The Quarterly review of economics and business最新文献

This article presents a model of the intensity of care provided by hospitals and physicians and how such intensity was affected by the change to prospective payment by Medicare. Prospective payment introduced an incentive for hospitals to shorten average length of stay, but in order to keep the patient recovery level constant, intensity of inpatient care was forced to increase. Physicians reacted to hospital changes by increasing their own intensity of care provided to inpatients. Implications of the model for admissions and physician office time are also explored. Empirical results indicate that for the period 1983-1987, spanning the introduction of PPS, both hospital and physician intensity of care per inpatient rose significantly.

Mark Pauly claims that a "competitive" health care system will solve the health care cost crisis. This article examines how well the competitive solution deals with the five central problems of the health care system: (1) almost universal lack of adequate health insurance for nursing homes and home care; (2) Medicaid's penurious approach to payment for health services for the poor; (3) the emergence of a dual health care system, especially for children; (4) the entrenched waste and inefficiency of the health care system; and (5) consumers' inability to judge the quality of health care. The competitive solution does not eliminate any of these problems--and may not even improve some of them.

This article reviews the causes of growth in health care costs and concludes that only changes in the rate of growth in intensity of care are likely to be effective. It proposes a model of consumer choice (with advice) among health plans, and competition among plans on the basis of the rate at which new technology is introduced, as a solution to the problem of picking the appropriate rate. It argues that the existence of the uninsured is evidence of government failure.

Health policy decisions are made in an uneven manner, eluding attempts to explain developments with a coherent theory. Numerous explanations have been suggested to explain individual policy actions, but recently Feldstein has attempted a broader formulation. This Self-Interest Model of Health Policy, however, assumes full knowledge of a policy's benefits and costs. This is an unrealistic assumption, and the model is unable to explain important decisions that have been made in three areas: insurance for long-term care, universal access, and efficiency incentives. This article presents a broader, more powerful formulation of the Feldstein model, specifically incorporating public ignorance as a policy determinant. The vital role of education and health policy research is underscored.

This article reviews the attempts of the 1970s and 1980s to rationalize health care provision in the United States. It critically discusses the contorted debate between competition and regulation as a means of controlling health care costs. The second part of the article takes up Eli Ginzberg's contentions about American health care. We agree that the United States has not been able to control medical inflation because it lacks the necessary condition of concentrated finance. But we present evidence from public opinion polls in the 1970s and the 1980s that challenges Professor Ginzberg's contention that "there is no evidence that the American people want to change [their] system" of medical care.

Serious problems exist with the nature of health care financing in the United States. This article summarizes problems caused by the high cost of serving an aging population, the lack of incentives in insurance plans for preventive care, and the growing number of uninsured people in the population. The article then focuses on efforts to bring about greater efficiency by changing the contractual relations between the principal--either the payor or the patient--and the agent--the provider. These new contracts attempt to place a greater share of the financial burden on the provider. Evidence of the success of these new contracts is mixed. The major point of the article is that real efficiencies will not be reached unless these incentive mechanisms together with competitive market forces relieve the excess capacity in the health care industry.

These are comments about how policy issues at the federal level may create a demand for research in several areas of health economics. As background, there is a discussion of the current federal budget situation and the cost-containment pressures this puts on public health programs. The longer-term problem of financing of the Medicare trust fund is also discussed. Four areas where new research may affect future health policy are identified: the market for physician's services, medical technology, competition in health care, and the market for health insurance.

This article uses a self-interest model to explain health care legislation. Seemingly uncoordinated, contradictory, inefficient, and inequitable legislative outcome are shown to be the result of a rational process in which the participants, including legislators, act according to their calculation of costs and benefits. Those groups able to offer political support receive net benefits at the expense of those who are less politically powerful. This framework is used to examine different types of health legislation with the emphasis on explicit redistributive policies such as Medicare and Medicaid.

This serves as an introduction to this special issue devoted to a selection of papers chosen and revised from a conference on public policy entitled "Health Care Policy: Where Is the Revolution Headed?" sponsored by the Thomas Jefferson Program in Public Policy at the College of William and Mary, Williamsburg, VA, November 12-14, 1987.