The Baxter health policy review最新文献

The recent debate on national health care reform marked another case of policy being considered without reference to how--or even if--it could be implemented. The debate revolved around broad issues, such as universal versus partial coverage, mandatory versus voluntary alliances, and the respective roles of government and the market in health care. The ease or even the possibility of successful implementation was not an ingredient in evaluating proposals. The burden of making health care reform work falls to the states. Whether in response to national reform or in implementing their own programs, they must move from a general reform blueprint to an actual program that delivers services. The hands-on role of the states in designing and operating programs makes their implementation duties both unavoidable and critical. This chapter explores implementation issues that should be considered an integral part of planning for health care reform, at both the federal and the state level. The chapter has two goals. First, it makes a case for altering the usual approach to designing reform and recommends paying attention to implementation early in the policy process, rather than treating it as an afterthough. Second, it is intended to help policymakers design implementable programs and anticipate pitfalls. To achieve these goals, it examines the state role in health care reform; state capacity to carry out this role; examples of state health care reform initiatives and lessons for implementation drawn from these efforts; and barriers to successful implementation. The chapter concludes with recommendations for policymakers.

Quality measurement is not a new idea. However, in recent years, several new trends have gained prominence: greater interest in publicly reported information on quality of care, access to care, and patient satisfaction; an increased focus on health plans and integrated systems of care rather than on institutional providers and practitioners as the unit of observation; wide adoption of the techniques of continuous quality improvement within the health care sector; increased use of clinical practice guidelines to improve care for a broad range of medical conditions; incorporation of computer technology into the clinical setting; and greater appreciation for health outcomes as a measure of quality of care. This chapter first reviews the changes in the medical landscape that have seeded these trends and the distinction between quality assurance and quality improvement. It then focuses on public policy concerns, in particular on the emergence of publicly disseminated information about quality of care, now often called "quality report cards." The major prototypes of these reports developed to date, the responses to quality reporting by different members of the delivery system, and the major criticisms of this approach are reviewed. The chapter concludes by predicting probable developments and the strategies most likely to move health care forward in a productive direction.

Interest in Medicare, the government's second largest social program after Social Security, reached a new high in 1995, not as part of health care reform, but as a vehicle for deficit reduction and because of a desire by Congress to restructure the program to encourage enhanced choice for beneficiaries and greater use of managed care. Medicaid, a major payer of long-term care and financer of coverage for low-income elderly, also is slated to undergo major restructuring in the next few years. As Congress and the nation debate the future of these key programs for older Americans, a number of critical issues deserve attention. Medicare's costs are very high--but not necessarily unreasonable in the face of the demands on health care services for this part of the population. And even with these high costs, a number of important gaps in coverage remain a problem for seniors. Deductibles and copayments are also high--especially for hospital and skilled nursing services. But pressure for change may well lead to higher, not lower, cost-sharing requirements. Medicare remains a largely fee-for-service program at a time when the national health care system is shifting increasingly to a managed care environment. Moving Medicare in that direction is one likely option for change. While it is desirable to have Medicare move in concert with the rest of the system, a number of issues stand in the way of an effortless move to managed care for the elderly. Moreover, coordination of long-term and acute care services may be even more challenging in such an environment. Medicaid covers long-term care services for older Americans, but only for those who have depleted most of their assets and income. Even when people do become eligible, Medicaid covers primarily institutional care. But little is likely to change this picture in the next few years, and private efforts through expansion of long-term care insurance will likely provide only a partial solution.

Health care spending in the United States has continued to outpace the growth in national income and the growth in spending in other countries. And yet many Americans are without sufficient health care. Since the failure of national health care reform proposals put forward by the Clinton administration and others, the United States has had to look for other solutions to the problem of how to control spending in this sector. Can the new competitive approach of managed care succeed where other cost control measures of the past have failed? This chapter begins with an examination of the problems facing health care today, outlines recent trends in health care spending, and details reasons why spending is rising so rapidly at this time. The historical context of health care reform proposals and government attempts to control spending are described next and the reasons why some of these plans made no progress are explained. The health care payment systems of other industrialized nations that have seen some success in controlling costs are analyzed. Comparison of these systems with proposed plans for reforming the U.S. system provide insights and lessons for the United States. Finally, the chapter describes managed care and managed competition and makes the argument that managed care has the potential to respond to many of the health care spending problems facing the United States. However, more data on this subject are needed, and the authors call for a national monitoring entity to assess the progress of managed care in meeting the health care needs of the public.

Largely because of its indifference to spiraling costs, the professional domination model is being replaced by a market model based on competition among managed care plans and integrated delivery systems. In general, the more fully integrated previously competing providers become--for instance, by assuming financial risk together--the less legal risk is present, because of a decreased possibility of improper conspiratorial or collective behavior. Nevertheless, provider joint ventures and integrated delivery systems face a complex interaction of practical challenges and various legal and regulatory risks. This chapter explores ways in which laws involving fraud and abuse, self-referral, private inurement, corporate practice of medicine, Medicare reimbursement policy, and antitrust enforcement affect typical integrated delivery systems. From a legal standpoint, it might seem logical that the laws regulating health care providers would support and promote integration. A permissive legal environment to foster development of an integrated service network model assumes its development in a delivery system in which networks are at financial risk for the services provided. However, many of the laws and regulations governing integrated provider development were established at a time when joint ventures and other alliances were organizing in a predominantly fee-for-service environment and were generating significant increases in health care costs without producing demonstrable efficiencies or quality enhancements. The results is a fundamental inconsistency in government policy. The demand for collaboration by purchasers and legislatures does not necessarily cause the vast body of health care regulators to revise their concerns that many of the very collaborative activities being encouraged trigger potentially illegal acts and relationships. In a market model, the application of federal and state antitrust laws is especially important. In 1993 and 1994, the Department of Justice and the Federal Trade Commission jointly issued "Statements of Antitrust Enforcement Policy" in a number of areas of provider uncertainty. For integrated delivery systems, the primary focus of antitrust analysis is "market power." Systems without market power (i.e., the ability to force a purchaser to do something that the purchaser would not do in a competitive market) cannot harm consumers and should be free from serious antitrust risk. Where a network may have market power, its activities may be limited only if demonstrable anticompetitive effects outweigh the benefits of the efficiencies claimed by the new arrangement. The chapter concludes that vigorous antitrust enforcement may be required to promote market competition among integrated networks of providers and the managed care plans they serve.

The U.S. health care system is restructuring at a dizzying pace. In many parts of the country, managed care has moved into third-generation models emphasizing capitated payment for enrolled lives and, in the process, turning most providers and institutions into cost centers to be managed rather than generators of revenue. While the full impact of the new managed care models remains to be seen, most evidence to date suggests that it tends to reduce inpatient use, may be associated with greater use of physician services and preventive care, and appears to result in no net differences either positive or negative with regard to quality or outcomes of care in comparison with fee-for-service plans. Some patients, however, tend to be somewhat less satisfied with scheduling of appointments and the amount of time spent with providers. There is no persuasive evidence that managed care lowers the rate of growth in overall health care costs within a given market. Further, managed care performance varies considerably across the country, and the factors influencing managed care performance are not well understood. Organized delivery systems are a somewhat more recent phenomenon representing various forms of ownership and strategic alliances among hospitals, physicians, and insurers designed to provide more cost-effective care to defined populations by achieving desired levels of functional, physician-system, and clinical integration. Early evidence suggests that organized delivery systems that are more integrated have the potential to provide more accessible coordinated care across the continuum, and appear to be associated with higher levels of inpatient productivity, greater total system revenue, greater total system cash flow, and greater total system operating margin than less integrated delivery forms. Some key success factors for developing organized delivery systems have been identified. Important roles are played by organizational culture, information systems, internal incentives, total quality management, physician leadership, and the growth of group practices. This chapter describes the growth and evolution of managed care and organized delivery systems, the research evidence regarding managed care and organized delivery systems, and the likely future organization of the health system in light of recent trends and evidence. It also highlights some of the more important public policy implications of the new health care infrastructure.

This discussion on likely changes and challenges for the health insurance industry over the coming decade assumes that significant national reform of health care financing for the privately insured population will not occur--or, if it does, that it will mirror the insurance market reforms that many states already have undertaken. First, the changes in private insurance coverage during the past several years are considered, with particular attention to the erosion of employer-based coverage and to the rising influence of public insurance programs--especially Medicaid--on the private insurance market. Next is a description of the changing web of state laws and regulations governing private health insurance. At this writing, virtually every state has enacted or is considering reforms of the small group market to limit what many perceive as unfair or destructive insurer practices and to set new ground rules for competition among insurance arrangements. The changing nature of private insurance contracts in the United States is considered next. Evolving from conventional fee-for-service contracts, private insurance is increasingly a complex mixture of capitation, partial capitation, and reinsurance of capitated arrangements. Finally, this chapter discusses three issues of increasing importance in shaping the marketplace for private insurers: (1) the federal preemption of states' regulatory authority over self-insured employer plans; (2) emerging state regulation to restructure competition in the health insurance and health care markets; and (3) the growing interest of both federal and state governments in medical savings accounts to finance health insurance and health care spending.

Disability is discussed in terms of three categories: conditions that result from biomedical conditions and chronic, lifelong illnesses; role or social functioning difficulties that result from behavioral, developmental, or brain disorders; and conditions that limit physical functioning. The range and depth of services needed by the disabled result in higher costs of health care for this population. Because their service needs vary so widely, no single program can address all of the needs equally. Currently, no integrated public policy or program is specifically designed to serve people with disabilities. Rather, they are served by a range of programs that provide specific benefits (e.g., health, social services, and income). Section 1 of this chapter provides an overview on extending the concept of managed care to disabled populations. Special attention is paid to the financing of health care, the delivery of care, reforming the health care system, the cost-containment potential of managed care, and the need to align care with the nature of the individual disability. In sections 2 and 3, the current status of managed care for two special populations--children and the mentally ill--is discussed in greater detail. Section 2 addresses the characteristics of chronically ill and disabled children, public and private health insurance coverage of children with disabilities, other public programs for chronically ill children, and current directions and strategic choices for managed pediatric care. Section 3 describes the mentally ill and the system of providers that currently supplies care to them, offers some conclusions regarding how managed care is changing the policy debate in mental health care, assesses the key factors affecting policy choices in managed care, and considers prospects for the future shape of managed behavioral health care.

The word "rationing" has come to play a central role in the national health policy debate. Alas, it is also one of the most misunderstood of words. Its injection into the debate has generated far more heat than light. This chapter reviews the definition of "rationing" preferred by the profession that takes as its task the study of how individuals and society respond to and deal with scarcity, namely, the economics profession. It will be shown that economists usually consider all limits on the distribution of a scarce good or services to be "rationing," whether that limit takes the form of a price barrier or some method of non-price allocation--for example, queues or allocation by lottery. To make a distinction between allocation through freely competitive markets and other forms of resource allocation, economists distinguish between "price rationing" and "non-price rationing." This is a meaningful distinction. Adoption of the economist's definition of "rationing" would greatly clarify the national health policy debate. Next, the discussion turns to the controversial proposition, commonly made by most economists and a handful of their allies in the medical profession, that an economically efficient health care system will inevitably engage in the pervasive withholding of services that may be sought by patients and their physicians, and that it will do so to enhance the quality and efficiency of the health care system overall. If managed competition lives up to its current billing, it will entail rationing of precisely that sort. Unfortunately, the individualist tradition of the United States, as it expresses itself in the tort system, may seriously hinder managed competition from achieving its stated goal. Finally, this chapter offers some conjectures on the approach to rationing likely to be taken by the United States health care system in the twenty-first century. It is argued that, far from having been inconclusive, the most recent congressional debate on health care reform actually gave official sanction to a three-tiered health system, with fairly severe rationing in the bottom tier and virtually none in the top tier. While such tiering has always been present in the U.S. health care system, the phenomenon has hitherto been treated as a blemish to be removed by government--now it will probably remain a permanent fixture.