, competition among private insurers has failed miserably in achieving this goal. In order to achieve this goal, competition among insurers must be regulated in an entirely different manner than it is currently. This article describes the ways in which health insurance is currently regulated, and argues that passive regulation directed at assuring financial solvency of insurers should be transformed into an active purchasing authority. This purchasing authority would empower the demand side, creating an environment of managed competition that rewarded those provider groups able to offer high quality, economical care.

Consumer Advocacy↗
PubMed1993

The United States needs a health system like other countries.

Every developed country except the United States has a comprehensive health system for coverage, service provision, and finance. Social policy in the United States once was guided by thinkers who realized this, and the Social Security system--complete except for health insurance--resulted. The climate of thinking changed, and health policy for some time has been dominated by classical economists who argue that free competitive markets will solve all problems. They justify their arguments by claiming that the only alternative is full government takeovers of service and financing, as in Canada. While this debate has dragged along, problems in the United States have become grave. Instead of reviving the institutional economics and social policies that once served the United States well, the Clinton administration has turned policy over to devotees of managed competition. But the problem is how to organize the country, and national health insurance--easily observed in other countries--is superior to the current chaos and free-market utopias in the United States. Important aims would be achieved, such as expanding coverage, obtaining stable revenue, and containing costs. Important political barriers can be overcome, such as resistance by small business. Such a health system includes machinery for setting goals and implementing results, involving collaboration among providers, payers, and government.

Canada↗
PubMed1994

The effect of physician practice organization on efficient utilization of hospital resources.

OBJECTIVE: This study examines variations in the efficient use of hospital resources across individual physicians. DATA SOURCES AND SETTING: The study is conducted over a two-year period (1989-1990) in all short-term general hospitals with 50 or more beds in Arizona. We examine hospital discharge data for 43,625 women undergoing cesarean sections and vaginal deliveries without complications. These data include physician identifiers that permit us to link patient information with information on physicians provided by the state medical association. STUDY DESIGN: The study first measures the contribution of physician characteristics to the explanatory power of regression models that predict resource use. It then tests hypothesized effects on resource utilization exerted by two sets of physician level factors: physician background and physician practice organization. The latter includes effects of hospital practice volume, concentration of hospital practice, percent managed care patients in one's hospital practice, and diversity of patients treated. Efficiency (inefficiency) is measured as the degree of variation in patient charges and length of stay below (above) the average of treating all patients with the same condition in the same hospital in the same year with the same severity of illness, controlling for discharge status and the presence of complications. PRINCIPAL FINDINGS: After controlling for patient factors, physician characteristics explain a significant amount of the variability in hospital charges and length of stay in the two maternity conditions. Results also support hypotheses that efficiency is influenced by practice organization factors such as patient volume and managed care load. Physicians with larger practices and a higher share of managed care patients appear to be more efficient. CONCLUSIONS: The results suggest that health care reform efforts to develop physician-hospital networks and managed competition may promote greater parsimony in physicians' practice behavior.

Arizona↗
PubMed1994

Health reform: what will it take to pass?

The health care reform debate has begun in earnest, but the outcome for 1994 is highly uncertain. Divisions among Democrats on health care reform are very serious, with conservative Democrats closer to mainstream Republicans than to their own congressional leadership on the key issues of spending limits, price controls, and employer mandates. Because 1994 is an election year, and given the commitment of the president to reform, passage of legislation that is somewhere between a less regulatory form of managed competition and incremental reform is possible. But because of the divisions within Congress and the president's overly ambitious starting point, near-term passage is not inevitable.

Financing, Government↗
PubMed1996

Professionalism, responsibility, and service in academic medicine.

BACKGROUND: Academic medical centers have responded to health care reform initiatives by launching a series of strategic plans designed to maintain patient flow and reduce hospital expenditures. Thought is also being given to processes by which the faculty can individually and collectively adjust to these changes and maintain morale at a time when reductions in the labor force and pay cuts are virtually certain. Physicians are concerned because managed care threatens their autonomy and jeopardizes the traditional ways in which they have carried out their multiple missions. Some doctors believe that it will become increasingly difficult to obtain genuine satisfaction from their job. METHODS: The strategies that academic medical centers have begun to use to address the numerous challenges posed by a system of health care based on managed competition are reviewed. Potential mechanisms by which academic departments can continue to find fulfillment in an environment that threatens their traditional missions and values are discussed. RESULTS: A study of the social and historical origins of medicine in the United States reveals that the introduction of corporate medicine in the United States was destined to happen. Strategies implemented by academic medical centers in response to managed care include building an integrated delivery network, the acquisition of primary care practices, increasing cost-effectiveness, and creating physician-hospital organizations. Emphasis must be placed on integrating traditional core values (excellence, leadership, and innovation) with newer values such as patient focus, accountability, and diversity. A shift from rugged individualism to entrepreneurial teamwork is crucial. These reforms, although frightening at the onset, can serve to reaffirm our commitment to academic medicine and preserve our mission. CONCLUSIONS: The evolving managed care environment offers unique opportunities for academic medical centers to shape and positively impact health care delivery in the twenty-first century. In a reconfigured model that combines core values with newer values, university-based physicians can continue to reap the intangible rewards derived from patient care, research, and education.

Academic Medical Centers↗
PubMed1996

Managing space for managed care: the challenge for a multispecialty group practice.

A project that began as an architectural study to determine space requirements and remedy space deficiencies for an academic medical center's faculty multispecialty group practice led to development of an analytical methodology for assessing real space needs and viable options for solutions in the context of the group's operational policies, physician practice patterns, and business goals. Major facility investments for new or renovated construction demand significant capital expenditure, which can severely affect a group's ability to complete as a financially viable player in a marketplace environment of increasingly competitive managed care delivery systems. The methodology created during this project helped the group practice to understand how they could optimize the use of existing space, minimize capital costs, and provide flexibility for future developments.

Academic Medical Centers↗
PubMed1994

Coverage of mental health and substance abuse services under a single-payer health care system.

Health care reform proposals based on a single-payer system of health care insurance were introduced in the U.S. Congress in 1992 and 1993 but were superseded by the Clinton Administration's health care reform proposal, which was based on managed competition. In a single-payer system, the government collects all health care funding and pays private- and public-sector providers; similar providers are paid the same rate. Other features include consumer choice of providers, distribution of risk of high utilization over the entire nation, and control of health care expenses via an annual national health care budget. Such proposals cover outpatient, inpatient, and long-term care and case management services for mental illness and substance abuse disorders, call for periodic utilization review of continuing mental health care, and eliminate the distinction between public and private services based on limits of coverage. The last provision particularly affects severely or chronically mentally ill persons who are likely to exhaust their private insurance coverage.

Health Care Reform↗
PubMed1995

Restructuring: a tale of four cities.

As the United States struggles to redefine the cost and delivery of health services, health care executives struggle to identify the most appropriate strategic agenda. With the model for the market evolution of health care becoming an accepted industry paradigm, it serves as an excellent medium for discussing the potential challenges an institution may face as its market progresses toward managed competition. Four cities, each at a different stage of evolution, are discussed in an effort to help health care executives in craft strategies for sustaining their institution's viability.

Arkansas↗
PubMed2001

[Health care supply regulation].

In the current context of health systems' reforms, the regulation would have to occupy a major place in the new role of the State concerning health in order that the system could reach the essential objective to control the quantity and the distribution of health services and to insure an optimal, efficient and equitable coverage of the population's needs. Authors pass in review, in a first part, current regulation means of health care supply, public and private, put in place in Tunisia and suggest their development in areas not covered yet; notably these in relation with the quality and the cost-containment of health care. The current regulation is interested especially in areas of the infrastructure, equipment, medicines and pharmaceutical products and financial and human resources of the sector. In a second part, means of regulation of health care supply are exposed and could serve as basis to the reform of the current health system. It is thus the mastery of the medical demography, incentives for health care providers, payment systems, fees and rates of professionals and the free choice and the managed competition between providers. Authors conclude by the necessity to promote patients' rights in the health system and to valorise its human resources, through the development of information on performances of providers and the continuous training of professionals.

Cost Control↗
PubMed1993

Physician organizations and physician-hospital organizations: models for managing change.

The health care environment is expected to undergo significant change in the coming years. The continued growth of managed care, in particular will exert a profound impact on medical practice. This trend will be accelerated if a managed competition approach to health system reform is adopted at the federal level. As physicians continue to consider possible strategies by which to adapt to the changing practice environment, two options may merit special consideration: first, integration with other physicians, particularly through formation of a medical group and, second, vertical integration with a hospital, through formation of a PHO. Although PHOs are a relatively recent phenomenon, they represent a potentially powerful strategy by which physicians and hospitals can combine forces to take a leadership role in managed care contracting. Through careful planning, development of a sound legal structure and efficient governance process, and implementation of effective criteria for participation in the PHO, it is possible to further the goals of the physician and hospital participants, while meeting the needs of payers.

Delivery of Health Care↗
PubMedDate not supplied

An "All-American" health reform proposal.

Reforming the U.S. health care system is frequently thought of in absolutist terms: managed competition versus rate regulation; federal versus state administration; and business mandates versus individual insurance purchases. While these choices must be resolved over the long run, the transition to a new health care system will take several years and require more flexible solutions. The "All-American" Deal offers just that. It requires individual households to be insured and allows businesses to voluntarily offer health insurance; relies on the federal income tax system to collect income-based premiums and transfer funds to states through risk-adjusted payments; and lets states manage the disbursement of funds for uninsured residents.

Budgets↗
PubMed1994

Implications of health-care reform proposals for black Americans.

A recent increase in the number of black Americans who lack public or private health insurance means that current proposals to reform the U.S. health-care system have particular relevance for the black community. This paper reviews the major reform proposals offered by President Clinton and Congressional leaders with an eye toward estimating the possible impact on black Americans. The proposals offer concepts ranging from managed competition and "play or pay" to caps on health-insurance premiums, incentives for primary-care providers, "sin" taxes, and outcomes analysis. Though some of these concepts offer opportunities for improving black Americans' access to quality care, most have potential shortcomings that could worsen health status in the black community.

Black or African American↗