Reforming the health care delivery system

The health care delivery system is evolving rapidly. There have been changes in the way health care is financed, the types of treatments available, the sites of care, and the physician patient relationship. These changes have resulted primarily from reactions to health care cost inflation. Health care reform is likely to accelerate some of these changes. The threat/promise of health care reform has already accelerated the consolidation of the health care services market. Health care reform is likely to reduce the number of insurers, increase the number of Americans in managed health care plans, increase the number of physicians in group practice, change provider income, and in general make the health care delivery system more concentrated and vertically integrated.     

Managed care and the rationalization of mental health services

Managed care represents a response to the wider institutional demand for technical rationality and efficiency, and it may be in conflict with professionally generated logics of mental health care which emphasize the delivery of quality care, as well as providing services to all who need care. The organizational and policy conundrum is to balance conflicting institutional demands for efficiency (cost savings) and effectiveness (access and quality). This paper examines managed care in one public sector mental health care system that has attempted to incorporate the principles of managed care into a community based system of care and to overcome the potential contradictions between demands for efficiency and professional logics of care. Both qualitative and quantitative data are used to examine changes in organizational structure and service offerings; providers' experience of managed care, and the effect of managed care on working conditions and work experiences, and changes in the goals of the organization as measured by the specification of client outcomes. I find that, while increased performance accountability and outcome assessment (in keeping with demands for efficiency) have the potential to improve mental health care services, in fact, providers report that the primary effect of managed care has been an emphasis on cost containment, and there has been a corresponding de-emphasis on the provision of community based services for clients with long term care needs. However, there is potential for professional logics to be maintained by larger institutional forces demanding quality care.     

Issues of quality and consumer rights in the health care market

This Issue Brief describes how the structure of the health care market has changed in the recent years. It outlines the growth in managed care and the changes in the types of managed care plans available. In addition, it discusses the issue of quality in the health care market. It also includes an overview of the legislative topics and issues relating to quality and consumer rights that policymakers are currently considering. Growth in national health expenditures, the medical care price index, and employer health care costs has slowed significantly since 1990. This decreased growth has coincided with substantial increases in managed care plan enrollment. The percentage of employees enrolled in managed care plans increased from 48 percent to 85 percent from 1992 to 1997. Quality is a multidimensional concept. Although individuals may agree on its components, they may disagree on the relative importance of these components. Therefore, disagreement exists not only on how to measure quality but also on how it is defined. Consequently, policy decisions need to be based on an evaluation of a particular law's effect as opposed to its stated goal or intent. This distinction is important because a law that addresses access or consumer rights does not necessarily address the quality of care a consumer receives. Ultimately, whether an individual believes that a law truly addresses quality will depend in a large part on his or her subjective opinion of what quality entails. To date, comparison of the quality of managed care plans with that of fee-for-service plans has not produced results that uniformly differentiate between these two plan types in either a positive or a negative way. In addition, it is important to note that the current debate on the quality of care provided in the health care market is not new to the present managed care era. The regulations and mandates discussed in this report would not guarantee increased quality in the health care market, unless quality is defined as easier access for those with health insurance. However, if quality is defined as the success of the outcomes of health services provided, the effect of these regulations on quality is in need of further research. Yet, the regulations would have some impact on the costs of health benefits and insurance. This impact has been estimated to be relatively small to substantial, depending on the interpretation of the mandates and assumptions derived from that interpretation. Regardless of the magnitude of the estimated increases, some research has shown that these regulations could have serious implications for the likelihood of small businesses offering health benefits. While these health plan regulations effect on quality depends on one's definition of quality, costs would increase regardless of the definition one uses. Consequently, these regulations would come at a price. Thus, legislators must decide between: (a) imposing regulation that would increase access and consumer "rights" for those with insurance but would be of questionable value to the quality of outcomes, and (b) allowing existing market forces to improve quality through experimentation and competitive forces.     

NEW TRENDS IN THE DOCTOR-PATIENT RELATIONSHIP: IMPACTS OF MANAGED CARE ON THE GROWTH OF A CONSUMER PROTECTIONS MODEL

Managed care is prompting a large revision not only in the ways doctors are employed and paid but also in the essence of the relationship between doctors and patients. In medical sociology, a discipline with a long-standing focus on scrutinizing the role of both the physician and the patient, there has already been discussion of a shift from the doctor as more all knowing to a less dominant position vis-a-vis both the patient and delivery of care. Patients are aware of shifts that place physicians in an environment characterized by new roles and responsibilities, such as acting as a gatekeeper. Limitations on health care coverage and the rethinking of roles have led to a depiction of the patient as the consumer of care and the managed care plan's becoming the commercial enterprise from which a service is obtained. The model of the patient as consumer of medically related goods and services appears to be growing, as does a model of the physician as one who contracts for a specified range of services for specific patients. In this article, trends in and problems with contemporary managed care are raised. Calls for patients' rights legislation may be among the health trends of the new millennium.     

Medicaid Managed Care Programs for High-Risk Older People in Massachusetts

The Commonwealth of Massachusetts has undertaken a major initiative in the development of comprehensive managed health care programs for two sets of high-risk older people: those who are frail and homebound and those who reside in nursing homes. This effort has been coordinated by the state's Department of Public Welfare (DPW; Medical Assistance [Medicaid] Program) and Executive Office of Elder Affairs, and expedited ba a set of Health Care Financy Administration (HCFA) waivers and by the state's revised Nurse Practice Act (MGS Chapter 56). Than act allows nurse-practioners and physician assistants expanded roles as primary providers in home care and nursing home settings. The managed care initiatives have supplemented other efforts (1) to coordinate health and social services for older people, (2) to provide as broad a range as possible of community-based services for older people, and (3) to enroll as many older adults as possible in Health Maintenance Organization (HMO) "Senior Plans" and other similar "Competive Medical Plans."

Though there is still no evidence of the managed care programs' effects, this article summarizes some of the possible risks and benefits of managed care programs for those kinds of populations and presents an agenda of questions that evaluations of managed care programs must address.     

Technology, skills, and health care labor markets

Conclusion I examine the role of technological change in health care labor markets. One of the biggest issues in the U.S. economy over the recent past has been rapidly rising health care costs. Conventional wisdom holds the main factor driving these costs increases has been technological change. These changes in technology have lead to a direct transformation in the delivery of health care and have also lead to indirect transformations through the reshaping of the private and public insurance industry. My findings are consistent with the idea that technological change has resulted in an increase in demand for higher skilled workers in the industry, while being labor-saving among low-skill workers. The earnings of RNs and health therapists rose rapidly over the 1983 to 1993 period, declined between 1993 and 1996, but then began to rise again after 1996. It is generally believed that managed care has had a one-time cost reducing effect in the industry by eliminating some of the inefficiencies associated with fee-for-service health insurance (Newhouse, 1992). The results here suggest a similar finding in the labor market. I appreciate helpful comments from Laurence Baker, James Bennett, Ann Frost, Barry Hirsch, Joanne Spetz, and Daphne Taras.     

How physician-employees experience their work lives in a changing HMO

The present study advances our understanding of both physician adaptation and the physician-organization relationship in a managed care environment defined by structural diversity and constant change. It does so through a longitudinal examination of a single group of physician-employees experiencing their work lives within a nonprofit health maintenance organization (HMO) in the midst of major strategic developments. Using interview, observation, and archival data collected over a five-year period, the analysis reveals that the form and substance of individual physician adaptation to organizational life is dependent upon social exchanges over time with the HMO, making it an emergent, evolutionary process rather than a pre-determined, static phenomenon. However, the results also demonstrate that physician adaptive response to rapid, unpredictable organizational change is slow and delayed, in particular when this change makes physicians more dependent on their employing organization. This confers an advantage onto the organization vis-à-vis professionals in interpreting and responding to environmental change. These insights should encourage sociologists to employ research designs and contingency models of physician attitudes and behavior that capture the dynamic and particularistic nature of everyday physician work life in contemporary health care.     

The economics of child care and public policy

Child care denotes any arrangement used by a working parent for care of a child, including self-care. This article is concerned with the factors that influence the demand for market modes of child care by two parent families with working mothers. A unique aspect of the study is that it is able to assess the impact of a child care subsidy program. An implication of the analysis is that the demand for market care is price elastic and is therefore susceptible to considerable change through programs of increased subsidization.     

Health care reform: managed competition and beyond

Since the election, the health care reform debate has focused on three broad features: implementation of managed competition, changes in the tax treatment of health insurance, and the imposition of budget caps or targets. The basic element of managed competition is the creation of sponsors who act as collective purchasing agents for large groups of individuals. One of the potentially most politically difficult issues in implementing any health care reform proposal is likely to be defining the minimum standard benefit package. It will determine the costs society bears, the income of providers, the health of many individuals, and the attributes of a workable health care reform package. Managed competition is intended to foster competition among health plans on the basis of cost and quality. The measures of quality actually employed in the health care system will determine in large part the incentives faced by insurers, providers, and consumers. The problem of adverse selection is potentially the most important issue in reforming the health insurance market. If individuals can opt not to purchase health benefits, poorer risks will be more likely to purchase health insurance than good risks, and at minimum the price of these benefits will be higher than would otherwise be the case. Managed competition requires that individuals share at least some of the financial consequences of their choices among health plans. As a result, most managed competition proposals change the tax code by limiting the exclusion of employer contributions to health insurance from worker's taxable income. Changing the health insurance market, mandating employer health benefits, and changing the tax code may have significant effects on the health care delivery system, but they are unlikely to reduce health care cost inflation in the near term. One of the proposals for restraining the growth in health care costs is the imposition of a budget on the amount spent on health care services. The combination of the constraints placed on federal governmental action by the budget and the significant political problems involved in reaching a consensus on the important elements of health care reform may limit the ability of the federal government to implement national health care reform in the near term. As a result, individual states may be encouraged by the federal government to continue to experiment with their own health reform programs.     

Defining the challenges of providing long-term care: the case of the nursing home industry's response to the AIDS epidemic

Acquired Immune Deficiency Syndrome (AIDS) is now viewed as a chronic disease requiring long-term management. As a result, more persons with AIDS (PWAs) are seeking long-term care in facilities that have primarily served the elderly. In some regions, however, the nursing home market into which PWAs may introduce new demand is a market already characterized by excess demand. In light of this, competition for limited long-term care resources may develop between the frail elderly and PWAs. The nursing home industry has raised many issues regarding the feasibility of admitting AIDS patients as residents, but little is known about how important these issues are in deciding admissions policy. How the industry perceives and resolves the concerns it has regarding delivery of care to PWAs can affect the overall long-term care system and thus affect the traditional users-the frail elderly. Knowing the concerns and preferences of the industry may help guide and anticipate future changes in the system. In this pilot study, a random sample of 250 nursing home administrators in the five highest AIDS-incidence areas in the United States was surveyed to determine (1) the industry's concerns and issues regarding AIDS care, (2) data regarding requests for admission by PWAs to nursing homes, and (3) data concerning the industry's preferred way of delivering AIDS care. Important admissions policy issues cited by the respondents included the ability to meet special care needs, costs of care, and inadequate reimbursement. The majority also believed the most appropriate methods of providing care were special care units for AIDS within nursing homes or dedicated HIV/AIDS nursing facilities.     

AN ECONOMETRIC MODEL OF THE DEMAND FOR CHILD CARE

Child care denotes any arrangement used by a working parent for care of a child, including self-care. This paper is concerned with the factors that influence the demand for market modes of child care by two parent families with working mothers. An econometric model is specified that relates the demand for child care to price, income, and other economic variables. Because of the discrete nature of the child care decision, the multinomial logit probability model is used to analyze the data. The empirical results suggest that the demand for child care is sensitive to both prices and income.     

Health care consolidation and the changing health care marketplace. A review of the literature and issues

This Issue Brief examines the academic literature and issues in consolidation of the hospital sector in the context of responses to changes in the competitive environment. It analyzes the motivations for consolidation as well as its effects. Hospital merger activity has increased dramatically in recent years. The current wave of mergers is primarily a reaction to a competitive environment that is placing a greater emphasis on controlling costs and forcing high-cost providers out of the market. The growth of managed care has placed considerable pressure on providers of health care and, in particular, on hospitals. The evolution of insurance companies' behavior helps explain the recent hospital consolidation movement. As managed care has become the dominant type of coverage in the last decade, insurance companies have become more active in trying to control costs--a reversion to their previous practices before the advent of managed care. Insurance companies have placed cost constraints on providers, both in the early years of health insurance and currently, when there are strong competitive forces. Hospitals claim that their primary merger motives are improving efficiency and the quality of care. The empirical evidence on this claim is mixed. Vertical integration (between suppliers and buyers of health care services, such as between hospitals and physicians) has appealed to hospitals because of their need to obtain more patients. More research is needed to explore the effects of vertical integration in the health care sector. In one of the more significant recent legal rulings, the U.S. Justice Department lost a 1997 case challenging the merger of two hospitals in the New York City metropolitan area. This, along with other recent losses by the antitrust authorities, does not bode well for the government's ability to prevent hospital mergers in metropolitan areas. It is difficult to generalize on an appropriate antitrust policy for hospital mergers. Hospital consolidation is likely to continue at a rapid pace. Since some developments may reduce the cost of employee benefits while others may increase the cost of these benefits, the final effect on the provision of health care benefits by employers is uncertain. Employers must pay close attention to the hospital consolidation movement because it will lead to important changes in the provision of health care benefits.     

高职护理多专业方向培养模式的构想

从护理人才市场需求出发,依据紧缺护理岗位市场调研结果,提出通过建构特色明显的课程体系,优化组合现有实验设备和教学力量,实现后期分流培养,重点向院前急救护理、康复护理、老年护理方向培养,为提高就业竞争力,拓宽就业渠道提供了新思路。     

Caring for informal caregivers: policy approaches to the provision of direct support services

Despite being the backbone of modern welfare states, the informal care sector for elderly people in need of long-term care is highly dysfunctional. The majority of informal caregivers are overburdened on account of their care-related activities, although an evolving market for support services directly aimed at relieving informal caregivers is observable. In this paper, we examine the reasons for the imperfect exchange between demand and supply in this market, applying the economic theory of market failure. Through a case study of Austria based on an empirical, qualitative survey of all direct support services and their suppliers on the national level as well as in three provinces, an understanding of this market's main players and mechanisms is derived. Thus, the authors determine that three different system types can be identified beyond the historical regional discrepancies. They illustrate the approaches to service provision for informal caregivers: centralized and public, laissez-faire and private, and a radically decentralized network for informal caregivers. Still, lack of information, social and psychological barriers, as well as high transaction costs, are identified which undermine the support service market for informal care. If the costs of the formal long-term care sector are to be contained despite demographic developments, better policy approaches will be necessary to overcome this challenge. In light of this, recommendations are derived to ensure a better exchange between supply and demand. By providing an initial empirical understanding and analysis of this market and its imperfections, the authors pioneer future quantitative research in this field.     

Assisted homeownership, investment and their roles in private property price dynamics in Hong Kong

Hong Kong not only has one of the most institutionally-involved housing markets, but also one of the most developed stock markets in the world. In the meantime, the function of real estate has become increasingly important, yet increasingly vague at the same time. This paper attempts to explore the significant factors in the price adjustments of residential properties. It is found that while most market fundamentals are not significant in explaining property price movements, the roles of investment concerns and of government policy changes in assisted homeownership (HOS) are much more critical in this regard. On the one hand, real estate prices are driven more by investor demand, rather than by user demand; and residential properties are used to hedge against price risks in the stock market, instead of against inflation. On the other hand, while the upgrading hypothesis is confirmed in this study, the situation of Hong Kong turns out to be a bit different from the Singapore experience. As the production of HOS flats is suspended until further notice, the resale HOS market has managed to pull a fraction of homebuyers from the private sector. This particular finding shows that the government’s decision to suspend HOS flat production and sale in Fall 2002 has not accomplished what was intended to achieve. Instead, this leads to several implications, which are then discussed.     

The effectiveness of health care cost management strategies: a review of the evidence

This Issue Brief discusses the evolution of the health care delivery and financing systems and its effects on health care cost management and describes the changes in the health care delivery system as they pertain to managed care. It presents empirical evidence on the effectiveness of managed care and concludes with an analysis of the potential of future health care reform to influence the evolution of the health care delivery system and affect health care costs. Between 1987 and 1993, total enrollment in health maintenance organizations (HMOs) increased from 28.6 million to 39.8 million, representing an additional 11.2 million individuals, or 4 percent of the U.S. population. At the same time, new forms of managed care organizations emerged. Enrollment in preferred provider organizations increased from 12.2 million individuals in 1987 to 58 million in 1992, and enrollment in point-of-service plans increased from virtually none in 1987 to 2.3 million individuals in 1992. In addition, the percentage of traditional fee-for-service plans with some form of utilization review increased to 95 percent in 1990 from 41 percent in 1987. Measuring the effects of the changing delivery system on the costs and quality of health care services has been a difficult task, resulting in considerable disagreement as to whether or not costs have been affected. In a recent report, the Congressional Budget Office recognizes two new major findings. First, managed care can provide cost-effective health care at a level of quality comparable with the care typically provided by a fee-for-service plan. Second, independent practice associations can be as effective as group- or staff-model HMOs under certain conditions. In the future, we are likely to see a continued movement of Americans into managed care arrangements, an increase in the number of physicians forming networks, a reduction in the number of insurers, an increase in the number of employers joining coalitions to purchase health care services for their employees, and a health care system that is generally more concentrated and vertically integrated.     

The mother market

Giving a woman good prenatal and maternity care can capture the health-care spending of her entire family for life. The next decade will bring several challenges to those who market maternity products and services, including fewer new moms, fewer babies in many markets, more minority mothers, and the end of childbearing for the baby-boom generation. The biggest challenge will be to provide a wide range of high-quality childbirth options in the cost-conscious world of managed health care.     

Individual vs. household determinants of the demand for medical care: A study of rural families

This article investigates, from a household perspective, the demand for medical care. Earlier (economic) studies have typically focused on individual utilization patterns; however, the data set employed here allows for an investigation of the role of other family members on individual demand. The theoretical results suggest that the labor force status (via the wage rate) of one family member may, in addition to influencing that person's rate of medical care use, effect the utilization of other household members. Separate physician visit demand equations are estimated for husbands, wives, and the household unit. The empirical results indicate that the wife's (full) cost of receiving medical care is a significant determinant of utilization by both the husband and other family members. Overall, the findings suggest that demand studies should take the presence of other household members and family structure into consideration when analyzing the determinants of individual medical care utilization.This study was supported in part by grant no. 1R03 HSO 2417-01 from the National Center for Health Services Research, HHS.Laurence Miners received his Ph.D. in economics from the University of North Carolina at Chapel Hill. He is currently an Associate Professor at Fairfield University and his research interests are focused mainly in the areas of health and labor economics. Correspondence concerning this article should be addressed to Laurence Miners, Department of Economics, Fairfield University, Fairfield, CT 06430.     

欧美儿童照顾社会政策的发展及借鉴

20世纪70年代以来,儿童照顾问题在西方社会由个体家庭责任演变为普遍的社会需求,被置于国家、市场和家庭关系的政治话语中。面对新的儿童照顾安排需求,欧美国家发展出亲职假、公共儿童照顾服务和经济支持三种途径来重新分配儿童照顾的任务、成本和责任。儿童照顾政策不仅影响妇女的劳动力参与,还与儿童的福利水平高低密切相关。确立照顾权利是公民社会权利的重要组成部分,建构一个由国家、市场、志愿组织和家庭共同提供的"混合照顾"体系,改变照顾工作在家庭内部不平等的性别分工以及把儿童照顾政策作为解决其他社会问题的政策工具都是值得中国借鉴的经验。