Consumer-driven health care: just a tweak or a revolution?

Although some believe that consumer-driven health care amounts to nothing more than a tweak to the current system of third-party payment, others see it as a far more profound development. They argue that enabling patients to control more of their health care dollars will lead to transformation throughout the health care system, starting with a demand for information. Once patients control the resources and are equipped with information, they will expect health care providers to deliver high-quality services at reasonable prices and at the convenience of the buyer.     

Managing for health: why health care?

Health and health care are increasingly big business. The challenge is to apply our knowledge and skills to meet people's needs, if not their demands as efficiently, effectively and beneficially as possible. Value for money is the slogan. For those who deliver the goods as required, the converse, money for value should equally apply, and not only in a market driven system. This paper offers a very personal view of these issues in the light of recent UK policy developments.     

Price: a market signal of quality in health care insurance policies?

Choosing a good quality health insurance policy is important for most individuals in this country. The choice task is however, made quite complicated by the existence of many alternative policies which are each characterized by multiple attributes. This paper examines whether the price (i.e., premium) of a health insurance plan can give a reliable signal about the objective quality level of the plan. Empirical analysis of real-world data shows that overall, price is positively correlated with such quality. Statistical significance tests are conducted to separately evaluate such correlations for different categories of health insurances. Finally, the empirical results are used to indicate implications for consumer decision making.     

Fee-for-service or donation? Hungarian perspectives on informal payment for health care

Informal payments are known to be widespread in the post-communist health care systems of Central and Eastern Europe. However, their role and nature remains contentious with the debate characterized by much polemic. This paper aims to make sense of this debate by reviewing and summarizing the main arguments of the theoretical debate in Hungary. The review examines the possible causes of informal payment, the motivation of the actors involved and the impact of informal payment on system performance, focusing on efficiency and equity. The lines of arguments are summarized in two contrasting hypotheses, which envisage informal payment as either a donation or a fee-for-service. Evidence pertaining to the scale of informal payments and the motivation of patients are reviewed, but found to be inconclusive to verify the hypotheses. Although focused on Hungary, accounts from other countries facing informal payments show similar threads of discussion and dilemmas. These theories should be tested further using evidence from existing studies and new empirical research, since the validity of the gratitude payment concept is a central dilemma of effective policy making in the area. To orient future research, a possible agenda is outlined, which links evidence to be obtained to the defining features of gratitude payments.     

Public health policies: a Scandinavian model?

AIM: To identify how public health problems are identified, explained, and addressed in Scandinavian public health programmes. METHODS: Recent public health white papers from Denmark, Norway, and Sweden have been studied asking the following questions. How are policies and activities justified? Which problems and causes are identified? What is to be done? To what extent are the interpretations and suggested interventions in accordance with liberal or social democratic political ideals? RESULTS: The programmes studied give similar reasons for dealing with public health, namely the wish to create good lives for citizens and to improve the economy of society. The health problems identified are almost the same: cancer, heart disease, diabetes, musculoskeletal diseases, and mental illness. The Danish programme differs from its Norwegian and Swedish counterparts with regard to explanations and suggested solutions to the problems. It may be characterized as more liberal. While the Danish programme stresses the importance of individual behaviour, responsibility, and autonomy, the two others emphasize social relations, living conditions, and participation in addition to behavioural factors. Political responsibility for the health of the population is emphasized in the Norwegian and Swedish programmes. The Swedish programme, in particular, stresses common values such as equality and equal rights, and the significance of the welfare state. The Norwegian programme underlines the importance of empowering the individual, an ambition that could also be seen as a social liberal ambition to increase the self-determination of citizens. CONCLUSION: There is not one Scandinavian model in public health policy but several: a Danish model mainly adhering to liberal ideals, a Norwegian one that could tentatively be labelled social liberal, and a Swedish model adhering to more social democratic ideals.     

Food policies: a threat to health?

Food policies deliver large quantities of food relatively safely, but they are failing to deliver healthy diets. Policies fall into three broad categories: the supply of sufficient amounts of food (food security); the provision of food free from contamination (food safety); the provision of a healthy diet available to all (nutritional quality). These three aspects are dealt with by institutions that rarely engage with each other, let alone coordinate their strategies. Greater financial support has been given to agricultural policy than to any other joint EU endeavour. In the last decade food safety has dominated headlines and has influenced recent changes to EU food policies. New food authorities and agencies have been established and ministerial responsibilities have been redefined. Yet, it is nutrition, or rather 'mis-nutrition', that is the largest single cause of death and disease within the region, and indeed worldwide. This need not be the case. Nutrition and dietary policies may find themselves in close alliance with policies for sustainable agriculture. However, the change in thinking that will be required will mean reconsidering the role of commercial food production. Successful nutrition policies may yet prove to be the next major step in the improvement of public health.     

Is home health care a substitute for hospital care?

A previous study used aggregate (region-level) data to investigate whether home health care serves as a substitute for inpatient hospital care and concluded that "there is no evidence that services provided at home replace hospital services." However, that study was based on a cross-section of regions observed at a single point of time and did not control for unobserved regional heterogeneity. In this article, state-level employment data are used to reexamine whether home health care serves as a substitute for inpatient hospital care. This analysis is based on longitudinal (panel) data--observations on states in two time periods--which enable the reduction or elimination of biases that arise from use of cross-sectional data. This study finds that states that had higher home health care employment growth during the period 1998-2008 tended to have lower hospital employment growth, controlling for changes in population. Moreover, states that had higher home health care payroll growth tended to have lower hospital payroll growth. The estimates indicate that the reduction in hospital payroll associated with a $1,000 increase in home health payroll is not less than $1,542, and may be as high as $2,315. This study does not find a significant relationship between growth in utilization of home health care and growth in utilization of nursing and residential care facilities. An important reason why home health care may serve as a substitute for hospital care is that the availability of home health care may allow patients to be discharged from the hospital earlier. Hospital discharge data from the Healthcare Cost and Utilization Project are used to test the hypothesis that use of home health care reduces the length of hospital stays. Major Diagnostic Categories with larger increases in the fraction of patients discharged to home health care tended to have larger declines in mean length of stay (LOS). Between 1998 and 2008, mean LOS declined by 4.1%, from 4.78 to 4.59 days. The estimates are consistent with the hypothesis that this was entirely due to the increase in the fraction of hospital patients discharged to home health care, from 6.4% in 1998 to 9.9% in 2008. The estimated reduction in 2008 hospital costs resulting from the rise in the fraction of hospital patients discharged to home health care may have been 36% larger than the increase in the payroll of the home health care industry.     

A renewed focus on primary health care: revitalize or reframe?

Background  

Sex work is receiving increased attention in southern Africa. In the context of South Africa's intense preparation for hosting the 2010 FIFA World Cup, anxiety over HIV transmission in the context of sex work has sparked debate on the most appropriate legal response to this industry.     

A renewed focus on primary health care: revitalize or reframe?

The year 2008 celebrated 30 years of Primary Health Care (PHC) policy emerging from the Alma Ata Declaration with publication of two key reports, the World Health Report 2008 and the Report of the Commission on the Social Determinants of Health. Both reports reaffirmed the relevance of PHC in terms of its vision and values in today's world. However, important challenges in terms of defining PHC, equity and empowerment need to be addressed.     

Vermont's Catamount Health: a roadmap for health care reform?

Vermont's new health reform program was enacted under a Republican governor in a state with a Democrat-controlled legislature. It thus serves as an intriguing approach to resolving political differences in health care. James Maxwell's interview of Vermont governor Jim Douglas provides background and insight on these reforms. I build on the interview, focusing on what changed between the 2005 reform failure and the passage of the new reforms. Key to the reform's political success was the recognition by both sides that it focused on issues of bipartisan concern: cost control through the effective management and prevention of disease.     

Robust design: a new tool for health care quality?

Robust design is a powerful technique for developing processes that produce desirable outcomes, even in the presence of factors that cannot be controlled or cannot be controlled economically. In the past 12 years several leading high-technology manufacturing companies in the United States have applied robust design methods with considerable success. This article discusses the basic concepts of robust design and speculates on how these ideas might be applied to health care quality management.     

Satisfaction for health care employees: a quest for the Holy Grail?

This article proposes that, across industries, too much has been made of the importance of job satisfaction and its impact on organizational effectiveness. In addition, so much attention has been directed toward satisfaction that many health care employees, particularly nurses, now expect job satisfaction from their employers as an entitlement. In nursing, feelings about job satisfaction may, in fact, be exacerbated by the idealism which leads the young person entering the field to expect to be in a "helping profession" where workers almost automatically encounter the satisfaction that comes from giving the help which the patient desperately needs. Faced with the realities of long hours, grueling and often menial tasks, and sometimes churlish patients and physicians, the young nurse may, in fact, enter a period of deep dissatisfaction and of questioning nursing as a career choice. This situation is not unique to nurses. Many health care professionals face equally dissatisfying aspects of their jobs. Our focus is primarily on reducing job dissatisfaction, rather than improving job satisfaction, through practical solutions for those charged with attracting and retaining health care employees during tight labor markets.     

What should a country spend on health care?

Per capita health spending across countries ranges by more than 100 to 1, leading many people to ask, "What should a country spend on health care?" This paper discusses four approaches to this question and demonstrates how each approach, in effect, answers a slightly different question, all of which are important to public policy decisions regarding health care spending. The paper also addresses a commonly cited World Health Organization statement that countries should spend 5 percent of national income on health care services.     

Achieving universal health insurance in Korea: a model for other developing countries?

As developing countries explore alternative methods to provide universal health insurance coverage, one potential model is South Korea. In twelve years (from 1977 to 1989), Korea was able to achieve universal health insurance coverage first by mandating employer based health insurance coverage for medium and large firms and then by establishing regional health insurance systems for small firms, farmers and the self-employed. A government medical aid insurance program was instituted for low income citizens. The specifics of the plan and some of the issues encountered in implementing the plan may be of interest to developing countries who want to achieve universal health insurance while maintaining a significant role for the private sector.