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PubMed1986

Financing home health-care products and services.

Factors affecting growth of the home health-care (HHC) industry are identified, basic principles of HHC product and service reimbursement are reviewed, and third-party payer coverage criteria and payment methods for HHC products and services are discussed. Reimbursement for HHC services has suffered from the absence of a financing mechanism for long-term care. Providers of HHC services are burdened by the laborious process of obtaining favorable coverage determinations for short-term-care patients when home care substitutes for institutional care. When home care is covered benefit, there is often a complex mix of confusing coverage rules, coverage criteria that differ among public and private payers, and interpretations of coverage criteria that differ among local carrier personnel. Private financing obstacles and federal budget deficits will deter the development of an adequate financing mechanism for HHC. The growth of health-maintenance organizations and competitive medical plans will help to reduce reimbursement complexity. Long-term changes in HHC financing may become less important if capitation payment is successful.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1986

Recent developments in organizing and financing health-care services.

Recent developments in the organization and financing of health-care services are described. All recent developments reflect an effort by both private and public payers to restrict use of health-care services, as well as to control price. Private use-review programs, such as second-surgical-opinion services and case-management services, are increasingly being used. The number of hospital admissions and length of patient stay continue to decline, but, because of increasing complexity of care, the cost of pharmaceutical services has not decreased proportionately. Points relating to health-care financing in the federal reconciliation budget effective May 1, 1986, are reviewed, as are other new federal regulations affecting the structure of services and terms of reimbursement under the Medicare and Medicaid programs. For Medicare, these include new scope objectives for professional review organizations, decreased return-on-equity payments to for-profit hospitals for outpatient services and to skilled nursing facilities, and elimination of waiver-of-liability presumptions for hospitals. Also, physicians must now identify specific services provided during each inpatient hospital visit. Most developments related to home health-care services pertain to limiting the cost of durable medical equipment. Alternative types of health care based on capitation funding, such as health maintenance organizations, competitive medical plans, and preferred provider organizations, will continue to grow in both the public and private sectors, and the use of private use-review programs for controlling costs is expected to accelerate in the next year.

Delivery of Health Care↗
PubMedDate not supplied

Managed competition: a health reform plan that "puts people first".

With its emphasis on consumer information; proper incentives for physicians, hospitals, and insurers; and fair tax treatment; managed competition deserves the attention it has received in the debate over how to reform the U.S. health system. It provides a better route to ensuring access and controlling costs than alternative proposals. President-elect Clinton should use the managed competition model as a blueprint for the health plan he has promised in the first 100 days in office.

Competitive Medical Plans↗
PubMed1993

Why managed care has failed to contain health costs.

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.

Competitive Medical Plans↗
PubMed1993

VIP interview: Alain C. Enthoven, Ph.D.

Alain C. Enthoven, Ph.D., is the Mariner S. Eccles Professor of Public and Private Management in the Graduate School of Business at Stanford University. He hold degrees in Economics from Stanford University, Oxford University (where he was a Rhodes scholar), and the Massachusetts Institute of Technology. Professor Enthoven has been an articulate advocate for restructuring the health care system. His far-reaching proposals on "consumer choice health plans" and "managed competition" in the 1930s established an intellectual framework for much of the current debate on national health policy. As a leader of the Jackson Hole Group, he favors internal market reform and employer tax incentives as the most effective means to control unnecessary medical costs.

Competitive Medical Plans↗
PubMed1993

The marketplace in health care reform. The demographic limitations of managed competition.

BACKGROUND: The theory of managed competition holds that the quality and economy of health care delivery will improve if independent provider groups compete for consumers. In sparsely populated areas where relatively few providers are required, however, it is not feasible to divide the provider community into competing groups. We examined the demographic features of health markets in the United States to see what proportion of the population lives in areas that might successfully support managed competition. METHODS: The ratios of physicians to enrollees in large staff-model health maintenance organizations were determined as an indicator of the staffing needs of an efficient health plan. These ratios were used to estimate the populations necessary to support health organizations with various ranges of specialty services. Metropolitan areas with populations large enough to support managed competition were identified. RESULTS: We estimated that a health care services market with a population of 1.2 million could support three fully independent plans. A population of 360,000 could support three plans that independently provided most acute care hospital services, but the plans would need to share hospital facilities and contract for tertiary services. A population of 180,000 could support three plans that provided primary care and many basic specialty services but that shared inpatient cardiology and urology services. Health markets with populations greater than 180,000 would include 71 percent of the U.S. population; those with populations greater than 360,000, 63 percent; and those with populations greater than 1.2 million, 42 percent. CONCLUSIONS: Reform of the U.S. health care system through expansion of managed competition is feasible in medium-sized or large metropolitan areas. Smaller metropolitan areas and rural areas would require alternative forms of organization and regulation of health care providers in order to improve quality and economy.

Adolescent↗
PubMed1993

Competition in the UK National Health Service: mission impossible?

Despite the dominant ideology of the 1980s being libertarian, pragmatism triumphed and, despite several attempts to privatise the UK National Health Service, the Thatcherite reforms maintained public finance and sought to create competition in the supply of health care. Even this partial reform was radical and has led to major changes in structure and process. However, the Government has refused to evaluate both the cost and the outcome of the reforms. Furthermore, with minimal definition of how the 'internal market' was to work, the Government has regulated the competitive processes in an ad hoc manner, often responding to obvious but unforeseen problems (e.g. local monopoly power). Competition is costly to create, requiring large investments in managerial personnel and information technology, and difficult to sustain because of the propensity of capitalists, through self interest, to destroy capitalism. Problems such as quality, equity and the closure of excess capacity were well defined prior to the NHS reforms and have not yet been resolved following the reforms. Whether adversarial rather than collaborative relationships are more efficient in the health care sector is unknown. Indeed there remains little evidence to sustain the claims of political rhetoric that competition 'works' i.e. increases efficiency, enhances equity and contains costs. Despite this reformers seek to create competition and complete mission impossible.

Competitive Medical Plans↗
PubMed2006

What does social enterprise mean for community nursing?

The concept of social enterprise has gained currency since the publication of the health white paper "Our Health, Our Care, Our Say" (Department of Health, 2001). Social enterprise is a way of introducing competition into health-care provision without focusing on extracting maximum profit, since in most cases any profits are reinvested into the enterprise. Rosemary Cook takes a look at the thinking behind social enterprise, its potential role in the NHS and what is could mean for community nursing.

Community Health Nursing↗
PubMedDate not supplied

Antitrust exemption: are health providers crying wolf?

Demands by health providers for relief from federal antitrust law have reached a new high as they examine the likely impact of managed competition on the way they do business. Indeed, the American Medical Association endorsed managed competition on the condition that doctors get an antitrust exemption; the Pharmaceutical Manufacturers Association recently said that drug makers needed to discuss prices before they could hold back increases. But the Federal Trade Commission, an independent agency, has shown no signs of revising its antitrust measures to reflect the enormous changes that lie before the health industry.

American Hospital Association↗
PubMed1993

Managed competition.

People don't like change. That includes materiel managers, administrators, and clinical providers. Managed competition or managed care will work if, and only if, the American professions and the American public recognize the value of highly educated and qualified clinical and nonclinical providers and if the health care industry responds in kind.

Attitude to Health↗
PubMed1994

Mental health services under health reform: the less government, the better.

Federal and state governments are now rapidly preparing to restructure the delivery and financing of health care services in the United States. Unfortunately, the bureaucratic structures promised under managed competition do not acknowledge the successes of private sector "market-regulated" programs. A needlessly costly and burdensome system could evolve that will undermine the goals of improved access and quality of care.

Competitive Medical Plans↗