Canadian and the United States' health care systems performance and governance: elements of convergence

International comparisons of the organisation and performance of health care sectors are increasingly informing policy makers about potential policies relating to health care. Politicians, academics and critics in both the United States and Canada have compared and contrasted the health care systems in the two countries. Public debate tends to emphasise the differences between the US and Canadian health care systems. But, dramatic differences between the organisation and performances of health care systems of the two countries would be surprising given that most elements of divergence have only emerged in the last fifty years, and that health systems tend to be driven by the same basic economic problems. This paper provides an overview of the main economic efficiency issues that must be addressed by health care delivery systems, as well as statistical and related evidence on both input usage and output performance of the two health care systems. While Canada clearly spends less on health care, it is difficult to conclude that Canada has a more efficient health care system than the United States. In particular, the US population puts greater demands on its national health care system owing to a combination of behavioural patterns and socio-economic disparities that contribute to much higher rates of violent accidents, as well as specific diseases and other health problems. Also, the stylized representation of the US system as being 'market-driven' and the Canadian system as being 'centrally controlled' is, increasingly, inept. Both systems are evolving toward bureaucratic models that rely more on internal competition than market competition for governance. In this respect, economic forces are nudging both systems towards a convergence of structure and performance.     

Professional ethics and institutional ethics: convergence or conflict?

During the last decades, an important debate about professions in general, and particularly about the medical profession, has taken place. The classic idea that professionals do have a "special mora lity", different from the common morality, which among other things give them legal impunity, came to a head. This causes a great deal of confusion among the professionals, incapable of reacting and redefining precisely their own identity. Some new concepts, like that of "internal morality" of professional activities, made the debate more difficult and confusing. On the other hand, the everyday more powerful influence of free market forces in the health care economy, has made that some decisions taken by health care managers would be considered by physicians as opposed to their professional duties and incompatible with them. This has been the origin of a debate about what is called in North America "New Professionalism". This debate deals with basic questions about the health care professional's identity at the beginning of this new Century.     

Telehealth: An Assessment of Growth and Distribution

Telemedicine uses telecommunications technologies to deliver health care to populations located at some distance from health care providers. Telehealth is a somewhat broader term that includes non-clinical applications (such as education). This article draws on data from a nationwide survey of telehealth networks that assesses the extent and character of telemedicine activity. Although statistics point to increased utilization, the distribution of growth has been skewed toward a few applications and it is not clear that rural areas would derive substantial benefit in the absence of federal subsidy. Reported barriers to building sustainable programs often seem to reflect concerns of large hospitals and health care systems rather than constraints faced by rural organizational and individual network members. The potential role of government in addressing barriers is discussed.     

部分国家政府举办公立医院的经验与启示

世界各国不论经济发达与否,均举办一定数量的公立医院。公立医院的重要地位和作用是：弥补市场缺陷、体现政府保障居民健康权益的责任,并在控制医药费用、提高卫生服务公平可及性、有效利用资源等方面发挥重要作用。不同卫生保健体制国家的公立医院功能定位具有不同特点：国民卫生服务体系国家强调政府主导卫生筹资,公立医院为人群提供免费或廉价的基本卫生服务;社会健康保险体制国家以德国为例,公立医院除承担一般性功能外主要提供住院服务;商业健康保险体制国家以市场为主导,公立医院的作用在于调节市场失灵,在医疗服务体系中发挥基础性但非主体性作用,并履行一定的社会职责。各国政府通过探索公立医院改革,如实行“管办分离”,以明确政府举办公立医院的职责。国际经验对我国的启示是：政府应举办一定数量的公立医院,为其承担大部分筹资,完善监管政策,促使其落实社会职能和责任;公立医院要通过高效率运行,为群众提供高质量的服务,并要代表国家医疗服务体系的先进水平,起到示范作用;政府进行公立医院改革要以转变政府职能为前提,并保障公立医院的社会功能;公立医院的功能应适应国家医药卫生体制的制度环境。     

Purchasing for health gain: The problems and prospects for purchasing for health gain in the "managed markets" of the NHS and other European health systems

"Purchasing for health gain" a phrase used to describe a strategicrole for purchasing bodies which were established in 1990 aspart of the UK NHS reforms. Is it an empty phrase, serving tohide the reality of purchaser's main task of controlling expenditure?Will the operational difficulties encountered in the first twoyears of the reforms continue to stand in the way of a strategicrole for public purchasing bodies? Is a strategic role impossiblein an "managed market" for health care? This paper considersthe concept of health gain and the difficulties encounteredby NHS purchasers. It is argued that 1) the term "internal market"is inadequate to describe the different frameworks and combinationsof features in different public health care systems with managedcompetition; 2) purchasing for health gain is more difficultin some types of "managed market" than in other types; 3) theway the UK market is developing may increase, rather than reducethe difficulties; 4) there is no evidence as yet that primarycare purchasers cannot purchase for health gain if they areorganized and rewarded for doing so; 4) performance assessmentof purchasers and purchaser competition would reduce their costsand increase their effectiveness in purchasing to improve thehealth status of their populations; 5) value choices are integralto purchasing for health gain and new processes and institutionsare needed to decide priorities and to introduce explicit rationing.The prospects, some solutions, and the implications for othercountries introducing similar changes are discussed.     

'Manacled competition': market reforms in German health care.

In 1993 Germany joined the small but swelling ranks of societies determined to explore managed competition as a means of slowing the growth of health spending by giving stakeholders new incentives for efficiency. Realizing the benefits of competition, however, demands changes in institutional norms and regulatory practices that now largely handcuff those who would follow competitive logic into "managed care." In time Germany's system of "manacled competition" may evolve into a happy higher synthesis of managed care and managed competition. Or policymakers may conclude that the political price of installing workable market forces in health care is too high and reconcile themselves to more traditional applications of political pressure.     

卫生事业公益性与福利性定性的本质区别是什么

卫生政策和医学基础理论研究,医疗卫生的现实发展困境,医疗卫生体制改革,重构宏观卫生政策框架和构建和谐社会,"不约而同"共同聚焦医疗卫生服务"公益"性质。社会问题的"定性"至关重要,性质将直接决定服务对象、服务范围、服务内容、资金来源和服务方式,决定国家、市场互动关系和社会边界,决定社会资源分配模式和国家社会责任。虽然公益性与福利性存在许多相同之处,但是公益性与福利性存在诸多本质性差别和不同,卫生服务正确性质应是"福利性",而非"公益性",更不是"一定福利政策的社会公益事业"。     

Private health insurance: a role model for European health systems

European health care systems will face major challenges in the near future. Demographic change and technological progress induce rising costs. In order to deal with these developments and to preserve the current level of health care provision, health care systems need to be highly efficient. Yet existing health care systems show a lot of inefficiencies that result in waste of scarce resources. Therefore, improvements in performance are necessary. In this article, we argue that a change in financing health care accompanied by the liberalisation of the market for health care service providers offers a promising solution. We develop a market-based model for financing health care and show how it can be put into practice without generating additional costs for society while meeting social equity criteria.     

The key role of health insurance in a cost-effective health care system. Towards regulated competition in the Dutch medical market.

The previous two sessions of this Symposium have dealt with incentives for cost-effective provider behaviour. Although incentive-reimbursement, which rewards the providers for delivery medical care in a cost-effective way, can be an important step towards a cost-effective health care system, it is not rewards the providers for delivering medical care in a cost-effective way, can be an important step towards a cost-effective health care system, it is not sufficient. As long as the insured consumers have both comprehensive health insurance coverage and freedom of choice of provider, providers will have great difficulty in resisting consumers' demand for ever more costly medical care, and politicians or other decision-makers will have great difficulty in restricting capacity and in preventing overcapacity. Fear of losing patients or voters might dominate. Therefore, in this session we shall focus on the key role of health insurance in a cost-effective health care system and on consumer incentives and insurer behaviour. If the consumers have a choice between several provider-insurer organizations. Although market forces do play an important role in a competitive health-care system, competition should not be confused with a "free market". Besides financial arrangements to protect the poor, pro-competitive regulation is needed to guarantee a "fair competition". Currently there is much consensus that the present Dutch health insurance system, in which 60% of the population is publicly insured and 40% is privately insured, should be replaced by a national health insurance scheme, which uniformly applies to the entire population. A few years ago, I made a proposal for such a scheme, which was based largely on the ideas of Ellwood, McClure, and Enthoven on competition between alternative delivery systems. The main features of this proposal will be discussed. In my opinion, the long-term prospects for regulated competition in the Dutch medical market seem rather favourable.     

A Better Idea for United States Health Care - The Balanced Choice Proposal

This article introduces a promising new health care financing proposal for physician payment called Balanced Choice. It summarizes the implications of health care economics and current well-publicized health care reform proposals, each of which is problematic for physicians and their patients. The Balanced Choice proposal is for an integrated two-tier national system, which has an economically efficient universal plan similar to single-payer, but with an option for enhanced services using market forces at the doctor-patient level to manage care. The two tiers are linked together and balanced so that each complements and enhances the other. Balanced Choice solves the problems of other proposals in a way that would work well for doctors and for patients, and represents a fresh and uniquely American solution to the problem of health care financing.The health care reform proposal recently passed by Congress maintains the inefficiencies and perverse incentives of an insurance model that rewards denial of care and imposes intolerable administrative burdens on the practice of medicine. A new universal proposal called Balanced Choice offers economic efficiency, administrative simplicity, and returns care management and control of fees to doctors and patients. To explain, we need to start with a review of basic health economics.     

Eliminating mother-to-child HIV transmission will require major improvements in maternal and child health services

Although some low- and middle-income countries have made progress toward eliminating mother-to-child transmission of HIV, others lack health systems that can deliver accessible and reliable care. We modeled how access to maternal and child health services and the effective delivery of interventions would affect efforts to eliminate HIV transmission during pregnancy and after childbirth in low- and middle-income countries. In countries with high HIV rates, our model predicts transmission rates of 19.7 percent at current levels of access and efficiency of maternal and child health and HIV treatment. Even if current treatment programs were carried out at or near perfect levels, we predict that significant residual mother-to-child transmission (7.9 percent) would remain. The model suggests that under current conditions, poor access to routine health services contributes three times more to overall mother-to-child HIV transmission than do current suboptimal levels of efficiency of anti-HIV-transmission interventions. We conclude that current efforts to optimize programs to prevent mother-to-child HIV transmission will not, on their own, eliminate HIV in newborns. Access to maternal and child health services will need to be dramatically improved, as will prevention measures, such as identifying and treating HIV before pregnancy.     

Health indicators and the organization of health care systems in western Europe.

OBJECTIVES. This study investigated the association between health care systems and health indicators in developed countries. METHODS. Cross-national comparisons were conducted with regression analysis between 17 Western European countries with two types of health care systems: national health services and social security systems. RESULTS. Health care expenditures were inversely correlated to potential years of life lost to females and to infant mortality rates; they were positively correlated to life expectancy for females. Regression models predicted that countries with national health services systems would have lower infant mortality rates at similar levels of gross domestic product (GDP) and health care expenditures. Finally, increases in health care expenditures would decrease the ratio of observed to predicted infant mortality rates according to GDP; this decrease would be greater in countries with national health services than in those with social security systems. The model predicted this difference to be about 13% at average levels of health expenditures. CONCLUSIONS. National health services seem to be more efficient at producing lower infant mortality rates than social security systems in Western European countries.     

The Dynamics of Community Health Care Consolidation: Acquisition of Physician Practices

Context

Health care delivery systems are becoming increasingly consolidated in urban areas of the United States. While this consolidation could increase efficiency and improve quality, it also could raise the cost of health care for payers. This article traces the consolidation trajectory in a single community, focusing on factors influencing recent acquisitions of physician practices by integrated delivery systems.

Methods

We used key informant interviews, supplemented by document analysis.

Findings

The acquisition of physician practices is a process that will be difficult to reverse in the current health care environment. Provider revenue uncertainty is a key factor driving consolidation, with public and private attempts to control health care costs contributing to that uncertainty. As these efforts will likely continue, and possibly intensify, community health care systems now are less consolidated than they will be in the future. Acquisitions of multispecialty and primary care practices by integrated delivery systems follow a common process, with relatively predictable issues relating to purchase agreements, employment contracts, and compensation. Acquisitions of single-specialty practices are less common, with motivations for acquisitions likely to vary by specialty type, group size, and market structure. Total cost of care contracting could be an important catalyst for practice acquisitions in the future.

Conclusions

In the past, market and regulatory forces aimed at controlling costs have both encouraged and rewarded the consolidation of providers, with important new developments likely to create momentum for further consolidation, including acquisitions of physician practices.     

Ambulatory care heads for the 21st century

There is increasing market pressure to deliver ambulatory care in a most traditional manner, that is, with a high level of service and personal touch. The ambulatory care providers of the future will meet this demand. However, they will do so with approaches and support systems that are anything but traditional. Care is increasingly being delivered in large, integrated systems. Extraordinary service levels are being made feasible again--this time through a combination of new support systems, including total quality management task forces, patterns of care software, consolidated phone centers that can provide access from anywhere anytime, electronic data interfaces, and the Internet.     

Managing the unmanageable: public hospital systems

There are significant challenges to those who work in large public health care delivery systems: political imperatives; resource constraints; sometimes rigid personnel systems; and, the reality that everything occurs in a public forum. The fact that many nations are reviewing and, in some instances, restructuring their national health care systems, has added to the complexity and feeling of continual turbulence experienced by their managers. State run systems like that in the United Kingdom are introducing market forces to increase effectiveness and value for money; while market systems, like that in the United States, are increasing regulatory interventions to achieve the kind of cost control available to countries with large public systems which operate with global budgets. Public hospitals in the United States offer examples of public institutions operating in a highly competitive market environment. A decade of management changes undertaken to enhance the efficiency and effectiveness of the New York City Health and Hospitals Corporation (HHC), the largest public hospital system in the United States, is presented as a case study of public health services and public management in a market environment.     

Well-being revisited: improving the health of a population

Changes in society and the healthcare system are challenging healthcare executives to do more than provide medical services. Leaders now take broader responsibility for the health and well-being of the people and communities they serve. Health--the "state of complete physical, mental and social well-being and not merely the absence of disease or infirmity" (World Health Organization 1944)--is determined by four forces: environment, heredity, lifestyle, and medical care services. Health-care managers who want to improve the health of their served populations must improve these forces. Strategic and operational lessons can be learned from the pioneering work done by several hospitals, health plans, and healthcare systems to improve their local environment, heredity, lifestyles, and medical care services. Managers who wish to improve health in their communities should strongly embrace and commit to "health" rather than mere "medical services" in their mission, vision, and values. They should collaborate with many other organizations and people--such as schools, churches, police, and businesses--to build partnerships that extend beyond the healthcare sector into the total community. Healthcare organizations should provide some resources and funds to improve the health of their served populations, and they should view this commitment as an investment (especially if there are capitated lives) rather than as an expense. They should also obtain public and private grant funds and leverage the resources of their collaborative partners to improve their local environment, heredity, lifestyles, and medical care services. Finally, leaders can advocate and support public policy that would improve the four forces that shape health.     

The dynamics of the health labour market

One of the most important components of health care systems is human resources for health (HRH)--the people that deliver the services. One key challenge facing policy makers is to ensure that health care systems have sufficient HRH capacity to deliver services that improve or maintain population health. In a predominantly public system, this involves policy makers assessing the health care needs of the population, deriving the HRH requirements to meet those needs, and putting policies in place that move the current HRH employment level, skill mix, geographic distribution and productivity towards the desired level. This last step relies on understanding the labour market dynamics of the health care sector, specifically the determinants of labour demand and labour supply. We argue that traditional HRH policy in developing countries has focussed on determining the HRH requirements to address population needs and has largely ignored the labour market dynamics aspect. This is one of the reasons that HRH policies often do not achieve their objectives. We argue for the need to incorporate more explicitly the behaviour of those who supply labour--doctors, nurses and other providers--those who demand labour, and how these actors respond to incentives when formulating health workforce policy.     

Managed care in the United States: promises, evidence to date and future directions

In the United States, health maintenance organizations (HMOs) and preferred provider organizations (PPOs) have proliferated during the past decade. To a great extent, their growth has been based on the perceived promise of these organizations to reduce health care costs without compromising quality of care and introduce a level of competition into the health care market that would result in a more efficient and effective health care system. This paper examines the promise of managed care as delivered through HMOs and PPOs, the evidence to date on the extent to which their promise has been met, and recent developments in the organization of managed care systems.     

Managing change in the era of health reform: organized delivery systems of public health.

As U.S. Medicaid managed care programs proliferate, it appears that traditional clinical training and practice often provide insufficient preparation for physicians to meet the care requirements of Medicaid beneficiaries adequately. State and local health departments have extensive experience with this population's need for preventive care, social support services, care coordination, and referral. Organized delivery systems of managed care can merge the expertise of primary care practitioners, public health professionals, and other community resources to deliver comprehensive care. Although the described model includes Medicaid as the payer, it would remain viable should Medicaid be terminated and universal coverage enacted.     

International trade agreements: hazards to health?

Since the 1980s, neoliberal policies have prescribed reducing the role of governments, relying on market forces to organize and provide health care and other vital human services. In this context, international trade agreements increasingly serve as mechanisms to enforce the privatization, deregulation, and decentralization of health care and other services, with important implications for democracy as well as for health. Critics contend that social austerity and "free" trade agreements contribute to the rise in global poverty and economic inequality and instability, and therefore to increased preventable illness and death. Under new agreements through the World Trade Organization that cover vital human services such as health care, water, education, and energy, unaccountable, secret trade tribunals could overrule decisions by democratically elected officials on public financing for national health care systems, licensing and training standards for health professionals, patient safety and quality regulations, occupational safety and health, control of hazardous substances such as tobacco and alcohol, the environment, and affordable access to safe water and sanitation. International negotiations in 2003 in Cancun and in Miami suggested that countervailing views are developing momentum. A concerned health care community has begun to call for a moratorium on trade negotiations on health care and water, and to reinvigorate an alternative vision of universal access to vital services.