There are three main problems at present in the area of health care: — an imbalance between the amounts of state financing for health care and the guarantees offurnishing medical assistanceto the citizenry at no charge; — a lack of coordination in the activities and contradictions in the mutual relations of the entities receiving state financing for health care, engendered by the decentralization of management and transition to a system of mandatory medical insurance; — an absence of competitive behavior among insurance organizations and medical institutions, despite the adoption of the institutions of a market economy into the system of health care.
The cutbacks in Medicare and Medicaid reimbursement, and the Republican takeover of Capitol Hill and the state legislatures as a result of recent elections, suggest that the payer-driven forces of managed care, capitated payment, and the regional networks (alliances) will serve as centerpieces to improve the organization, financing, and delivery of America's health services. These "voluntary" alliances that are now being forged as an amalgam of health providers and insurance underwriters, often foreshadow the powerful, geographically linked regional health networks that are evolving into oligopolies throughout the United States. As the Department of Justice and the Federal Trade Commission are unable to appropriately analyze the efficacy of most prospective mergers, the American health field increasingly can expect monopolistic environments. In this process, the public eventually may demand the formation of state health services commissions. Within this framework, the German decentralized, multipayer, multitier approach, which historically is self-governing and allows for negotiating reimbursement rates between insurers and providers, offers a preferred option to the traditional American public utility model.
OBJECTIVE: In 1990 the state of Arkansas shifted financial responsibility for state hospital services to community mental health centers; through a policy known as "bed buy-back," centers now authorize all state hospital admissions and prospectively purchase bed days for their patients. Characteristics of patients hospitalized before and after implementation of the policy were examined to determine how the policy affected hospital admission rates, types of patients admitted, and the amount of contact between CMHC and hospital staff about admitted patients, as well as how these elements were affected differently in rural and urban areas. METHODS: Changes in the types of patients admitted over the 13 months before and 14 months after the change in financing were studied through retrospective chart review of 648 patients. Administrative data were used to examine changes in numbers of admissions for 30 months before and 26 months afterward. Data were analyzed by piecewise regression, least-squares, and logistic regression analyses. RESULTS: After financial decentralization, state hospital use was reduced in both urban and rural areas, although the reduction in urban areas was proportionally greater. Contrary to expectation, admissions were not limited to the most severely ill, disruptive, or substance-abusing patients, nor were they more likely to be readmitted. For patients who were admitted, communication between the community and the state hospital was greater than before financial decentralization. CONCLUSIONS: Shifting financial responsibility for patient care significantly reduced state hospital use, did not affect patient mix, and apparently increased coordination of care between community and hospital. Whether bed buy-back has affected the kind or quality of services delivered in the community awaits further study.
James D. Bentley, J Chusid, G D'Antuono, Joyce V. Kelly · 5 authors
The contemporary academic medical center is a complex organization providing medical and other professional health education, biomedical and behavioral research, and a comprehensive range of patient care services. This paper presents data from the Association of American Medical Colleges' 1989 survey of 125 member faculty practice plans. The survey data showed that 62% of the 74 responding plans were units or associations within the medical school corporate structure. Plans were organized along a broad continuum from the autonomous, departmental model with decentralized governance and management to the group model with centralized governance and management. The growth of managed care, increased competition, and a greater reliance by the medical school on clinical practice income as a financing source are causing the practice plan to expand beyond billing of professional fees. The survey data showed that 75% of the practice plans operated satellite centers, and 61% planned to build new ambulatory care facilities in order to expand and improve services to patients. The practice plans also have adapted to changes in third-party reimbursement and are establishing mechanisms to negotiate managed care contracts involving multiple clinical departments to increase referrals and maintain patient shares; 86% of the plans participate in at least one managed-care organization. The role of the practice plan will continue to evolve in response to the needs of the academic medical center for a cooperative and supportive environment in which to conduct its traditional missions of teaching, research, and patient care.
Establishing a system of family practice clinics with physicians from its medical staff enabled Mercy Hospital Medical Center, Des Moines, IA, not only to meet consumers' changing needs and wants but also to develop a long-term strategy for survival. The joint venture, which has grown to 9 clinics and 30 physicians since its inception in 1983, does not restrict the hospital from entering into similar relationships with other physician groups. Neither does it restrict physicians from entering new arrangements or using other hospitals. Each clinic operates quasi-autonomously in serving its own patients, and issues such as hiring, firing, hours of operation, and local public relations are handled in a decentralized manner. Other matters--insurance coverage, marketing programs, accounting and data processing systems--are standardized throughout the organization. Challenges involved in undertaking such a project include overcoming resistance from employees, building public awareness of the project, and creating an open, trusting relationship between physicians and administrators. It is particularly important to foster the support of physicians "outside" the partnership and to include those who remain in private practice in marketing efforts.
Stephen T. Miller, Roger Vander Zwagg, Melanie Joyner, John W. Runyan
Observations of a publicly-financed system for the medical care of a large number of persons with chronic diseases have been made over seven years. The system combines decentralized, nurse-staffed neighborhood clinics, operated by a public health department, with a central referral clinic for consultations and the management of complicated problems. After seven years in the chronic disease program 55% of 1,004 patients with diagnoses of diabetes mellitus, hypertension, and cardiac diseases were still receiving care, 19% had died, and 26% had been lost to the program. In the seventh year, the mean diastolic blood pressure in hypertensives was 84 mm Hg and the mean serum glucose in diabetics was 203 mg/dl. For the group under care, hospital days/1000/year were 74% of the rate during the year before referral to the program and out-patient visits/1000/year were approximately the same as before referral. However, two-thirds of the visits, formerly made to a public hospital, were now being made to neighborhood clinics. The system appears to be an effective method of providing medical services for persons who formerly used the public hospital as their source of outpatient care.
Open access
Primary Care and Health Outcomes
Chronic Disease Management Strategies
Health Systems, Economic Evaluations, Quality of Life
People in the United States have generally ignored Canada's long experience with extensive public financing and management of its health system. This is unfortunate because the two countries are similar in so many ways that Canada's experience is very pertinent to the continuing debate in the United States over increasing government involvement in health care. Two lessons emerge from Canada's experience. First, while many in the United States are dubious about more government involvement in health care, Canada's overall experience has been favorable. Second, Canada's experience suggests some specific forms that such public involvement should take to improve the performance of the health system. One important reason for Canada's favorable experience has been the decentralization of government decision-making. Constitutionally, the ten provinces have jurisdiction over most health services, so they are key decision-makers. The federal government, however, has had an important role in the shaping of Canada's health system, most importantly by offering subsidies to provinces willing to establish certain health programs that meet its standards. Canada's extensive public financing of health services is the most striking difference between its health system and that of the United States. In each province all medically necessary physician services and most inpatient and outpatient hospital services are publicly financed for all residents. Hospital services have been publicly financed for more than twenty years and physician services for more than ten years. Provincial agencies administer the programs, reimbursing physicians predominantly on a fee-for-service basis. Hospitals typically receive biweekly payments based on their provincially approved budgets. The provincial plans are financed jointly by the federal and provincial governments, largely from their general revenues. Few now bother to collect premiums or special health taxes, and minimal use is made of deterrent charges. The provinces vary considerably in the extent to which other personal health services are publicly financed. For example, some finance dental services for children; some, prescription drugs for people aged sixty-five years and over.