Health maintenance insurance: Toward an optimal HMO

The financial incentive structure of today's health maintenance organizations addresses certain problems attributed to fee-for-service medical care, but at a theoretical level it does not induce optimal provider behavior. Health maintenance insurance—a combined package of medical, morbidity/disability, and life insurance—encourages providers to compete for the health dollar, and not simply the medical care dollar, thereby remedying deficiencies in prepayment and promoting true health maintenance. The principle underlying health maintenance insurance emphasizes the need to search for effective means of preventing disability, morbidity, and premature death.This is a revised version of a paper presented at the 105th Annual Meeting of the American Public Health Association, Washington, D.C., October 30–November 3, 1977.     

SCIENTIFIC‐BUREAUCRATIC MEDICINE AND UK HEALTH POLICY1

One prominent method for controlling health costs is to find measures for the management of demand. Various options exist for this; and many of them have been tried during the fifty years of the UK's National Health Service. Current policy now focuses on what may be called “scientific‐bureaucratic medicine.” This policy is based on the assumptions that valid medical knowledge is derived from accumulated research evidence and that such knowledge should be implemented through clinical guidelines which are enforced to some extent. This UK development has parallels with the US Agency for Health Care Policy and Research whose experience, therefore, raises some policy issues for the UK.     

Government stewardship and primary health care in Guatemala since 1996

This article analyzes the role of government stewardship in the expansion of primary health care in post‐conflict Guatemala. By the time the Peace Accords were signed in 1996, the country's primary health care system was scarcely functioning with virtually no services available in rural indigenous areas. To address this gaping void/deficiency, the Ministry of Public Health and Social Assistance (MSPAS) embarked on a progressive expansion of primary services aimed at covering the majority of rural poor. Through a series of legal, policy, and program reforms up to 2014, the MSPAS dramatically expanded primary coverage and greatly improved basic health indicators for the entire population. To succeed in this effort, the MSPAS and its partners needed to simultaneously grow their stewardship capacity to oversee and develop the primary health system. On the basis of recent health systems strengthening literature, we propose a stewardship framework of 6 critical functions and use it to analyze the gains in government capacity that enabled the achievement of many of the country's primary health goals. Of the 6 stewardship functions, “building relationships, coalitions, and partnerships” especially with civil society organizations stands out as one of the keys to MSPAS success.     

Quality of care assessment: policy relevant issues

This paper reviews the quality assessment literature, presents a study which compares five different methods of assessing quality of care, and proposes policy recommendations. Results are: (1) Most quality assessment issues are a century old. (2) The results of assessment of quality of care are dependent on the method used; therefore, more methodologic research is needed. (3) The use of lists of criteria, concerning what a physician does, to assess quality of care could result in decreased efficiency in the health system by requiring the performance of ineffective procedures. (4) It is not certain that examination of the level of care rendered will increase the health level of the population; therefore, any national program which assesses quality of care must be prospectively evaluated. (5) A quality assessment system must be concerned with both the population who received services at the institution, and the population who did not but for whom the institution is responsible.From the Carnegie-Commonwealth Clinical Scholar Program of the Johns Hopkins University.Supported in part by grants 5R01HS00110 and 5T01HS00112 from the National Center for Health Services Research and Development and by the Carnegie Corporation and Commonwealth Fund. Dr. Brook was a Carnegie-Commonwealth Clinical Scholar and is now a Commissioned Officer in the U.S. Public Health Service stationed at the National Center for Health Services Research and Development. This paper does not represent the official position of this agency.     

Cheap and Dirty: The Effect of Contracting Out Cleaning on Efficiency and Effectiveness

Contracting out of public services, especially ancillary services, has been a key feature of New Public Management since the 1980s. By 2014, more than £100 billion of U.K. public services were being contracted out annually to the private sector. A number of high‐profile cases have prompted a debate about the value for money that these contracts provide. Value for money comprises both the cost and the quality of the services. This article empirically tests the contestability and quality shading hypotheses of contracting out in the context of cleaning services in the English National Health Service. Additionally, a new hypothesis of coupling is presented and tested: the effect of contracting of ancillary services on patient health outcomes, using the hospital‐acquired infection rate as our measure. Using data from 2010–11 to 2013–14 for 130 National Health Service trusts, the study finds that private providers are cheaper but dirtier than their in‐house counterparts.     

Bureaucratic institutional design: the case of the Italian NHS

We propose a model where a regional government’s choice of the number of bureaucratic agencies operating in a region depends upon the degree of substitutability and complementarity of the bureaucratic services being demanded. We show that, if the government perceives the citizens’ demand as a demand for substitutable services, it will choose provision by two independent agencies. If the government perceives the citizens’ demand as a demand for complementary services, it will choose provision by a single consolidated agency. Exogenous shocks to the number of citizens amplify these incentives. Evidence from the Italian National Health Service (NHS) supports this hypothesis. Results show a positive effect of proxies of substitutable services on the number of regional local health authorities and a negative effect of proxies of complementary services. The major immigration amnesties, taken as shocks to the number of citizens entitled to the service, magnify these effects.     

MANAGED COMPETITION IN FLORIDA HEALTH CARE: ITS STRENGTHS AND WEAKNESSES

Managed competition in health care is a model for reform that has been adopted by several states and considered as a model for national health care reform. This article assesses the strengths and weaknesses of managed competition in Florida based on the responses of essential participants in the managed competition network and data from network documents. Results of the analysis reveal that the strength of the reform has been in offering small employers and their employees a wide choice of health care insurance and in providing them with information to make informed health insurance choices. In addition to increasing choice and information, the managed competition network has become the small group insurance industry watchdog, applying pressure to keep the market fair and functioning. However, cost control difficulties and a continued limited access to health insurance demonstrate the weaknesses of the Florida reform. The article concludes by discussing the politicization of health care reform in Florida and the future of this reform effort in a changing political climate.     

Medicaid,the States and Health Care Reform

Health care reform in the US is relying extensively on Medicaid for achieving universal health coverage. This article addresses the question of whether Medicaid is an appropriate foundation for reducing the ranks of the uninsured, given its dependence on economic conditions and the vulnerability of state budgets, along with the ever-changing preferences of governors and legislators. This article assesses the effects of the ebb and flow of Medicaid policy-making on at‐risk populations and what this implies for the Affordable Care Act. By establishing a nationwide income floor at 133% of the Federal Poverty Level, the legislation eliminates eligibility inequities across the states. However, it is argued that when state budgets are strained, as they undoubtedly will be when the reform bill is fully implemented, local officials will downsize benefit packages, raise co-payments, mandate more managed care, and reduce provider payments, negatively affecting the availability, scope, and quality of services.     

Medicaid matters: children's health and Medicaid eligibility expansions.

In the late 1980s, a series of federal laws were enacted which expanded Medicaid eligibility to more of the nation's children. States had a great amount of discretion in how fast and how far these expansions were implemented. As a result, there was great variation among the states in defining who was eligible for the program. This variation provides a rare opportunity to disentangle the effect of Medicaid from a child's socioeconomic status. Using data from the National Health Interview Survey, we address whether the Medicaid expansions improved the health and functional status of children. Econometric models were developed using fixed-effects regressions, and were estimated separately for white, black, and Hispanic children. White children experienced statistically significant reductions in acute health conditions and functional limitations. Black and Hispanic children showed some evidence of improved health conditions and functional status, but this evidence is inconclusive in the study sample. This may be due to differences in their access to appropriate health services or to the smaller sample size of minorities in each geographic area. The findings are also relevant to the implementation of the Children' Health Insurance Program (CHIP), the latest federal effort to expand access to health care to poor and near poor children. In many states, CHIP is being implemented in whole or in part through further Medicaid expansions.     

Partnerships to Improve Rural and Remote Health Care

It is well known that rural communities do not have access to the same range of healthcare services as urban communities and that health status is poorer in rural areas. As models of health service delivery are changing from treatment and illness prevention to wellness models, health providers are under increasing pressure to re-engineer healthcare services to rural and remote areas in a climate of shrinking resources and community skepticism. The purpose of this article is to examine a developing model of partnership in rural Tasmaniain the context of these changes to health service delivery, changes to health professional training and the application of information and telecommunications technology. The partners are the Tasmanian Department of Health and Human Services and the University of Tasmania. The establishment of the university's Rural Health Teaching Sites in conjunction with the Tasmanian Telehealth Network provides a demonstration of this partnership in action.     

Public values and administrative reforms in French health care

Public value appears to be reborn out of the ashes of earlier failed new public management (NPM)‐driven policies in health care. It advocates greater consultation of the civic society and autonomy of public managers in decision‐making. In France, the 2009 Hospital, Patient, Health, and Territory law recentralized the health system and strengthened the central government to restore consistency in policy implementation and address earlier NPM shortcomings. The 2014 Health Project heralds a phase of policy hybridization that not only preserves earlier NPM tools but also seeks to reaffirm the role of the public and the medical profession in the governance of the health system. Copyright © 2016 John Wiley & Sons, Ltd.     

The quest for a better performing health system: Public expertise and corporate management recipes in France

Though the government pledged to cut the public deficit from 7.7% of the gross domestic product in 2010 to 3% by 2013, thereby responding to EU Normative power, health expenditures continue to rise, because public demands are higher and more social problems are handled in the health care setting. With French budget deficit threatening France's credit rating, novel instruments were needed. These included corporate management recipes (e.g., pay for performance contracts, patient volume targets, and management by objectives), new compensation mechanisms (e.g., activity‐based accounting and a nationwide scale of health care costs) and far‐reaching laws (e.g., the 2009 HPST bill). Our approach investigates some critical elements of the French health care system. We focus on primary (e.g., family physicians and General Practitioners) and secondary (e.g., hospital and specialty) care. We explore how policies such as the standardization of health services, the regrouping of health policy decisions within the larger Regional Health Agencies, affected citizens' engagement and physicians' autonomy. A French welfare elite pursued a hybrid strategy, regulating quasi‐markets of care providers in a postcompetitive government, while creating supportive conditions for a vibrant private hospital sector. Reforms also emphasized evidenced‐based policy, outputs‐rather than outcome‐measurement, and performance evaluation in a bid to streamline the delivery of health services.     

The Effects of Mandated Health Insurance Benefits for Autism on Out‐of‐Pocket Costs and Access to Treatment

As of 2014, 37 states have passed mandates requiring many private health insurance policies to cover diagnostic and treatment services for autism spectrum disorders (ASDs). We explore whether ASD mandates are associated with out‐of‐pocket costs, financial burden, and cost or insurance‐related problems with access to treatment among privately insured children with special health care needs (CSHCNs). We use difference‐in‐difference and difference‐in‐difference‐in‐difference approaches, comparing pre–post mandate changes in outcomes among CSHCN who have ASD versus CSHCN other than ASD. Data come from the 2005 to 2006 and the 2009 to 2010 waves of the National Survey of CSHCN. Based on the model used, our findings show no statistically significant association between state ASD mandates and caregivers’ reports about financial burden, access to care, and unmet need for services. However, we do find some evidence that ASD mandates may have beneficial effects in states in which greater percentages of privately insured individuals are subject to the mandates. We caution that we do not study the characteristics of ASD mandates in detail, and most ASD mandates have gone into effect very recently during our study period.     

Mental health and substance abuse insurance parity for federal employees: How did health plans respond?

A fundamental concern with competitive health insurance markets is that they will not supply efficient levels of coverage for treatment of costly, chronic, and predictable illnesses, such as mental illness. Since the inception of employer-based health insurance, coverage for mental health services has been offered on a more limited basis than coverage for general medical services. While mental health advocates view insurance limits as evidence of discrimination, adverse selection and moral hazard can also explain these differences in coverage. The intent of parity regulation is to equalize private insurance coverage for mental and physical illness (an equity concern) and to eliminate wasteful forms of competition due to adverse selection (an efficiency concern). In 2001, a presidential directive requiring comprehensive parity was implemented in the Federal Employees Health Benefits (FEHB) Program. In this study, we examine how health plans responded to the parity directive. Results show that in comparison with a set of unaffected health plans, federal employee plans were significantly more likely to augment managed care through contracts with managed behavioral health "carve-out" firms after parity. This finding helps to explain the absence of an effect of the FEHB Program directive on total spending, and is relevant to the policy debate in Congress over federal parity.     

National health insurance: Some lessons from the Canadian experience

In the current American debate over national health insurance an examination of the Canadian governmental experience is very instructive. Canada is enough like the United States to make the effects of Canadian health insurance policies rather like a large natural experiment. The Canadian experience—universal government health insurance administered by the ten provinces with some fiscal and policy variations—can be used to predict the impact in the United States of proposed national health insurance plans on the medical care system, and the reaction of mass publics and national policymakers to these effects.The central purpose of the Canadian national health insurance was to reduce and hopefully eliminate financial barriers to medical care. In this it succeeded. But it also produced results which Canadian policymakers never anticipated: essentially unexpected side-effects on cost, quality, organization, and manpower distribution of the particular national health insurance program adopted. It should be cause for concern, the article concludes, that most of the prominent American national health insurance proposals resemble the Canadian program in failing to provide a single level of government with both the means and incentives to curb the inflationary effects of national health insurance. The lesson from Canada is that unless the system has very strong anti-inflationary mechanisms and incentives built into it, national health insurance will feed the fires of medical inflation despite great formal governmental authority to control it.     

THE GOVERNMENT AND HOSPITAL COMMITTEES OF MANAGEMENT IN VICTORIA

Abstract: A new method has recently been introduced for selecting members of Victorian hospital committees of management: they are to be appointed by the Minister of Health, instead of being nominally elected by "contributors" to the hospitals. The 1977 Health Commission Act, which contains these new appointment provisions, gives the state government additional powers over the hospitals, and the power to appoint committees of management could contribute to this augmented control. The new method of selection, however, is expected to make little difference in practice to the committees. Neither the former Liberal state government, in framing the Health Commission Act, nor recent official inquiries have considered seriously the capacity of these committees as they are now constituted to maintain a high degree of hospital autonomy, despite the hospitals' heavy reliance on public funds. By leaving undisturbed these inheritors of the voluntary hospital tradition, the former Liberal government, though it has left its Labor successor with some new powers, has left it also with a potential obstacle to implementing the kinds of reforming measures recommended for the state's health services.     

Rating and Evaluating Health Systems: The Value of the Life Expectancy Approach

ABSTRACT

Cross-national ranking and rating of public services does not always provide the conditions for effective cross-national learning, because such learning requires causal understanding of the mechanisms underlying ranking scores. That causal understanding means grappling with the production functions involved in public services, and it is particularly difficult for organizations or policy domains where processes are more readily measurable than outcomes relative to goals. Health is to a large extent a policy domain of that type, which makes effective ranking and comparison difficult and also presents a particular challenge for cross-national learning. Numerous attempts have been made to compare the efficiency of different health care systems, and though there is a certain logic about such approaches to ranking and rating, this paper argues that much can be learnt for health policy using life expectancy as the basis for ranking and comparison.     

Presidential address medical governance: Are we ready to prescribe?

Federal and state governments in the United States play substantial and complex roles in promoting, subsidizing, regulating, and even providing health care in the United States. Financial pressures on Medicare and Medicaid, concerns about the translation of evidence‐based findings into medical practice, and efforts to reduce the number of people without any health insurance are likely to expand governments' roles even further in the future. Although a large body of research seeks ways to improve the delivery of medical services, relatively little research addresses the advantages and disadvantages of the various governance arrangements that are or could be used to make better collective decisions about the allocation of medical resources. Assessments of the many types of governance arrangements already employed—advisory committees such as those employed by the Food and Drug Administration, menu‐creating commissions with narrow mandates such as the Oregon Health Plan, and stakeholders trusteeships such as the Organ Procurement and Transplantation Network—should be an important topic for health policy research pursued by public policy and management scholars. Absent these efforts, the policy community may not be able to offer good advice about medical governance. © 2007 by the Association for Public Policy Analysis and Management     

The Impact of Health Insurance on Preventive Care and Health Behaviors: Evidence from the First Two Years of the ACA Medicaid Expansions

The U.S. population receives suboptimal levels of preventive care and has a high prevalence of risky health behaviors. One goal of the Affordable Care Act (ACA) was to increase preventive care and improve health behaviors by expanding access to health insurance. This paper estimates how the ACA‐facilitated state‐level expansions of Medicaid in 2014 affected these outcomes. Using data from the Behavioral Risk Factor Surveillance System, and a difference‐in‐differences model that compares states that did and did not expand Medicaid, we examine the impact of the expansions on preventive care (e.g., dental visits, immunizations, mammograms, cancer screenings), risky health behaviors (e.g., smoking, heavy drinking, lack of exercise, obesity), and self‐assessed health. We find that the expansions increased insurance coverage and access to care among the targeted population of low‐income childless adults. The expansions also increased use of certain forms of preventive care, but there is no evidence that they increased ex ante moral hazard (i.e., there is no evidence that risky health behaviors increased in response to health insurance coverage). The Medicaid expansions also modestly improved self‐assessed health.