The new Israeli health care reform: an analysis of a national need

This paper describes the current situation of health care services in Israel. Major problems are discussed and analyzed in terms of the dualism of the main health organizations (the Ministry of Health and the General Sickness Fund), the multiplicity and discontinuity of health care delivery, quality-of-care problems, and the uneven geographical distribution of facilities. A proposal for a reform of the health care system is outlined, and its principles enumerated. This reform, suggested by the Ministry of Health, reflects a new approach of separating the direct provision of care from the executive functions of planning and control of services. The Ministry's proposal is analyzed, and its implications are discussed in relation to the American health care system.     

地方政府债务风险的宪法学释析

地方政府债务风险的处理应当遵循宪法逻辑,即政府与公民是一种信托关系,只要公民权利的需求仍在,政府就没有破产的理由。因此,地方政府破产只是财政破产但行政不破产。在地方政府破产重整程序中,地方政府提供的保障民生的基本公共服务优先于地方债的债权,因为前者保护的是大多数人的基本生存权。诉诸民主体制才能从源头上控制政府的发债权进...     

关于建设法治政府的几点思考

国务院《全面推进依法行政实施纲要》确立了建设法治政府的目标 ,要实现这一目标 ,必须转变政府职能 ,改变行政管理体制。只有科学界定和依法规范职能 ,才能真正建设“有限”和“有为”政府 ;只有改变行政管理体制 ,才能为依法行政提供制度保障     

From shared cost to block funding and beyond: the politics of health insurance in Canada

This paper takes as its starting point recent major changes in arrangements between the federal and provincial government in Canada concerning the sharing of costs for health insurance programs. The switch from a shared cost (conditional grant) to a modified block funding system was motivated by federal desires to limit and make predictable their expenditures, by provincial desires to increase the flexibility of their allocation of funds and by a mutual desire to limit any growth of health care costs as a proportion of GNP. Concerns related directly to improving medical care delivery were insignificant The changes will effectively centralize responsibility for program financing and program delivery, thus providing a powerful incentive for provincial governments to apply very strong measures to control costs. For reasons largely external to the relationship between public sector insurers and the suppliers of medical services, these attempts are unlikely to be successful in the short run. The probable impact of this difficulty on government and members of the health care delivery system is assessed.     

Risk avoidance and missed opportunities in mental health reform: the case of Israel

Passage of the National Health Insurance Law (NHI) [National Health Insurance Law (NHI) (1994). Israel Law Code, 1469, 156 (Hebrew).] provided a window of opportunity for mental health reform in Israel. The reform called for transfer, within a period of 3 years, of responsibility for psychiatric services formerly provided mostly by the Ministry of Health, to Israel's four major healthcare providers. Planners of mental health reform in Israel saw in the NHI Law an opportunity to bring about far-reaching structural changes in mental health policy and service provision, shifting the locus of care from psychiatric hospitals to the community. This paper reports results of a case study assessing factors that hindered or promoted the planned reform. The theoretical and conceptual framework of the study was derived from public policy theories and in particular on those related to public agenda and agenda setting processes. The study was also informed by organizational and interorganizational theories and exchange theory. Data was gathered from documents and interviews of key informants. Sources of data included official reports, proceedings of Knesset's Labor and Social Affairs (LSA) Committee, Ministry of Health documents, healthcare providers' reports, budget documents, newspaper analysis, and about 60 interviews with persons who played important roles in the process of the negotiations regarding the reform efforts. Analysis identified the major stakeholders and their concerns, distinguishing between the key stakeholders involved directly in the negotiations and secondary or additional stakeholders outside the main circle, some of whom were very involved and influential in the process. The study identified the major issues and the problems that emerged during the process of negotiations. Analysis of the failure of the attempt to implement the reform reveals a combination of obstacles emanating from the process of negotiation, on the one hand, and from the larger political, economic and social context, on the other. Findings show that conflict of interests and risk avoidance of the major stakeholders were major obstacles to reaching agreement on a formula for implementation. The major risks were related to the inability to predict future demand for ambulatory services, uncertainty regarding future costs, and disagreements regarding the reliability and validity of data. Contextual factors that undermined the chances for successful implementation of the reform included lack of a strong political commitment and a coalition supporting the reform, a financial crisis in the health system resulting from early stages of implementation of the National Health Insurance Law, and social turmoil created by the Rabin government's attempts to implement the Oslo agreements. This turmoil ultimately culminated in the assassination of the Prime Minister Yitzchak Rabin, creating a climate far from conducive to generating public interest in mental health reform and facilitating the planned change. As a result the mental health system remained virtually unchanged.     

Collection from third party payers of reasonable costs of healthcare services--DoD. Final rule

This final rule establishes a new rule under the Third Party Collection program for determining the reasonable costs of health care services provided by facilities of the uniformed services in cases in which care is provided under TRICARE Resource Sharing Agreements. For purposes of the Third Party Collection program such services will be treated the same as other services provided by facilities of the uniformed services. The final rule also lowers the high cost ancillary threshold value from $60 to $25 per 24-hour day for patients that come to the uniformed services facility for ancillary services requested by a source other than a uniformed services facility. The reasonable costs of such services will be accumulated on a daily basis. The Department of Defense is now implementing TRICARE, a major structural reform of the military health care system, featuring adoption of managed care practices in military hospitals and by special civilian contract provider networks. Consistent with TRICARE, as part of the Third Party Collection Program, DoD is transitioning to a billing and collection system in which all costs borne by DoD Medical Treatment Facilities (MTFs) will be billed by the MTF providing the care. Thus, all care performed within the facility, plus an added amount for supplemental care purchased by the facility, will be billed by the MTF. Conversely, care provided outside the MTF under other arrangements will be billed by the provider of that care.     

Toward a national personal assistance program: the independent living model of long-term care for persons with disabilities.

Long-term care for people with disabilities in this country traditionally has been provided through family members and friends. Federal and state policy has focused primarily on financing professional health care services provided through nursing homes and home health agencies. An alternative to these models of long-term care is the "independent living model," which is based on the provision of services by nonprofessional personal assistants in the disabled person's home. We describe the model and consider why it is not the dominant approach to long-term care in the United States. We go on to assess options for developing a national personal assistance services program based on the independent living framework, discussing how covered services should be defined, how the program should be financed, whether the program should use means testing, how eligibility and level of benefits should be determined, and what role government should play in implementing the program. Several legislative approaches to developing a national program are explored.     

Medicare Program; establishment of the Medicare+Choice Program--HCFA. Interim final rule with comment period

The Balanced Budget Act of 1997 (BBA) establishes a new Medicare+Choice (M+C) program that significantly expands the health care options available to Medicare beneficiaries. Under this program, eligible individuals may elect to receive Medicare benefits through enrollment in one of an array of private health plan choices beyond the original Medicare program or the plans now available through managed care organizations under section 1876 of the Social Security Act. Among the alternatives that will be available to Medicare beneficiaries are M+C coordinated care plans (including plans offered by health maintenance organizations, preferred provider organizations, and provider-sponsored organizations), M+C "MSA" plans, that is, a combination of a high deductible M+C health insurance plan and a contribution to an M+C medical savings account (MSA), and M+C private fee-for-service plans. The introduction of the M+C program will have a profound effect on Medicare beneficiaries and on the health plans and providers that furnish care. The new provisions of the Medicare statute, set forth as Part C of title XVIII of the Social Security Act, address a wide range of areas, including eligibility and enrollment, benefits and beneficiary protections, quality assurance, participating providers, payments to M+C organizations, premiums, appeals and grievances, and contracting rules. This interim final rule explains and implements these provisions. In addition, we are soliciting letters of intent from organizations that intend to offer M+C MSA plans to Medicare beneficiaries and/or to serve as M+C MSA trustees.     

浅探二十一世纪我国政府运行模式的转变

西方各国在上个世纪末的二十年展开了一场轰轰烈烈的政府改革运动,相对于以往的政府治理来说无论是理论上还是实践上都取得了长足的进展,这对于我国政府改革是一个重要的启示。本文就我国政府运行的观念、运行的过程及运行的结果三个方面谈谈新公共管理对我国转变政府运行理念的启迪。     

MacDill 65 demonstration of military managed care--DoD. Notice of demonstration project

This notice is to advise interested parties of a demonstration project in which DoD will enroll up to 2,000 Medicare-eligible military retirees at MacDill Air Force Base to primary care managers. The MacDill 65 demonstration project seeks to show that a DoD-operated program can provide primary health care services to beneficiaries eligible for both military health care and Medicare more effectively and efficiently than under the current DoD-operated system. In this project, DoD will grant enrollees in the program priority access to primary health care at MacDill in exchange for their agreement to receive all of their primary health care from MacDill AFB. Additional services, available at the military treatment facility at MacDill AFB, will be granted to these enrollees at a higher priority than that granted to other retirees and their family members not enrolled in TRICARE Prime. Funding for the demonstration for care provided will come from an additional $2 million per year over the current level of DoD expenditures on care provided to the MacDill AFB Medicare-eligible population. Claims for care provided to enrollees outside the MTF will be submitted to Medicare on a fee-for-service basis by the civilian provider. At the end of the project, DoD will conduct an analysis of the benefits and costs of the program. DoD will conduct the demonstration over three years, from October 1, 1998, to September 30, 2001. This demonstration project is being conducted under the authority of 10 USC 1092.     

医疗改革中行政指导相关问题研究

随着我国法治进程的不断加快和医疗卫生环境的不断变化,行政指导作为＂市场经济国家关于市场功能、政府角色和行政模式的政策选择不断演进的结果,＂具有柔和、民主的色彩,既体现了行政行为的目的性,又兼顾了市场经济的自由性,已成为政府主导医疗改革不可或缺的重要手段。但是,由于我国行政指导法律机制不健全以及现实中政府责任意识淡薄,使得行政指导影响了医疗改革的效果及目标的实现。对此,本文认为,行政指导法治化是促进医疗改革的重要途径。     

A conversation with Donald Berwick on implementing national health reform

Michael Birnbaum interviews Donald Berwick shortly after his departure from the Centers for Medicare and Medicaid Services about the national health care landscape. Berwick discusses the strategic vision, policy levers, operational challenges, and political significance of federal health care reform. He rejects the notion that the Affordable Care Act represents a government takeover of health care financing or service delivery but says the law's Medicaid expansion and its creation of health benefit exchanges present a "watershed moment for American federalism." Berwick argues that the solution to Medicare's cost-containment challenge lies in quality improvement. He is optimistic that accountable care organizations can deliver savings and suggests that shifting risk downstream to providers throws the health insurance model into question. Finally, looking to the future, Berwick sees a race against time to make American health care more affordable.     

The Independent Medicare Advisory Committee: death panel or smart governing?

This comment explores whether health care reform legislation establishes an administrative body effectively charged with the rationing of health care resources; insofar as it establishes a presidentially appointed Independent Medicare Advisory Committee (IMAC). IMAC would be charged with "making two annual reports dictating updated rates for Medicare providers including physicians, hospitals, skilled nursing facilities, home health, and durable medical equipment." IMAC's recommendations would be implemented nationally, subject to a Congressional vote. Congress would be granted a thirty-day window to achieve a simple majority for or against the IMAC recommendations. Part I is an introduction. Part II of this article covers the history of American health care. It lays out the federal government's evolving role in the arena of public health and health care, starting in the mid-nineteenth century and continues up to the present day. Part III examines the existing process by which Medicare spending is controlled. This part focuses on the administrative procedures that control Medicare reimbursements. Part IV examines IMAC. This part discusses IMAC's statutory provisions and the administrative transparency laws IMAC would be bound to follow. The close of this part, draws on three analogies as a gauge for how IMAC will operate: Senator Tom Daschle's Federal Health Board (FHB) proposal; the administrative oversight of the Federal Reserve; and the United Kingdom's National Institute for Health and Clinical Excellence (NICE). Part V creates a snapshot of the U.S. health care system as it operates today. This part emphasizes cost, quality, and accessibility of health care, with comparisons to international and state-run health care systems. Throughout this article there are a number of words, phrases, and agencies that have been given acronyms. For convenience, an index of these acronyms is provided in an appendix following the article.     

The Evolution of the CPC’s Conception of Association and Regulation of Social Organizations in China

Freedom of association and all institutions coming with it have not been accepted by the Chinese government. Instead, Chinese social organization administration is based upon the concept of association held by the Communist Party of China (CPC). The Chinese government had adopted a “total control” model of social organization administration in the era of totalitarianism before the “Opening-up and Reform”, leaving almost no room for social organizations to survive, because the CPC had regarded social organizations as “revolutionary” and “deconstructive”. The Chinese has adopted a graduated control system to administrate social organizations in the era of authoritarianism after the “Opening-up and Reform”, treating social organizations differently according to their threats to the ruling order and their utilities for economic development, because the CPC has viewed social organizations as a “challenging” but “auxiliary” power. The on-going “innovation of registration and administration of social organizations” is not a return to international standard regarding social organization administration in China, but only partial reform of the graduate control system still based upon the CPC’s conception of association as “challenging” but “auxiliary”. Social organizations capable of providing public goods in areas of economic development and social services are given more favorable treatment by the government while political and religious organizations are still tightly controlled by the government.     

社会组织建设中的政府作用探析——以吉林省为视角

社会组织建设是党的十七大提出的一项重要任务。社会组织的建设与发展离不开政府在多方面发挥作用。本文以吉林省为视角,从社会组织建设过程中发挥政府作用的紧迫性及现实性入手,论述了现阶段社会组织建设中的政府作用应该体现在哪些方面及如何体现的问题,以期为吉林省社会组织的建设与发展提供借鉴与参考。     

Making the Health Insurance Flexibility and Accountability (HIFA) waiver work through collaborative governance

This paper argues that collaborative governance should be an essential component in any HIFA waiver proposal, due to the fact that the health care system is moving away from a federal and hierarchical program design and implementation towards a more local, collaborative approach. As several current collaborative projects demonstrate, collaboration may overcome barriers to health expansion program success, such as stakeholder buy-in, notice, and state access to private health coverage information. Furthermore, collaboration within the context of the HIFA waiver process may maximize the strengths of current collaborations, such as providing: (a) access to greater and more stable funding sources; (b) access to a facilitator that can collect and distribute data; and (c) an avenue for accountability. Multiple challenges in ensuring collaborative governance are reviewed. Ms. Zabawa argues that these challenges are not insurmountable if states adopt a truly collaborative approach to designing and implementing programs under the HIFA waiver; there may be hope in expanding and improving health coverage, since collaboration is the most appropriate mechanism to address the complexity of health system reform.     

Aligning physician decision-making with the goals of health care organizations: are there any lessons from law firms?

In order to achieve efficiency in the delivery of health care services, it is essential to align more closely the behavior of physicians with the goals of the health care organization with which they are affiliated. Achieving alignment presents a number of challenges, including legal constraints, a long tradition of physician independence, a tendency for physicians to become involved in procurement decisions, and a scarcity of comparative effectiveness data that could serve as a basis for treatment protocols and purchasing decisions. The article discusses these challenges and suggests some partial solutions. In addition, it compares the incentives that affect physicians in health care organizations and partners in law firms and suggests that there may be some lessons that health care organizations can learn from the firms.     

Mandatory HIV testing used to bar potential immigrants

Last year Canada turned away 75 people with HIV/AIDS because the federal government said that they would place excessive demands on publically funded services. Another 207 people with HIV/AIDS were allowed to enter Canada, mainly because of exemptions to the excessive-demand provisions. HIV/AIDS organizations have objected to the government's policy of mandatory HIV-antibody testing of potential immigrants and have expressed concerns about the way in which excessive demand is calculated.     

Nonprofit and for-profit medical care: shifting roles and implications for health policy

The contemporary expansion of investor-owned health care facilities has stimulated much controversy but little response from policymakers. We believe this results from the apparently ambiguous relationship between ownership and socially valued outcomes. In our assessment, this ambiguity occurs largely because the effects of ownership are mediated in complex ways by characteristics of the services being delivered and the training of health care providers. Reviewing both the history and current performance of nonprofit and for-profit health care facilities, we identify some of the more important of these mediating factors. Taking these into account, there is a consistent influence of ownership on the delivery of health services. On the basis of this analysis, we discuss appropriate policy responses to the future growth of investor-owned health care organizations.