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PubMed1994

Risk-adjusted capitation: recent experiences in The Netherlands.

The market-oriented health care reforms taking place in the Netherlands show a clear resemblance to the proposals for managed competition in U.S. health care. In both countries good risk adjustment mechanisms that prevent cream skimming--that is, that prevent plans from selecting the best health risks--are critical to the success of the reforms. In this paper we present an overview of the Dutch reforms and of our research concerning risk-adjusted capitation payments. Although we are optimistic about the technical possibilities for solving the problem of cream skimming, the implementation of good risk-adjusted capitation is a long-term challenge.

Capitation Fee↗
PubMed2004

The impact of healthcare reform in the Netherlands.

In 1987, the Dekker committee proposed managed competition as the dominant principle for reforming healthcare in The Netherlands. Considerable progress has been made in implementing the Dekker proposal, such as risk-adjusted capitation of Sick Funds, yearly open enrollment and selective contracting with providers. The centre-right government, which came to power in 2003, plans to implement the final steps in the coming years, which will drastically change pharmaceutical policies and shift power from central government to regional actors in healthcare. The current price reference system, which was initiated in 1991, has failed in containing expenditure or providing incentives towards efficiency. For new drugs, which can not be clustered in the price reference system or for which the producer wants a premium price, a pharmacoeconomic study and budget impact analysis is formally required from 2005 onwards. This fourth hurdle may limit access to new drugs, which contribute considerably to expenditure or for which relative efficiency is above a certain cost-effectiveness threshold. In line with the Dekker principle, insurance companies are expected to step into the market and initiate policies to reduce costs. However, the government seems somewhat reluctant to abandon instruments belonging to old supply-side regulation. Given the current healthcare cost explosion, which coincides with an economic recession, it remains to be seen whether politicians will really shift the power to the insurers and not return to traditional cost-containment policies.

Drug Utilization Review↗
PubMed2006

Silenced complaints, suppressed expectations: the cumulative effects of home care rationing.

In many Western welfare jurisdictions, publicly provided home care is being eroded and its provision increasingly individualized. These shifts are of a particular significance for older women, a group for whom supportive home care has been an important buttress against the social and physical jeopardies of old age. A longitudinal, qualitative study of such women in Ontario, Canada, spanned the implementation of managed competition in home care and a period of rapid privatization and service rationing. Study participants experienced cuts and, stemming from increasingly precarious employment conditions in the home care workforce, inconsistent care providers. These changes generated distress, insecurity, and isolation in participants' lives. This article explores how their complaints about insufficient care were silenced: by fear, hopelessness, and the cultural injunction to put a stoic and selfless face on the limitations of old age. Their accounts reveal how large material and discursive shifts and state restructuring come to penetrate identity, feeling, and speech. This examination of the silencing of complaint at home care's front lines reveals the cumulative effects of rationing; it also illuminates how, if heard, service users' voices can inform collective struggles to resist the degradation of home care and reposition older people in relation to the state.

Adult↗
PubMed1990

The CIO and IRM (information resources management) alliance: maneuvering for the competitive edge in hospital information management.

In 1986, Johns noted that "The hospital industry was caught unprepared for the external demands and information needs required in a case-mix reimbursement environment." Lack of a data-processing philosophy and inattention to external forces were cited as having hampered technology upgrade and integration of financial and clinical databases. The intervening years have witnessed a growth of information dissemination in the health care industry concerning information value and resource management. The frequency of appearance of articles on information management in the professional literature and the number of workshops and professional meetings addressing the topic attest to the current visibility of the information resource. Despite this flurry of interest, the industry has not developed its own models of information resources management nor validated its information evolution with accepted management information systems models. While interest in health care information resource management exists, understanding of the complex issues in this area has not developed as one would expect. While there are a myriad of reasons for this, a contributing factor is the lack of a research foundation for development and application of theory and models. Even though various graduate programs exist in medical informatics and biomedical computing, few concentrate on the study of health information resource management from an organizational perspective. Because of this, academic research in the area has been minimal. The scarcity of graduate-level programs has also meant that few individuals have been educated to deal with the challenges of managing the many disparate functional activities associated with health care information resource management. Due to a variety of internal and external forces, extreme demands were placed on the hospital information resource during the past decade.(ABSTRACT TRUNCATED AT 250 WORDS)

Hospital Administrators↗
PubMed1992

Fear of regulation spurs activity on reform alternatives.

A variety of programs and proposals designed to head off governmental intervention are being touted as answers to the vexing problems of healthcare delivery--specifically cost and access. Among the market-based initiatives are those based on the concept of "managed competition," which aims to match large groups of consumers with cost-conscious healthcare providers and allow them to compete for patients based on quality and efficiency.

Cost Control↗
PubMed1992

Yes, the market can curb health costs.

Memo to Clinton's transition team: forget those tough expenditure ceilings you're considering. Look instead at what managed competition is already accomplishing.

Competitive Medical Plans↗
PubMed1993

Managing acute care.

In the last few years, much medical-facility construction has been driven by what insurers want. Hospitals have built facilities for well-reimbursed procedures and closed money-losing ones. Health-maintenance organizations increasingly expect to hold down costs by making prepayment arrangements with doctors and their hospitals. President Clinton has pledged early action on health-care reform, which will likely change planners' priorities. Whether the nation goes to Clintonian "managed competition" or a Canadian-style nationwide single-payer system (the two most likely options), the projects on these pages reflect two large-scale trends that are likely to continue: the movement of more procedures from inpatient to outpatient facilities and the separation of treatment functions from ordinary office and administrative tasks so that the latter are not performed in the same high-cost buildings as technology-intensive procedures. Various schemes that make care more "patient-centered" have been tried and been shown to speed healing, even for outpatients, but such hard-to-quantify issues get short shrift in an era of knee-jerk cost containment. The challenge in tomorrow's healthcare universe--whatever it becomes--will be to keep these issues on the table.

Architecture↗
PubMedDate not supplied

Taxing health benefits: snake oil ... or smart health policy?

Limiting the tax-free treatment of employer-paid health benefits is a cornerstone of managed competition, the health reform approach favored by the Clinton Administration. Organized labor argues that the idea is a double-whammy for wage-strapped workers, while a leading academic calls it a good solution to one of the nation's worst public policies.

Community Participation↗
PubMed1993

California health care in the 21st Century. A vision for reform.

California Insurance Commissioner John Garamendi's proposal for revamping the state's health care system is considered by many to be an improvement on Alain Enthoven's version of managed competition because it separates insurance from employment and includes budgets and a single source of financing. Princeton sociologist Paul Starr, a prominent member of the national Health Care Taskforce, is a proponent of a similar plan on a national basis. This is an excerpt from the Executive Summary of the plan; in 1992 the California legislature approved a commission to study the proposal, only to have it vetoed by Governor Pete Wilson.

California↗
PubMed1993

The American Health Security Act of 1993.

The American Health Security Act (S 491, HR 1200) was introduced in the U.S. Senate by Paul Wellstone (D-MN) and in the House of Representatives by John Conyers (D-MI) and Jim McDermott (D-WA), along with 54 co-sponsors. The legislation, which replaces and strengthens the 1992 bill proposed by former Rep. Marty Russo and Sen. Wellstone, presents a single-payer alternative to managed competition proposals. This summary is excerpted from material provided by Sen. Wellstone's office.

Health Policy↗
PubMed1993

Health reform: setting the agenda for long term care.

The White House Task Force on National Health Care Reform, headed by First Lady Hillary Rodham Clinton, is expected to release its prescription for health care reform this month. From the outset, Clinton's mandate was clear: to provide universal coverage while reining in costs for delivering quality health care. Before President Clinton was even sworn into office, he had outlined the major principles that would shape the health reform debate. Global budgeting would establish limits on all health care expenditures, thereby containing health costs. Under a system of managed competition, employers would form health alliances for consumers to negotiate for cost-effective health care at the community level. So far, a basic approach to health care reform has emerged. A key element is universal coverage--with an emphasis on acute, preventive, and mental health care. Other likely pieces are employer-employee contributions to health care plans, laws that guarantee continued coverage if an individual changes jobs or becomes ill, and health insurance alliances that would help assure individual access to low-cost health care. What still is not clear is the extent to which long term care will be included in the basic benefits package. A confidential report circulated by the task force last month includes four options for long term care: incremental Medicaid reform; a new federal/state program to replace Medicaid; a social insurance program for home and community-based services; or full social insurance for long term care. Some work group members have identified an additional option: prefunded long term care insurance.(ABSTRACT TRUNCATED AT 250 WORDS)

Health Policy↗
PubMedDate not supplied

Turning swords into plowshares: lessons from the military health system.

Policymakers are searching everywhere for examples of how best to reform the nation's health care system. A major reform model from an unexpected quarter--the U.S. military--is making great strides forward and contains many of the ingredients in the national reform debate: global budgeting, pooled-payer funding, private industry competition, managed care, prevention, and reallocation of resources.

Budgets↗
PubMed1993

The national health care phobia.

Opinion: Clinton's plan for 'managed competition' won't work. A look at a misunderstood alternative that could provide inexpensive, first-rate care.

Competitive Medical Plans↗
PubMed1993

Health care study on industry perspective on health reform. The Boston Consulting Group.

Many senior health care executives support President Clinton's health care reform objectives, although they question the government's ability to execute reform and control escalating health care costs, according to a survey released by The Boston Consulting Group. The survey also revealed that the majority of those interviewed endorse managed competition and believe that universal coverage is the right goal to pursue. Seventy-five CEOs or senior executives at some of the nation's largest teaching and community hospitals, HMOs, pharmaceutical companies, and medical suppliers were interviewed by The Boston Consulting Group for the survey.

Administrative Personnel↗
PubMed1994

Is there an alternative to a National Health Board for Technology Assessment?

The National Health Board, a lynchpin of the managed competition philosophy of health reform, would perform a necessary function in regards to technology assessment for clinical decision making. However, would such an agency have what it takes to provide adequate turnaround, and nonbiased decision-making ability to play this crucial part of the reform process?

Decision Making, Organizational↗
PubMed1994

"East meets West".

For most of the 70s and 80s, the East was considered to be the center of hospital rate regulation and the West the center for free-market competition. Managed care in the East was "home grown" and large, national public companies generally stayed away from these markets. But, in a fascinating shift amid a great deal of turbulence, the East is starting to look at lot like the West. Economics are driving reforms and the best move for lawmakers is to stay out of the way. The train has already left the station. Perhaps the most frightening thing about the most recent Group Health Association data is that the President comes from a state with less than 3% HMO penetration. Many of his trusted advisors come from that state, including physicians who report on the home front.

Attitude to Health↗
PubMed1993

AMA's Todd pushes for reform--cautiously. Interview by Richard L. Clark.

James S. Todd, MD, executive vice president, American Medical Association (AMA), believes there are only two ways to make sure all Americans are covered by health insurance--raise taxes or decrease benefits. In an interview with Richard L. Clarke, FHFMA, president, Healthcare Financial Management Association, Todd discusses the AMA's national healthcare reform plan and the AMA's outlook on global budgets, managed competition, and physician-hospital relationships.

American Medical Association↗