Emeritus Faculty, Acad Council, Freeman Spogli Institute for International Studies
'Redefining health care': medical homes or archipelagos to navigate?
Health affairs (Project Hope)
; 26 (5): 1366–72
This paper provides an analysis of the structure of the health care delivery system, emphasizing physician group practices. The authors argue for comprehensive integrated delivery systems (IDSs). The jumping-off point for their analysis is the recently published Redefining Health Care: Creating Value-Based Competition on Results, by Michael Porter and Elizabeth Teisberg. The authors focus on the book's core idea that competitors should be freestanding integrated practice units (or "islands in archipelagos") versus IDSs (or "medical homes"). In any case, the authors contend that this issue should be resolved by competition to attract and serve informed, cost-conscious, responsible consumers on a level playing field.
View details for PubMedID 17848447
- To Control Costs Expand Managed Care and Managed Competition. JAMA 2019
- How Systems Analysis, Cost-Effectiveness Analysis, or Benefit-Cost Analysis First Became Influential in Federal Government Program Decision-Making JOURNAL OF BENEFIT-COST ANALYSIS 2019; 10 (2): 146–55
Managed Competition: The Author Replies.
Health affairs (Project Hope)
2018; 37 (12): 2100
View details for PubMedID 30633685
- Managed Competition: The Author Replies HEALTH AFFAIRS 2018; 37 (12): 2102
With Roots In California, Managed Competition Still Aims To Reform Health Care.
Health affairs (Project Hope)
2018; 37 (9): 1425–30
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 2015; 34 (12): 2095-2103
Reforming Medicare by reforming incentives.
The New England journal of medicine
2011; 364 (21): e44
View details for PubMedID 21561341
Reform incentives to create a demand for health system reengineering.
Studies in health technology and informatics
2010; 153: 209-227
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
2009; 15 (10): S284-90
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
2009; 150 (7): 493-?
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
Going Dutch--managed-competition health insurance in the Netherlands.
The New England journal of medicine
2007; 357 (24): 2421–23
View details for PubMedID 18077805
New directions for public health care purchasers? Responses to looming challenges
2006; 25 (6): 1518-1528
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
2006; 25 (6): 1538-1547
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
2006; 39 (3): 289-305
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 2005; 24 (5): W5420-W5433
Competition in health care: it takes systems to pursue quality and efficiency.
2005: W5-420 33
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
2004; 23 (6): 136-140
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
2004; 58 (7): 60-64
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
2004; 23 (2): 25-27
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?
2003; 22 (4): W237-W249
View details for Web of Science ID 000184054800040
Covering the uninsured. Two perspectives on the government's role.
2003; 44 (4): 22-24
View details for PubMedID 12920865
A leading publication.
2003; 44 (3): 26-29
View details for PubMedID 12808755
- The rise and fall of a Kaiser Permanente expansion region MILBANK QUARTERLY 2003; 81 (4): 567-?
Employment-based health insurance is failing: now what?
2003: W3-237 49
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
2002; 27 (1): 37-48
View details for PubMedID 11942418
Commentary: competition made them do it.
BMJ (Clinical research ed.)
2002; 324 (7330): 143
View details for PubMedID 11822331
- Consumer choice and the managed care backlash AMERICAN JOURNAL OF LAW & MEDICINE 2001; 27 (1): 1-15
Structural problems of managed care in California and some options for ameliorating them
CALIFORNIA MANAGEMENT REVIEW
2000; 43 (1): 50-?
View details for Web of Science ID 000166508300005
Modernising the NHS - A promising start but fundamental reform is needed
BRITISH MEDICAL JOURNAL
2000; 320 (7245): 1329-1331
View details for Web of Science ID 000087077400032
- A promising start, but fundamental reform is needed. BMJ (Clinical research ed.) 2000; 320 (7245): 1329-1331
- Unrealistic expectations born of defective institutions JOURNAL OF HEALTH POLITICS POLICY AND LAW 1999; 24 (5): 931-939
The managed care backlash and the task force in California
1998; 17 (4): 95-110
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
1998; 23 (1): 7-17
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 1997; 16 (6): 150-156
- Markets and collective action in regulating managed care HEALTH AFFAIRS 1997; 16 (6): 26-32
Managed competition and California's health care economy
1996; 15 (1): 39-57
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
BROOKINGS INST. 1996: 185–206
View details for Web of Science ID A1996BG28V00007
- Health care quality management: A status report INTERNATIONAL ANESTHESIOLOGY CLINICS 1995; 33 (4): 1-14
Increasing cost-consciousness for managed care: reforming the tax treatment of health insurance expenditures.
Health care management (Philadelphia, Pa.)
1995; 2 (1): 109-114
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
1995; 14 (2): 24-39
"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
1994; 39 (10): 1413-1424
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.)
1994; 1 (1): 45-56
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
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 1994; 31 (2): 129-135
A SINGLE-PAYER SYSTEM IN JACKSON HOLE CLOTHING
1994; 13 (1): 81-95
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
1993; 12 (3): 27-43
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
1993; 23 (1): 13-15
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
1993; 7 (1): 20-24
View details for PubMedID 10125080
HEALTH-CARE COSTS - A MORAL AND ECONOMIC-PROBLEM
CALIFORNIA MANAGEMENT REVIEW
1993; 35 (2): 134-151
View details for Web of Science ID A1993KT85100007
THE HISTORY AND PRINCIPLES OF MANAGED COMPETITION
1993; 12: 24-48
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
1992; 6 (6): 580-?
View details for PubMedID 10128843
The Jackson Hole initiatives for a twenty-first century American health care system.
1992; 1 (3): 149-168
View details for PubMedID 1341934
Commentary: measuring the candidates on health care.
New England journal of medicine
1992; 327 (11): 807-809
View details for PubMedID 1501658
- QUALITY MANAGEMENT IN THE NHS - THE DOCTORS ROLE .2. BRITISH MEDICAL JOURNAL 1992; 304 (6822): 304-308
- QUALITY MANAGEMENT IN THE NHS - THE DOCTORS ROLE .1. BRITISH MEDICAL JOURNAL 1992; 304 (6821): 235-239
- INTERNAL MARKET REFORM OF THE BRITISH-NATIONAL-HEALTH-SERVICE HEALTH AFFAIRS 1991; 10 (3): 60-70
UNIVERSAL HEALTH-INSURANCE THROUGH INCENTIVES REFORM
JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION
1991; 265 (19): 2532-2536
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.
1990; 16 (4): 6-7
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
1990; 27 (4): 368-373
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 1989; 8 (3): 33-50
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
1989; 320 (2): 94-101
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
1989; 320 (1): 29-37
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
1988; 13 (2): 305-321
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 1988; 7 (3): 25-47
THE UNITED-STATES HEALTH-CARE ECONOMY - FROM GUILD TO MARKET IN 10 YEARS
1987; 7 (2): 241-251
View details for Web of Science ID A1987H192400011
PROSPECTIVE PAYMENT - WILL IT SOLVE MEDICARE FINANCIAL PROBLEM
ISSUES IN SCIENCE AND TECHNOLOGY
1984; 1 (1): 101-116
View details for Web of Science ID A1984TU16900009
SHOULD SURGERY BE REGIONALIZED
SURGICAL CLINICS OF NORTH AMERICA
1982; 62 (4): 657-668
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
1981; 21 (8): 18-21
View details for Web of Science ID A1981MA49700010
- HOW INTERESTED GROUPS HAVE RESPONDED TO A PROPOSAL FOR ECONOMIC COMPETITION IN HEALTH-SERVICES AMERICAN ECONOMIC REVIEW 1980; 70 (2): 142-148
SHOULD OPERATIONS BE REGIONALIZED - EMPIRICAL RELATION BETWEEN SURGICAL VOLUME AND MORTALITY
NEW ENGLAND JOURNAL OF MEDICINE
1979; 301 (25): 1364-1369
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
1979; 57 (1): 141-152
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
1978; 298 (13): 709-720
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
1978; 298 (12): 650-658
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
1975; 53 (3): 513-532
View details for Web of Science ID A1975V926500007