2016-17 Courses


All Publications


  • With Roots In California, Managed Competition Still Aims To Reform Health Care. Health affairs (Project Hope) Enthoven, A. C., Baker, L. C. 2018; 37 (9): 1425–30

    Abstract

    Managed competition is a concept that was born in California and has achieved a measure of acceptance there. As California and the United States as a whole continue to struggle with the challenge of providing high-quality health care at a manageable cost, it is worth asking whether managed competition-with its tools for harnessing market forces-continues to hold promise as a means of improving value in health care, and whether the standard conceptualization of managed competition should be modified in any way. In this article we reflect on four aspects of California's health care ecosystem that provide insights into these questions: integrated delivery systems, patients' choice of health plans, quality measurement, and new health care marketplace architectures such as Covered California and private insurance exchanges. Overall, while California's experience with managed competition has resulted in some challenges and adaptations, it also gives reason to believe that principles of managed competition continue to have the potential to be a powerful force toward creating a more efficient health care system.

    View details for PubMedID 30179555

  • Improving The Affordable Care Act: An Assessment Of Policy Options For Providing Subsidies HEALTH AFFAIRS Saltzman, E. A., Eibner, C., Enthoven, A. C. 2015; 34 (12): 2095-2103

    View details for DOI 10.1377/hlthaff.2015.0209

    View details for PubMedID 26643630

  • Reform incentives to create a demand for health system reengineering. Studies in health technology and informatics Enthoven, A. 2010; 153: 209-227

    Abstract

    America needs a far more efficient health care financing and delivery system than the one we have. Our present system is a serious threat to public finances and is pricing itself out of reach. At the root of the problem are incentives and organization. The present fragmented fee-for-service small practice model is filled with cost-increasing incentives. There are some relatively efficient organized delivery systems, mostly based on large multi-specialty group practices. Unfortunately, most consumers are not offered the opportunity to save money and get better care by choosing such a system. This situation presents great opportunities for improvement in performance by re-engineering the system. However, for this to happen, incentives must be fundamentally changed so that everyone is cost conscious and care is organized in accountable care systems seeking improvement.

    View details for PubMedID 20543247

  • Integrated delivery systems: the cure for fragmentation. American journal of managed care Enthoven, A. C. 2009; 15 (10): S284-90

    Abstract

    Our healthcare system is fragmented, with a misalignment of incentives, or lack of coordination, that spawns inefficient allocation of resources. Fragmentation adversely impacts quality, cost, and outcomes. Eliminating waste from unnecessary, unsafe care is crucial for improving quality and reducing costs--and making the system financially sustainable. Many believe this can be achieved through greater integration of healthcare delivery, more specifically via integrated delivery systems (IDSs). An IDS is an organized, coordinated, and collaborative network that links various healthcare providers to provide a coordinated, vertical continuum of services to a particular patient population or community. It is also accountable, both clinically and fiscally, for the clinical outcomes and health status of the population or community served, and has systems in place to manage and improve them. The marketplace already contains numerous styles and degrees of integration, ranging from Kaiser Permanente-style full integration, to more loosely organized individual practice associations, to public-private partnerships. Evidence suggests that IDSs can improve healthcare quality, improve outcomes, and reduce costs--especially for patients with complex needs--if properly implemented and coordinated. No single approach or public policy will fix the fragmented healthcare system, but IDSs represent an important step in the right direction.

    View details for PubMedID 20088632

  • Toward a 21st-Century Health Care System: Recommendations for Health Care Reform ANNALS OF INTERNAL MEDICINE Arrow, K., Auerbach, A., Bertko, J., Brownlee, S., Casalino, L. P., Cooper, J., Crosson, F. J., Enthoven, A., Falcone, E., Feldman, R. C., Fuchs, V. R., Garber, A. M., Gold, M. R., Goldman, D., Hadfield, G. K., Hall, M. A., Horwitz, R. I., Hooven, M., Jacobson, P. D., Jost, T. S., Kotlikoff, L. J., Levin, J., Levine, S., Levy, R., Linscott, K., Luft, H. S., Mashal, R., McFadden, D., Mechanic, D., Meltzer, D., Newhouse, J. P., Noll, R. G., Pietzsch, J. B., Pizzo, P., Reischauer, R. D., Rosenbaum, S., Sage, W., Schaeffer, L. D., Sheen, E., Silber, M., Skinner, J., Shortell, S. M., Thier, S. O., Tunis, S., Wulsin, L., Yock, P., Bin Nun, G., Bryan, S., Luxenburg, O., van de Ven, W. P. 2009; 150 (7): 493-?

    Abstract

    The coverage, cost, and quality problems of the U.S. health care system are evident. Sustainable health care reform must go beyond financing expanded access to care to substantially changing the organization and delivery of care. The FRESH-Thinking Project (www.fresh-thinking.org) held a series of workshops during which physicians, health policy experts, health insurance executives, business leaders, hospital administrators, economists, and others who represent diverse perspectives came together. This group agreed that the following 8 recommendations are fundamental to successful reform: 1. Replace the current fee-for-service payment system with a payment system that encourages and rewards innovation in the efficient delivery of quality care. The new payment system should invest in the development of outcome measures to guide payment. 2. Establish a securely funded, independent agency to sponsor and evaluate research on the comparative effectiveness of drugs, devices, and other medical interventions. 3. Simplify and rationalize federal and state laws and regulations to facilitate organizational innovation, support care coordination, and streamline financial and administrative functions. 4. Develop a health information technology infrastructure with national standards of interoperability to promote data exchange. 5. Create a national health database with the participation of all payers, delivery systems, and others who own health care data. Agree on methods to make de-identified information from this database on clinical interventions, patient outcomes, and costs available to researchers. 6. Identify revenue sources, including a cap on the tax exclusion of employer-based health insurance, to subsidize health care coverage with the goal of insuring all Americans. 7. Create state or regional insurance exchanges to pool risk, so that Americans without access to employer-based or other group insurance could obtain a standard benefits package through these exchanges. Employers should also be allowed to participate in these exchanges for their employees' coverage. 8. Create a health coverage board with broad stakeholder representation to determine and periodically update the affordable standard benefit package available through state or regional insurance exchanges.

    View details for Web of Science ID 000265117600008

    View details for PubMedID 19258550

  • New directions for public health care purchasers? Responses to looming challenges HEALTH AFFAIRS McKethan, A., Gitterman, D., Feezor, A., Enthoven, A. 2006; 25 (6): 1518-1528

    Abstract

    State public employee health plans (PEHPs) provide health benefits for millions of state and local workers, retirees, and their dependents nationwide. This paper explores major issues and challenges that PEHP leaders and state policymakers are addressing. These include the perennial challenge of funding benefits for a diverse and aging workforce; new accounting standards affecting public employers; and the changing relationship between states, retired public employees, and the Medicare program. Interviews with PEHP executives explored whether these are incremental challenges to which states can effectively adapt, or whether these challenges will catalyze broader and lasting change in the public employee and retiree health benefits arena.

    View details for DOI 10.1377/hlthaff.25.6.1518

    View details for Web of Science ID 000242033300010

    View details for PubMedID 17102175

  • Employment-based health insurance: Past, present, and future HEALTH AFFAIRS Enthoven, A. C., Fuchs, V. R. 2006; 25 (6): 1538-1547

    Abstract

    We review the rise, stabilization, and decline of employment-based insurance; discuss its transformation from quasi-social insurance to a system based on actuarial principles; and suggest that the presence of Medicare and Medicaid has weakened political pressure for universal coverage. We highlight employment-based insurance's flaws: high administrative costs, inequitable sharing of costs, inability to cover large segments of the population, contribution to labor-management strife, and the inability of employers to act collectively to make health care more cost-effective. We conclude with scenarios for possible trajectories: employment-based insurance flourishes, continues to erode, or is replaced by a more comprehensive system.

    View details for DOI 10.1377/hlthaff.25.6.1538

    View details for Web of Science ID 000242033300013

    View details for PubMedID 17102178

  • Connecting consumer choice to the healthcare system. Journal of health law Enthoven, A. 2006; 39 (3): 289-305

    Abstract

    American healthcare needs to be reformed into competing, efficient, comprehensive care systems. To get there from here, we need a health insurance market in which each person or household has a wide, responsible, informed, individual multiple choice of health care financing and delivery plans. The point of this is competing delivery systems, not just competing carriers. To compete, some carriers will create or contract with selective delivery systems or doctors selected for their quality and cost-effectiveness. Others will already be teamed up with large multispecialty group practices. On the other hand, high deductible plans will not help us get to a reformed delivery system.

    View details for PubMedID 17260543

  • Competition in health care: It takes systems to pursue quality and efficiency HEALTH AFFAIRS Enthoven, A. C., Tollen, L. A. 2005; 24 (5): W5420-W5433
  • Competition in health care: it takes systems to pursue quality and efficiency. Health affairs Enthoven, A. C., Tollen, L. A. 2005: W5-420 33

    Abstract

    Many stakeholders agree that the current model of U.S. health care competition is not working. Costs continue to rise at double-digit rates, and quality is far from optimal. One proposal for fixing health care markets is to eliminate provider networks and encourage informed, financially responsible consumers to choose the best provider for each condition. We argue that this "solution" will lead our health care markets toward even greater fragmentation and lack of coordination in the delivery system. Instead, we need markets that encourage integrated delivery systems, with incentives for teams of professionals to provide coordinated, efficient, evidence-based care, supported by state-of-the-art information technology.

    View details for PubMedID 16148024

  • Stanford University's experience with managed competition HEALTH AFFAIRS Enthoven, A. C., Talbott, B. 2004; 23 (6): 136-140

    Abstract

    Stanford University has a "managed competition" model of health insurance. Stanford contributes the cost of the low-cost plan, and employees are responsible for premium differences between this plan and other offerings. Each employee gets what he or she wants and is willing to pay for, and everyone has low-cost access to health insurance. Stanford risk-adjusts the premiums based on age and sex and plans soon to adjust including prescription drug data. In the past five years, premiums have risen rapidly, in line with the rest of the market. For competition to transform the delivery system, most employers in the region must adopt managed competition.

    View details for DOI 10.1377/hlthaff.23.6.136

    View details for Web of Science ID 000227835800019

    View details for PubMedID 15537591

  • Sustaining a market-based healthcare system. Healthcare financial management : journal of the Healthcare Financial Management Association Enthoven, A. C. 2004; 58 (7): 60-64

    Abstract

    Purchasers of health care are not holding the healthcare system accountable for quality and cost. Employers need to: Offer their employees a wide range of choices in health coverage. Earmark for employees' purchase a fixed dollar amount for health care set at or below the price of the low-priced plan. Insist that carriers and providers report the quality of care delivered.

    View details for PubMedID 15298295

  • Market forces and efficient health care systems HEALTH AFFAIRS Enthoven, A. C. 2004; 23 (2): 25-27

    Abstract

    The "market forces" to which economists ascribe the ability to motivate improvement in quality and efficiency are largely nonexistent in U.S. health care. One thus might ask, "Could market forces be made strong enough to deliver efficient health care systems?" There is some evidence to suggest that the answer is "Yes." This paper offers a short list of some changes that would be needed to create such a health care economy. Continued increases in costs and in the numbers of uninsured people will likely make a universal coverage model based on Medicare a politically popular choice, but such a model would not deliver efficient health care systems because it lacks sufficient incentives for consumers to choose less costly options.

    View details for DOI 10.1377/hlthaff.23.2.25

    View details for Web of Science ID 000220059700004

    View details for PubMedID 15046128

  • Employment-based health insurance is failing: Now what? HEALTH AFFAIRS Enthoven, A. C. 2003; 22 (4): W237-W249
  • Covering the uninsured. Two perspectives on the government's role. Healthplan Enthoven, A. 2003; 44 (4): 22-24

    View details for PubMedID 12920865

  • A leading publication. Healthplan Enthoven, A. 2003; 44 (3): 26-29

    View details for PubMedID 12808755

  • The rise and fall of a Kaiser Permanente expansion region MILBANK QUARTERLY Gitterman, D. P., Weiner, B. J., Domino, M. E., McKethan, A. N., Enthoven, A. C. 2003; 81 (4): 567-?

    View details for Web of Science ID 000187239000003

    View details for PubMedID 14678480

    View details for PubMedCentralID PMC2690244

  • Employment-based health insurance is failing: now what? Health affairs Enthoven, A. C. 2003: W3-237 49

    Abstract

    Employment-based health insurance is failing. Costs are out of control. Employers have no effective strategy to deal with this. They must think strategically about fundamental change. This analysis explains how employers' purchasing policies contribute to rising costs and block growth of economical care. Single-source managed care is ineffective, and effective managed care cannot be a single source. Employers should create exchanges through which they can offer employees wide, responsible, individual, multiple choices among health care delivery systems and create serious competition based on value for money. Recently introduced technology can assist this process.

    View details for PubMedID 14527258

  • The Fortune 500 model for health care: is now the time to change? Journal of health politics, policy and law Enthoven, A. C. 2002; 27 (1): 37-48

    View details for PubMedID 11942418

  • Consumer choice and the managed care backlash AMERICAN JOURNAL OF LAW & MEDICINE Enthoven, A. C., Schauffler, H. H., McMenamin, S. 2001; 27 (1): 1-15

    View details for Web of Science ID 000168358000001

    View details for PubMedID 11367819

  • Structural problems of managed care in California and some options for ameliorating them CALIFORNIA MANAGEMENT REVIEW Singer, S. J., Enthoven, A. C. 2000; 43 (1): 50-?
  • Modernising the NHS - A promising start but fundamental reform is needed BRITISH MEDICAL JOURNAL Enthoven, A. C. 2000; 320 (7245): 1329-1331
  • A promising start, but fundamental reform is needed. BMJ (Clinical research ed.) Enthoven, A. C. 2000; 320 (7245): 1329-1331

    View details for PubMedID 10807633

    View details for PubMedCentralID PMC1127318

  • Unrealistic expectations born of defective institutions JOURNAL OF HEALTH POLITICS POLICY AND LAW Enthoven, A. C., Singer, S. J. 1999; 24 (5): 931-939

    View details for Web of Science ID 000083736300006

    View details for PubMedID 10615602

  • The managed care backlash and the task force in California HEALTH AFFAIRS Enthoven, A. C., Singer, S. J. 1998; 17 (4): 95-110

    Abstract

    Signs of a managed care backlash in California are increasing. This paper reports and interprets the recently completed work of the California Managed Health Care Improvement Task Force, focusing on the managed care backlash and the state's regulatory response. Although cost containment was a contributing factor, the causes of and solutions to the backlash differ among consumers, physicians, health care workers, politicians, and health plans. The recommendations of the task force could improve the market for health insurance. However, lasting solutions to the profound problems causing the backlash will require fundamental cultural and systemic change.

    View details for Web of Science ID 000074933100013

    View details for PubMedID 9691553

  • Total hip replacement: A case history HEALTH CARE MANAGEMENT REVIEW Keston, V. J., Enthoven, A. C. 1998; 23 (1): 7-17

    Abstract

    The history of total hip replacement in the U.S. demonstrates that health care providers can reduce costs while improving quality. Nationwide, the cost of total hip replacements has declined dramatically while quality has improved. This article describes 14 clinical and management innovations ranging from patient education to competitive bidding.

    View details for Web of Science ID 000071807200002

    View details for PubMedID 9494816

  • Paying more twice: When employers subsidize higher-cost health plans HEALTH AFFAIRS Hunt, K. A., Singer, S. J., Gabel, J., Liston, D., Enthoven, A. C. 1997; 16 (6): 150-156

    View details for Web of Science ID A1997YH06000021

    View details for PubMedID 9444822

  • Markets and collective action in regulating managed care HEALTH AFFAIRS Enthoven, A. C., Singer, S. J. 1997; 16 (6): 26-32

    View details for Web of Science ID A1997YH06000004

    View details for PubMedID 9444805

  • Managed competition and California's health care economy HEALTH AFFAIRS Enthoven, A. C., Singer, S. J. 1996; 15 (1): 39-57

    Abstract

    There is evidence in California of a broad decline in health care costs to employment groups adopting managed care and managed competition--premium reductions up to 10 percent. National comparisons and utilization data generally confirm the beginning of lower costs. Large California medical groups and health systems have responded to pressure by finding ways to reduce costs and improve quality. While examples are encouraging, there is room for improvement. Two levels of competition have emerged and continue to evolve: carrier competition and delivery system competition. Each model has strengths and limitations, but the existing mix is driving down costs.

    View details for Web of Science ID A1996VB83800005

    View details for PubMedID 8920568

  • Market-based reform: What to regulate and by whom? Conference on the Problem that Will Not Go Away - Reforming US Health Care Financing Enthoven, A. C., Singer, S. J. BROOKINGS INST. 1996: 185–206
  • Health care quality management: A status report INTERNATIONAL ANESTHESIOLOGY CLINICS Vorhaus, C. B., Enthoven, A. C. 1995; 33 (4): 1-14

    View details for Web of Science ID A1995TN56600001

    View details for PubMedID 8964619

  • Increasing cost-consciousness for managed care: reforming the tax treatment of health insurance expenditures. Health care management (Philadelphia, Pa.) Enthoven, A. C., Singer, S. J. 1995; 2 (1): 109-114

    Abstract

    The current Internal Revenue Code encourages employees who receive health insurance as part of their benefits package to choose more costly coverage than they would buy with their own money. The authors propose an approach that corrects this problem as well as the inequities experienced by self-employed and unemployed people.

    View details for PubMedID 10165625

  • RESPONSIBLE CHOICES - THE JACKSON-HOLE GROUP PLAN FOR HEALTH REFORM HEALTH AFFAIRS Ellwood, P. M., Enthoven, A. C. 1995; 14 (2): 24-39

    Abstract

    "Responsible Choices" identifies the actions that the private sector and government should take to improve the U.S. health care system and accelerate and expand the health care revolution that is already underway. Policy proposals are made for Medicare; Medicaid; reforming the tax treatment of health insurance; insurance reforms and expanding group purchasing opportunities; and improving the availability of comparative information on health benefit offerings, quality accountability, and cost and coverage data. The recommendations refocus the Jackson Hole Group's original managed competition proposals contained in The 21st Century American Health System (1991).

    View details for Web of Science ID A1995RK80400004

    View details for PubMedID 7657245

  • ON THE IDEAL MARKET-STRUCTURE FOR 3RD-PARTY PURCHASING OF HEALTH-CARE SOCIAL SCIENCE & MEDICINE Enthoven, A. C. 1994; 39 (10): 1413-1424

    Abstract

    The ideal market structure would give each medical care organization effective incentives to produce maximum value for money for enrolled subscribers. It should be based on integrated financing and delivery systems--partnerships that link doctors, hospitals and insurers--with per capita prepayment, with providers at risk for cost of care and cost of poor quality, publicly accountable for quality and per capita costs. The ideal market structure must be managed by active intelligent collective purchasing agents, called sponsors, that contract with health care systems and set the rules of competition. Sponsors structure and manage the enrollment process; they create price-elastic demand; they manage risk selection; and they create and administer equitable rules of coverage. Microeconomic theory tells us what sponsors should do to get the market incentives right. There is no comparable political theory to tell us how their boards of directors should be constituted. The paper offers a list of undesirable political arrangements to be avoided and some desirable features of sponsor constitutions.

    View details for Web of Science ID A1994PM21000002

    View details for PubMedID 7863354

  • Choosing among health plans. Health care management (Philadelphia, Pa.) Enthoven, A. C., Singer, S. J. 1994; 1 (1): 45-56

    Abstract

    The health care reform system that is ultimately adopted, suggest the authors of this analysis, should rely on market forces, rather than government regulation, to reduce cost and improve quality in our health care delivery. A major portion of this paper compares the Health Security act (the Clinton proposal), the American Health Security Act (the McDermott bill), the Health Equity and Access Reform Today, HEART (the Chafee proposal), and the Managed Competition Act (the Cooper bill). The article focuses on the major areas of difference between these alternative proposals in the extent to which they would achieve true market-based reform, small group reform, universal coverage, and financing mechanisms.

    View details for PubMedID 10152356

  • Incentives for a better health care system. Journal of health care benefits Enthoven, A. C., Singer, S. J. 1994; 3 (6): 4-7

    View details for PubMedID 10135309

  • WHY NOT THE CLINTON HEALTH PLAN INQUIRY-THE JOURNAL OF HEALTH CARE ORGANIZATION PROVISION AND FINANCING ENTHOVEN, A. 1994; 31 (2): 129-135

    View details for Web of Science ID A1994NW86800003

    View details for PubMedID 8021018

  • A SINGLE-PAYER SYSTEM IN JACKSON HOLE CLOTHING HEALTH AFFAIRS Enthoven, A. C., Singer, S. J. 1994; 13 (1): 81-95

    Abstract

    President Clinton's Health Security Act relies on government regulation, not market forces, to control costs. The act creates an entitlement to comprehensive benefits and places the federal budget at risk for total health care costs in order to achieve universal coverage; it creates a system of new state purchasing monopsonies; and it attempts to control costs with price controls on health plan premiums, set and administered by a National Health Board that would be part of the executive branch, not insulated from political considerations. We believe there is a better way.

    View details for Web of Science ID A1994MX78800011

    View details for PubMedID 8188160

  • WHY MANAGED CARE HAS FAILED TO CONTAIN HEALTH COSTS HEALTH AFFAIRS Enthoven, A. C. 1993; 12 (3): 27-43

    Abstract

    Much evidence points to the fact that managed care plans (health maintenance organizations and preferred provider insurance) reduce costs and offer value for money. Yet they apparently have not helped to slow national health expenditures. One explanation is that the practices of purchasers (including government and employers), the tax laws, and other market imperfections have reduced the demand for real cost containment, depriving managed care plans of an adequate incentive to cut cost and price. These market conditions can and should be corrected; the managed competition proposal being discussed at the national level is a comprehensive plan for doing so.

    View details for Web of Science ID A1993MA42000002

    View details for PubMedID 8244240

  • Achieving effective cost control in comprehensive health care reform. The Jackson Hole "managed care managed competition" approach. Health PAC bulletin ENTHOVEN, A. 1993; 23 (1): 13-15

    Abstract

    The managed competition approach was originated by Alain Enthoven, a professor at the Stanford University Graduate School of Business, in the late 1970s, and has since been refined by Enthoven and a group of colleagues meeting in Jackson Hole, Wyoming. This outline was presented by Enthoven at hearings on cost control in health care reform held by Senator Edward Kennedy (D-MA) in December 1992.

    View details for PubMedID 10126169

  • Health care: a prescription for change. HMO practice / HMO Group Enthoven, A. C. 1993; 7 (1): 20-24

    View details for PubMedID 10125080

  • HEALTH-CARE COSTS - A MORAL AND ECONOMIC-PROBLEM CALIFORNIA MANAGEMENT REVIEW Enthoven, A. C. 1993; 35 (2): 134-151
  • THE HISTORY AND PRINCIPLES OF MANAGED COMPETITION HEALTH AFFAIRS Enthoven, A. C. 1993; 12: 24-48

    Abstract

    Managed competition in health care is an idea that has evolved over two decades of research and refinement. It is defined as a purchasing strategy to obtain maximum value for consumers and employers, using rules for competition derived from microeconomic principles. A sponsor (either an employer, a governmental entity, or a purchasing cooperative), acting on behalf of a large group of subscribers, structures and adjusts the market to overcome attempts by insurers to avoid price competition. The sponsor establishes rules of equity, selects participating plans, manages the enrollment process, creates price-elastic demand, and manages risk selection. Managed competition is based on comprehensive care organizations that integrate financing and delivery. Prospects for its success are based on the success and potential of a number of high-quality, cost-effective, organized systems of care already in existence, especially prepaid group practices. As it is outlined here, managed competition as a means to reform the U.S. health care system is compatible with Americans' preferences for pluralism, individual choice and responsibility, and universal coverage.

    View details for Web of Science ID A1993KT25500002

    View details for PubMedID 8477935

  • A cure for health costs. Clinical laboratory management review : official publication of the Clinical Laboratory Management Association / CLMA Enthoven, A. C. 1992; 6 (6): 580-?

    View details for PubMedID 10128843

  • The Jackson Hole initiatives for a twenty-first century American health care system. Health economics Ellwood, P. M., Enthoven, A. C., Etheredge, L. 1992; 1 (3): 149-168

    View details for PubMedID 1341934

  • Commentary: measuring the candidates on health care. New England journal of medicine Enthoven, A. C. 1992; 327 (11): 807-809

    View details for PubMedID 1501658

  • QUALITY MANAGEMENT IN THE NHS - THE DOCTORS ROLE .2. BRITISH MEDICAL JOURNAL Berwick, D. M., ENTHOVEN, A., Bunker, J. P. 1992; 304 (6822): 304-308

    View details for Web of Science ID A1992HC70800027

    View details for PubMedID 1739834

    View details for PubMedCentralID PMC1881077

  • QUALITY MANAGEMENT IN THE NHS - THE DOCTORS ROLE .1. BRITISH MEDICAL JOURNAL Berwick, D. M., ENTHOVEN, A., Bunker, J. P. 1992; 304 (6821): 235-239

    View details for Web of Science ID A1992HA98000029

    View details for PubMedID 1739800

    View details for PubMedCentralID PMC1881451

  • INTERNAL MARKET REFORM OF THE BRITISH-NATIONAL-HEALTH-SERVICE HEALTH AFFAIRS Enthoven, A. C. 1991; 10 (3): 60-70

    View details for Web of Science ID A1991GH82800004

    View details for PubMedID 1748391

  • UNIVERSAL HEALTH-INSURANCE THROUGH INCENTIVES REFORM JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Enthoven, A. C., Kronick, R. 1991; 265 (19): 2532-2536

    Abstract

    Roughly 35 million Americans have no health care coverage. Health care expenditures are out of control. The problems of access and cost are inextricably related. Important correctable causes include cost-unconscious demand, a system not organized for quality and economy, market failure, and public funds not distributed equitably or effectively to motivate widespread coverage. We propose Public Sponsor agencies to offer subsidized coverage to those otherwise uninsured, mandated employer-provided health insurance, premium contributions from all employers and employees, a limit on tax-free employer contributions to employee health insurance, and "managed competition". Our proposed new government revenues equal proposed new outlays. We believe our proposal will work because efficient managed care does exist and can provide satisfactory care for a cost far below that of the traditional fee-for-service third-party payment system. Presented with an opportunity to make an economically responsible choice, people choose value for money; the dynamic created by these individual choices will give providers strong incentives to render high-quality, economical care. We believe that providers will respond to these incentives.

    View details for Web of Science ID A1991FK90300027

    View details for PubMedID 2020071

  • A pivotal role for physician executives. Physician executive Enthoven, A. C., Vorhaus, C. B. 1990; 16 (4): 6-7

    Abstract

    Physician leaders are needed to fill a pivotal role in the health care industry of the '90s. Medical education based solely on traditional scientific methods will continue to produce physicians with excellent clinical and research skills. However, study of science alone will not produce physician leaders. Effective leaders will also need to understand the tools and concepts of organization and management. These leaders will need to participate in the process of formulating and implementing policies to promote the development of economical financing and delivery arrangements while simultaneously improve the quality of care provided.

    View details for PubMedID 10160657

  • MULTIPLE-CHOICE HEALTH-INSURANCE - THE LESSONS AND CHALLENGE TO EMPLOYERS INQUIRY-THE JOURNAL OF HEALTH CARE ORGANIZATION PROVISION AND FINANCING Enthoven, A. C. 1990; 27 (4): 368-373

    Abstract

    This paper offers a second opinion on the issues discussed by Stanley B. Jones in his paper, "Multiple Choice Health Insurance: The Lessons and Challenge to Private Insurers" in the Summer 1990 issue of Inquiry. Multiple choice of health plans is not containing costs of health care or insurance premiums because employers have not yet tried price competition with cost-conscious consumer choice. HMOs in multiple choice arrangements have not saved employers money because of the way employers manage competition. Effective management of competition must be an active process employing an array of tools to create incentives that reward production of high quality economical care.

    View details for Web of Science ID A1990ET83400009

    View details for PubMedID 2148310

  • EFFECTIVE MANAGEMENT OF COMPETITION IN THE FEHBP HEALTH AFFAIRS Enthoven, A. C. 1989; 8 (3): 33-50

    View details for Web of Science ID A1989AR17400003

    View details for PubMedID 2793048

  • A CONSUMER-CHOICE HEALTH PLAN FOR THE 1990S - UNIVERSAL HEALTH-INSURANCE IN A SYSTEM DESIGNED TO PROMOTE QUALITY AND ECONOMY .2. NEW ENGLAND JOURNAL OF MEDICINE ENTHOVEN, A., Kronick, R. 1989; 320 (2): 94-101

    Abstract

    We describe the characteristics necessary for a plan for universal health insurance to find broad acceptance. Such a plan must represent incremental, not radical, change; must respect the preferences of voters, patients, and providers; must avoid major disruption in satisfactory existing arrangements; must avoid creating major windfall gains or losses; must avoid large-scale income redistribution; and must not be inflationary. Our proposal would create a framework that would encourage the efficient organization of care. Successful organizations would probably be those that attracted the loyalty and commitment of physicians, integrated insurance and the provision of care, and aligned the interests of doctors and patients toward high-quality, cost-effective care. The proposal's chief potential disadvantage would be its effect on the employment opportunities of low-wage workers, but this effect could be minimized. In addition, we discuss a proposal to mandate coverage by employers of full-time employees, legislation enacted recently in Massachusetts, high-risk pools, and the system followed in Canada, comparing each of these alternatives with our proposal.

    View details for Web of Science ID A1989R736300005

    View details for PubMedID 2492082

  • A CONSUMER-CHOICE HEALTH PLAN FOR THE 1990S - UNIVERSAL HEALTH-INSURANCE IN A SYSTEM DESIGNED TO PROMOTE QUALITY AND ECONOMY .1. NEW ENGLAND JOURNAL OF MEDICINE ENTHOVEN, A., Kronick, R. 1989; 320 (1): 29-37

    Abstract

    America's health care economy is a paradox of excess and deprivation. We spend more than 11 percent of the gross national product on health care, yet roughly 35 million Americans have no financial protection from medical expenses. To an increasing degree, the present financing system is inflationary, unfair, and wasteful. In its place we need a strategy that addresses the whole system, offers financial protection from health care expenses to all, and promotes the development of economical financing and delivery arrangements. Such a strategy must be designed to be broadly acceptable in our society. To remedy the deprivation, we propose that everyone not covered by Medicare, Medicaid, or some other public program be enabled to buy affordable coverage, either through their employers or through a "public sponsor." To attack the excess, we propose a strategy of managed competition in which collective agents, called sponsors, such as the Health Care Financing Administration and large employers, contract with competing health plans and manage a process of informed cost-conscious consumer choice that rewards providers who deliver high-quality care economically.

    View details for Web of Science ID A1989R576400006

    View details for PubMedID 2642604

  • MANAGED COMPETITION OF ALTERNATIVE DELIVERY SYSTEMS JOURNAL OF HEALTH POLITICS POLICY AND LAW ENTHOVEN, A. 1988; 13 (2): 305-321

    Abstract

    The markets for health insurance and health care are not naturally competitive: they are susceptible to many forms of market failure. Health plans and consumers may use strategies that lead to inequity and inefficiency. But experience with successful models of competition suggests that tools are available to enable sponsors (active collective agents on the demand side who contract with health plans to structure and manage competition) to use competition to achieve a reasonable degree of efficiency and equity for their sponsored populations. All this implies a more complex, dynamic, and sophisticated view of competition than one usually finds in apologia for free markets. A free market is not possible in health insurance.

    View details for Web of Science ID A1988N659000007

    View details for PubMedID 3385169

  • MANAGED COMPETITION - AN AGENDA FOR ACTION HEALTH AFFAIRS Enthoven, A. C. 1988; 7 (3): 25-47

    View details for Web of Science ID A1988P320800002

    View details for PubMedID 3215621

  • THE UNITED-STATES HEALTH-CARE ECONOMY - FROM GUILD TO MARKET IN 10 YEARS HEALTH POLICY Enthoven, A. C. 1987; 7 (2): 241-251
  • PROSPECTIVE PAYMENT - WILL IT SOLVE MEDICARE FINANCIAL PROBLEM ISSUES IN SCIENCE AND TECHNOLOGY Enthoven, A. C., NOLL, R. G. 1984; 1 (1): 101-116
  • SHOULD SURGERY BE REGIONALIZED SURGICAL CLINICS OF NORTH AMERICA Bunker, J. P., Luft, H. S., ENTHOVEN, A. 1982; 62 (4): 657-668

    Abstract

    The authors suggest that new surgical procedures be carried out initially in selected institutions and that complex procedures for which it has been or can be demonstrated that mortality is inversely related to the volume of experience also be regionalized. Regionalization in the latter instance can have a small overall impact on surgical practice but a large impact on the adverse consequences of high risk operations that are performed only occasionally.

    View details for Web of Science ID A1982PG39400008

    View details for PubMedID 7112356

  • THE ECONOMIC-FUTURE OF HEALTH-CARE AMERICAN PHARMACY ENTHOVEN, A. 1981; 21 (8): 18-21
  • HOW INTERESTED GROUPS HAVE RESPONDED TO A PROPOSAL FOR ECONOMIC COMPETITION IN HEALTH-SERVICES AMERICAN ECONOMIC REVIEW Enthoven, A. C. 1980; 70 (2): 142-148

    View details for Web of Science ID A1980JW76100030

    View details for PubMedID 10246559

  • SHOULD OPERATIONS BE REGIONALIZED - EMPIRICAL RELATION BETWEEN SURGICAL VOLUME AND MORTALITY NEW ENGLAND JOURNAL OF MEDICINE Luft, H. S., Bunker, J. P., Enthoven, A. C. 1979; 301 (25): 1364-1369

    Abstract

    This study examines mortality rates for 12 surgical procedures of varying complexity in 1498 hospitals to determine whether there is a relation between a hospital's surgical volume and its surgical mortality. The mortality of open-heart surgery, vascular surgery, transurethral resection of the prostate, and coronary bypass decreased with increasing number of operations. Hospitals in which 200 or more of these operations were done annually had death rates, adjusted for case mix, 25 to 41 per cent lower than hospitals with lower volumes. For other procedures, the mortality curve flattened at lower volumes. For example, hospitals doing 50 to 100 total hip replacements attained a mortality rate for this procedure almost as low as that of hospitals doing 200 or more. Some procedures, such as cholecystectomy, showed no relation between volume and mortality. The results may reflect the effect of volume or experience on mortality, or referrals to institutions with better outcomes, as well as a number of other factors, such as patient selection. Regardless of the explanation, these data support the value of regionalization for certain operations.

    View details for Web of Science ID A1979HX81100003

    View details for PubMedID 503167

  • CONSUMER-CENTERED VS JOB-CENTERED HEALTH-INSURANCE HARVARD BUSINESS REVIEW Enthoven, A. C. 1979; 57 (1): 141-152

    Abstract

    Most employees and their dependents in the United States have health insurance provided by the employer or labor-management health and welfare fund. In this system, employees and their families lose their health insurance when the breadwinner loses his or her job while, at the same time, a Medicaid beneficiary can lose Medicaid eligibility by getting a job, even a poorly paid one. Most health insurance pays the doctor on the basis of fee-for-service and the hospital on the basis of cost-reimbursement, rewarding both with more revenue for providing more and more costly services. The insured employee has little or no incentive to seek out a less costly provider. There are no rewards for economy in this system. It should be little wonder, then, that health care costs are out of control. There are alternative financing and delivery systems with built-in incentives to use resources economically, but, the author of this article asserts, their ability to compete and attract patients with their superior economic efficiency is blocked by many laws and government programs. The author believes that the most effective and acceptable way to get costs under control, and at the same time achieve universal coverage, would be through a system of fair economic competition. He discusses his Consumer Choice Health Plan proposal and describes how one of the main barriers to competition is today's system of job-linked health insurance.

    View details for Web of Science ID A1979GC22900034

    View details for PubMedID 10239734

  • CONSUMER-CHOICE HEALTH PLAN .2. NATIONAL-HEALTH-INSURANCE PROPOSAL BASED ON REGULATED COMPETITION IN PRIVATE SECTOR NEW ENGLAND JOURNAL OF MEDICINE Enthoven, A. C. 1978; 298 (13): 709-720

    Abstract

    Medical costs are straining public finances. Direct economic regulation will raise costs, retard beneficial innovation and be increasingly burdensome to physicians. As an alternative, I suggest that the government change financial incentives by creating a system of competing health plans in which physicians and consumers can benefit from using resources wisely. Main proposals consist of changed tax laws, Medicare and Medicaid to subsidize individual premium payments by an amount based on financial and predicted medical need, as well as subsidies usable only for premiums in qualified health insurance or delivery plans operating under rules that include periodic open enrollment, community rating by actuarial category, premium rating by market area and a limit on each person's out-of pocket costs. Also, efficient systems should be allowed to pass on the full savings to consumers. Finally, incremental changes should be made in the present system to alter it fundamentally, but gradually and voluntarily. Freedom of choice for consumers and physicians should be preserved.

    View details for Web of Science ID A1978ES26600004

    View details for PubMedID 415241

  • CONSUMER-CHOICE HEALTH PLAN .1. INFLATION AND INEQUITY IN HEALTH-CARE TODAY - ALTERNATIVES FOR COST CONTROL AND AN ANALYSIS OF PROPOSALS FOR NATIONAL-HEALTH INSURANCE NEW ENGLAND JOURNAL OF MEDICINE Enthoven, A. C. 1978; 298 (12): 650-658

    Abstract

    The financing system for medical costs in this country suffers from severe inflation and inequity. The tax-supported system of fee for service for doctors, third-party intermediaries and cost reimbursement for hospitals produces inflation by rewarding cost-increasing behavior and failing to provide incentives for economy. The system is inequitable because the government pays more on behalf of those who choose more costly systems of care, because tax benefits subsidize the health insurance of the well-to-do, while not helping many low-income people, and because employment health insurance does not guarantee continuity of coverage and is regressive in its financing. Analysis of previous proposals for national health insurance shows none to be capable of solving most of these problems. Direct economic regulation by government will not improve the situation. Cost controls through incentives and regulated competition in the private sector are most likely to be effective.

    View details for Web of Science ID A1978ER30000004

    View details for PubMedID 415239

  • US FORCES IN EUROPE - HOW MANY - DOING WHAT FOREIGN AFFAIRS Enthoven, A. C. 1975; 53 (3): 513-532