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PubMed1994

Health care reform and professionalism.

With its emphasis on consumer choice of health plans, the current health care debate neglects a more fundamental crisis: changes in the traditional physician-patient relationship. This paper discusses how this relationship is being redefined and what it means for professionals in the future, particularly in the context of managed competition. The paper asserts that the final health reform plan must address flaws in the scientific and ethical basis of clinical practice. It calls for a flexible workforce policy that promotes shared decision making, lifetime learning, professional commitment to improved quality of care, a national evaluation program, and organizations to coordinate these efforts.

Decision Making, Organizational↗
PubMed1998

Economic organization of medicine and the Committee on the Costs of Medical Care.

Recent strategies in managed care and managed competition illustrate how health care reforms may reproduce the patterns of economic organization of their times. Such a reform approach is not a new development in the United States. The work of the 1927-1932 Committee on the Costs of Medical Care exemplifies an earlier effort that applied forms of economic organization to medical care. The committee tried to restructure medicine along lines consistent with its economic environment while attributing its models variously to science, profession, and business. Like current approaches, the committee's reports defined costs as the major problem and business models of organization as the major solution. The reports recommended expanded financial management and group medicine, which would include growth in self-supporting middle-class services such as fee clinics and middle-rate hospital units. Identifying these elements as corporate practice of medicine, the American Medical Association-based minority dissented from the final report in favor of conserving individual entrepreneurial practice. This continuum in forms of economic organization has limited structural reform strategies in medicine for the remainder of the century.

American Medical Association↗
PubMedDate not supplied

Global pricing for cardiac care: hard lessons for physicians and hospitals.

The challenges associated with global contracting are becoming apparent as more experience is gained. Contracts held by an open medical staff hospital provide an ever-changing equation. High-cost physicians can join the staff and alter the cost and quality outcomes that the hospital and physicians may anticipate. Also, physicians want to have assurances on how fee distribution is determined. For these reasons, some physicians are developing private contracting vehicles that assure their future. Managed competition is encouraging these creative models to respond to the market demands of payers; in some markets, these vehicles are creating the demand. It is important for both physicians and hospitals to be open to new creative models. Hospitals that insist on controlling the situation decrease its potential success. Flexibility ensures the ability of both entities to respond to new market demands. From the payer perspective, global contracting represents predictability of price and dependability of service. It encourages an economic relationship of dependence between a hospital and its physicians. Utilization of service is no longer the payers' problem; instead, the provider is asking the questions and managing the situation to assure that both quality and economic efficiency outcomes are achieved.

Cardiology Service, Hospital↗
PubMed1993

Finding equilibrium in U.S. physician supply.

One essential component of health system reform is to bring the number of physicians in line with the needs of the population. The physician supply policies of prepaid group practice health maintenance organizations have been cited as one model to achieve this goal. Planning for physician supply should be an explicit public-sector activity and should not be left to the private sector, because some areas are not sufficiently populated to support competing providers under a managed competition scheme. A new model for planning for physician supply should include the following strategies: (1) erecting barriers to entry into medical practice; (2) encouraging early retirement; (3) restructuring economic incentives; (4) reallocating physicians to underserved areas in the United States and abroad; and (5) creating new areas of professional responsibility for physicians.

Education, Medical↗
PubMed1997

Organized labor and health reform: union interests and the Clinton plan.

The fringe benefits on which most Americans have come to rely for health insurance constitute a critical foundation of both the postwar regime of labor relations and the distinctive American welfare state. One legacy of these complementary regimes was a wide variety of institutional commitments and organizational arrangements in the area of health benefits. That diversity of experiences created a range of political incentives for unions when it came to health reform. Thus, when President Clinton proposed a "managed competition" approach to health reform in 1993, divisions within the labor movement contributed to the ineffectiveness of the campaign mounted by supporters of the effort. This article reviews the development of a "private-sector welfare state" in the United States, documents the range of accompanying institutional arrangements, and suggests how they may have shaped the political calculations of certain unions when faced with the Clinton White House's reform proposal.

Health Care Reform↗
PubMed1994

Academic surgical group practices at the dawn of health reform.

OBJECTIVE: The authors collected, analyzed, and interpreted baseline data concerning academic surgical group practices as they function in the contemporary medical marketplace. SUMMARY AND BACKGROUND DATA: Health care reform officially began with President Clinton's recent address to Congress. Features of reform, such as universal coverage, managed competition, and regulation of graduate medical education (GME) challenge academic surgery. Data relevant to the governance, financial status, and market positions of academic surgical practices are not available. A current analysis of revenue sources and uses has not been published. METHODS: The authors used a 158-question survey to obtain information, for 1992, on adaptation to current market conditions, financial performance, and revenue uses in a sample of 100 academic surgical group practices. RESULTS: The response rate was 83%. Seventy-four selected group surveys were analyzed. Twenty-three groups are affiliated with private medical schools; 51 are affiliated with public medical schools. Fifty-seven per cent of the groups have satellite clinic networks, and 78% own or contract with managed-care entities. Eighty-six per cent of the groups derive more than 50% of referrals from outside the academic medical center. Gross revenue median was $35 million (range $10-$101 million). Revenue growth was reported by 66%. Payer mix trends show growth in government and health maintenance organization (HMO) payers. An average of 71% of faculty salaries come from practice. Practice revenues provide 68% of department expenses and 40% of research funds. Graduate medical education is supported directly by 69% of practice groups. CONCLUSIONS: Academic surgical group practices are vulnerable in the current marketplace. Revenue growth will be limited in the future because of weak payer mix and broad support of academic programs, including GME, using clinical income.

Academic Medical Centers↗
PubMed1993

1993 health care reforms at the state level: an update.

Health care system reform was one of the foremost political issues throughout 1993. While the Clinton Administration developed and proposed a national reform plan, many states enacted laws that call for altering the way in which health care is delivered to their residents. The following article examines health care reform legislation that was enacted at the state level in 1993. It focuses on managed competition plans, plans that seek to expand access to health insurance or to control health care expenditures, and plans that are aimed at reforming Medicaid and other state programs. Because so many states considered or enacted some type of health care reform legislation in 1993, this article provides an overview of the more significant reforms that became law, but it is not intended to serve as a comprehensive review of all state-level health care reforms.

Health Care Reform↗
PubMedDate not supplied

Comparing employee health benefits in the public and private sectors, 1997.

Data from the 1997 Robert Wood Johnson Foundation Employer Health Insurance Survey provide new information comparing public- and private-sector employee health benefits. The federal government is ahead of other employers in adopting managed competition principles using financial incentives and consumer information to promote choosing efficient plans. Federal employees experience a $200 annual compensation gap relative to those in the private sector, but it is partly explained by advantage in purchasing power. In contrast, state and local governments make higher payments toward health insurance than private-sector employers do. Their premiums are equivalent, but they pay a greater share of the total cost.

Efficiency, Organizational↗
PubMed1998

A practical approach to managing care under managed care. Case examples in pulmonary medicine.

As managed care medicine penetrates the health care marketplace, all those involved in the health care delivery process will have to redesign and restructure the way they provide health care services. With the current emphasis on controlling health care costs, providers will be compelled to come up with the successful strategies and methodologies that lead to the delivery of cost-effective high-quality care with positive, successful patient outcomes. Having the capability to analyze the information necessary to identify, measure, and monitor processes and outcomes is one of the key critical factors for success. Using information to identify opportunities for improvement, developing and implementing the appropriate process improvement activities, and being able to document and demonstrate the results of one's efforts are crucial for survival in a competitive managed care market.

Health Care Reform↗
PubMed1996

An historical perspective on the roots of managed care.

To most people, managed care and managed competition are terms of relatively recent origin, but the concepts are far from new. The use of these terms and their principal predecessors, prepaid group practice and medical care foundations, are symbolic of the underlying problems of the health care systems identified in the United States. With the passage of time, the individuals who first spoke loudly and well on the subject have come and gone, but the central theme of what they had to say was that major changes in the organization, financing, and delivery of health care are absolutely essential if high-quality preventive, diagnostic, and therapeutic care are to be available to the population at an acceptable cost. This paper reviews the early years of recognition of the need for change and the sporadic start of the changes. The presentation leaves out details on the recent growth of managed care and the political turmoil caused by the high level of medical costs, the inadequate documentation of the quality of care, and the large numbers of people who have no insurance or at best inadequate insurance.

Health Maintenance Organizations↗
PubMed1993

Health care delivery and the training of surgeons.

Most countries have mastered the art of cost containment by global budgeting for public expenditure. It is not as yet clear whether the other option, managed care, or managed competition will accomplish cost control in America. Robert Evans, a Canadian health care expert, remains skeptical. He says, "HMO's are the future, always have been and always will be." With few exceptions, the amount spent on health care is not a function of the system but of the gross domestic product per person. Great Britain is below the line expected for expenditure, which may be due to truly impressive waiting lists. The United States is above the line, which is probably related to the overhead costs to administer the system and the strong demand by patients for prompt and highly sophisticated diagnostic measures and treatments. Canada is on the line, but no other country has subscribed to the Canadian veto on private insurance. Reform or changes are occurring in all countries and will continue to do so. For example, we are as terrified of managed care in Canada as you are of our brand of socialized insurance. We distrust practice by protocol just as you abhor waiting lists. From my perspective as a surgeon, I envision an ideal system that would cover all citizens, would maintain choice of surgeon by patients, would provide mechanisms for cost containment that would have the active and continuous participation of the medical profession, and would provide for research and development. Any alteration in health care delivery in the United States that compromises biomedical research and development will be a retrogressive, expensive step that could adversely affect the health of nations everywhere. Finally, a continuing priority of our training programs must be to ensure that the surgeon participating in this system continues to treat each patient as an individual with concern for his or her own needs.

Canada↗
PubMedDate not supplied

Reimbursing insurance carriers: the case of 'MUFACE' in the Spanish health care system.

This article aims at contributing to the analysis of financial incentives in managed competition, on the basis of the literature on procurement and regulation under incomplete information. More specifically, we focus on MUFACE, the publicly funded health care system for Spanish civil servants and dependants. MUFACE makes up an internal market, where competing public and private insurers are reimbursed a flat capitation payment. Some of our results are that theoretically, both pre-contractual (adverse) selection of insurers contracted by MUFACE, and post-contractual risk selection of enrollees undertaken by insurers, should occur under flat capitation.

Capitation Fee↗
PubMed2006

Refined pipe theory for mechanistic modeling of wood development.

We present a mechanistic model of wood tissue development in response to changes in competition, management and climate. The model is based on a refinement of the pipe theory, where the constant ratio between sapwood and leaf area (pipe theory) is replaced by a ratio between pipe conductivity and leaf area. Simulated pipe conductivity changes with age, stand density and climate in response to changes in allocation or pipe radius, or both. The central equation of the model, which calculates the ratio of carbon (C) allocated to leaves and pipes, can be parameterized to describe the contrasting stem conductivity behavior of different tree species: from constant stem conductivity (functional homeostasis hypothesis) to height-related reduction in stem conductivity with age (hydraulic limitation hypothesis). The model simulates the daily growth of pipes (vessels or tracheids), fibers and parenchyma as well as vessel size and simulates the wood density profile and the earlywood to latewood ratio from these data. Initial runs indicate the model yields realistic seasonal changes in pipe radius (decreasing pipe radius from spring to autumn) and wood density, as well as realistic differences associated with the competitive status of trees (denser wood in suppressed trees).

Computer Simulation↗
PubMed1995

Health care financing reform in the United States: the community equity model.

The paper discusses the practical structural aspects required for implementing 'managed competition' reform policy which are often overlooked by policy designers of change. Namely, without fundamentally new organisational structures to mediate among the parties of interest, the policies for change will not be sufficient to meet the future. The paper discusses in some detail an organisational mediating structure called the Community Equity Model which organises care at the local neighbourhood or community level using the community as actual fundsholder. This puts the critical stakeholders in a practical mutual ownership relationship by making allocation, services and resource accountability a local act. The paper briefly discusses the organisational and information technology for this type of health care system redesign.

Community Health Planning↗
PubMedDate not supplied

[Public hospital payment system in Spain: the experience of Catalonia and Andalusia].

Since the mid-1990s, the introduction of new public hospital payment systems to improve the efficiency of Spanish hospitals within the context of managed competition has been debated. Blended systems, which recognize the importance of the activity performed, as well as the role of the hospital in the public health system, have emerged as the best-matched tools both in risk assignment and in efficiency-economic feasibility dialectic. In this article, the payment method used in Catalonia since 1997 is analyzed and contrasted with that introduced in Andalusia in 1998. The evaluation focuses on the instruments used to incorporate the mixed model in the two different settings. On the one hand, the capacity of diagnosis related groups (DRGs) to define hospital product cost is limited. Furthermore, DRGs require numerous adjustments before introduction into Spain. On the other hand, structural level can be defined through the Grade of Memberships in Catalonia and the Basic Centers in Andalusia. We also analyze the introduction of the different methods into Spain and their adaptation to the Catalan and Andalusian environments. The transition periods seem not to have led to a definitive solution and have served to highlight the fragility of the instruments used and of the use that has been made of them. We conclude that the introduction of new tools to improve hospital efficiency through payment systems was precipitate and, to a certain extent, naive. Public hospital payment systems can be considered to be effective when they manage to allocate resources over a period of time. Ensuring the efficiency of public hospitals implies daily work on the part of each hospital and the information systems generated by regional health systems and will not be achieved through external financial tools poorly adapted to the setting in which they are applied.

Diagnosis-Related Groups↗
PubMed1993

On being very smart: the mental health community's response in the health care reform debate.

President Clinton's proposal for a health care system based on managed competition began a dialogue within the mental health community about whether such a system would work in the mental health area. In early March a large coalition representing more than 30 mental health organizations, including advocacy organizations, state systems, professional associations, provider agencies, families, and consumers, formally transmitted to the President's Task Force on National Health Care Reform a document presenting a unified position on how mental health care should be delivered within a reformed health care system. The consensus document, reproduced here, maintains that a full range of services must be available to all children and adults with mental or emotional disorders. The document presents guidelines for containing costs, for standards of delivery for mental health services, and for the role of the states and the federal government within the new health care system.

Community Mental Health Services↗
PubMed1976

Health patterns associated with type A behavior: a managerial population.

Type A Behavior is a behavioral syndrome found to be related to coronary heart disease and characterized by excessive drive, ambition, and competitiveness. Managers from 12 different companies were examined for this syndrome and for a number of the known risk factors in coronary heart disease (blood pressure, cholesterol, triglycerides, uric acid, smoking, and fitness). Those individuals exhibiting extreme Type A Behavior (Type A) showed significantly higher blood pressure (systolic and diastolic) and higher cholesterol and triglyceride levels. A greater percentage of these individuals were cigarette smokers. On serum uric acid there were no differences. In each age group, Type A's were less interested in exercise, although differences in cardio-respiratory fitness were found only in the oldest age group. Type A Behavior also was related to age, education, company growth rates, and stress symptoms. Overall, the Type A1's were found to be higher on a number of risk factors known to be associated with coronary heart disease. With regard to the Type A2's (individuals with less developed Type A Behavior), the findings were not conclusive.

Administrative Personnel↗
PubMed1993

Clinton plan takes shape, but financing still big unknown.

Global budgets...managed competition...price controls. Many of their features have filled in as Hillary Rodham Clinton's health care reform task force wraps up its work--six weeks late and counting. Based on the numerous details that have come out in the past few months, Health Care Reform Week has assembled the following round-up of provisions likely to be included in the coming reform plan. The information in based on HCR Week's interviews with government officials and industry representatives plus recent news accounts and statements by Clinton administration and congressional officials. One certainty is that whatever is in the plan President Clinton sends to Congress, legislators' approval will be heavily influenced by the proposals' cost feasibility. Advocates of the largest possible range of benefits in the health care package, for example [HCRW Special Report, 5/17/93], already are hearing from skeptical lawmakers. New benefits are "fine so long as we are willing to do one thing: pay for them. And pay for them now," says House Ways & Means Committee Chairman Dan Rostenkowski (D-Ill.). "There's been a long, unhappy record in this town of paying for today's benefits with tomorrow's dollars." Here's a wrap up of what's come out to date.

Health Benefit Plans, Employee↗