Politics and economics of hospital cost containment

Voluntary and regulatory efforts toward hospital cost-containment have accelerated with rapid increases in those costs and under pressures of national health insurance. Possible causes of hospital cost inflation are examined in the context of market analysis and with reference to the nature of hospitals as institutions facing special combinations of economic and political conditions and pressures. Some details of voluntary experiments and state regulatory efforts are examined in order to assess the elements of experience to date and their relationships to causes of hospital cost inflation. Federal proposals for a regulatory cap on costs are also discussed along with a view of how such proposals are related to probable causes of hospital cost inflation and of the relevance of other experience.     

Power and cost containment in a Danish public hospital

The assumption that hospital decision-making is hierarchical in character underpins the policy formulation process in public as well as pluralist national health care systems. This article's analysis of decision-making in a Danish public hospital reinforces the contrary assertion: that effective authority in acute-care hospitals rests in an amorphous power relationship among the hospital's several occupational groups, in which physicians clearly have the upper hand. After a brief introduction to this Danish hospital, the article develops a detailed portrait of its informal power structure and of the different occupational groups' permanent power-maximizing strategies. Subsequently, the article assesses the impact of these strategies upon two recent efforts to contain the hospital's costs: a decision to close an expensive specialty clinic, and an attempt to shrink the hospital's size by transferring less sick elderly patients to a newly created rehabilitation facility. The study's findings suggest that efforts to impose hospital cost containment by exclusively political means are unlikely to succeed.     

Health insurance without provider influence: the limits of cost containment

In our previous paper, we showed that market forces can play a significant role in controlling health care costs and that a considerable amount of cost containment effort was pursued by third-party insurers in Oregon in the 1930s and 1940s. Although physicians were able to thwart this cost-control effort, a 1986 Supreme Court decision, FTC v. Indiana Federation of Dentists, found that a boycott of insurers by dentists violated Section 5 of the Federal Trade Commission Act. Further investigation of recent developments, including the recent Wickline v. California decision, indicates that the primary barriers to cost containment today are not obstructive tactics by providers or provider-controlled health insurance plans. Rather, the primary barriers are increases in the development and diffusion of new technology and society's apparent preference for paying for new tests and procedures regardless of economic efficiency.     

Finding the levers, finding the courage: lessons from cost containment in North America

"Learning" is broader and more complex than simply the orderly acquisition of new knowledge. At least as important is the evolution of the background of assumptions and beliefs held by the community, or its principal decision makers, and implicit in its institutions and policies. These may bear only a loose relation to evidence or knowledge narrowly defined. The pressures of cost escalation over the past twenty years, and the attempts at containment in the U.S. and Canada, have added substantially to our knowledge of how the health care system works. Containment is possible, and the successful mechanisms, thus far, are quite specific. But the results of these attempts and (in the U.S.) the continued escalation have also significantly shifted the broader set of assumptions in the community about appropriate priorities and policies in health care. Attitudes towards physician supply, variations in practice patterns, capitated practice, and for-profit organization, for example, have changed radically, although the supporting evidence has not. But cost pressures have created an audience which wants to hear, whose background assumptions provide a different "fit" for the evidence.     

Personnel leadership in action: doing something about health care cost containment

It's no secret that health care costs are skyrocketing and will continue to do so unless business, particularly personnel professionals, takes responsibility for containing them. This month, we present a panel report whose participants--ranging from the corporate manager of employee benefits at TRW to the director of public relations at Blue Cross Of Milwaukee--are taking concrete action to improve employee health and company expenses.     

Decisions without consequences: cost control and access in state Medicaid programs.

States have implemented a number of strategies to provide services, pay providers, and control Medicaid spending. We test the effects of some differences in state Medicaid policies on program enrollees' access to and use of health care services. Logistic and OLS regression analyses of cross-sectional data indicate that these policies exert significant influences on enrollees' access to health services but have a weaker direct effect on their use of them. However, we find evidence that utilization is affected indirectly (through increased access) by state policy decisions. Somewhat surprisingly, Medicaid policies designed to contain costs by limiting utilization appear to affect neither access nor utilization. Medicaid enrollees have greater access to a private physician in states with higher physician reimbursement and additional Medicare insurance for their enrollees. Other nonpolicy variables with pronounced impacts on access to private office physicians include race and the availability of private insurance.     

The devil is in the details: Managed care and the unforeseen costs of utilization review as a cost containment mechanism

This article addresses issues of liability when a single-payor in a national health care system makes a decision based on a utilization review program that injures the patient as a result. In Part I, the history of Managed Care Organizations (MCOs) is discussed to establish an understanding of the current health care landscape. Part II explains MCOs' use of utilization review to contain costs and analyzes the manner in which courts have addressed the issue of MCO liability for patient injuries sustained from denial ofcoverage. Finally, Part III concludes that current case law may limit a patient's access to a remedy for injuries sustained from a utilization review decision in a single-payor national health care system.     

美国反垄断思想的新发展--芝加哥学派与后芝加哥学派的比较

本文从四个方面比较了芝加哥学派与后芝加哥学派在反垄断思想上的差异。第一 ,市场机制能否调节市场失灵 ,或者说市场经济是否需要反垄断法的干预 ?第二 ,反垄断法究竟是以促进经济效率为首要目标还是以保护消费者福利为首要目标 ?第三 ,现实中厂商是否存在掠夺性定价 ?第四 ,纵向约束是否妨碍竞争 ,如何妨碍竞争 ?另外 ,文章还提供了反映美国反垄断政策从芝加哥学派向后芝加哥学派转变的一些经典案例。