Economics

Article Abstract:

The concept of 'managed care' in medicine implies that the insurers who pay for medical care want a role in evaluating and determining it. Some common assumptions underlie the concept. One is that much medical care is inappropriate, an idea supported by medical record audit studies. A study by the RAND Corporation found that between 16 and 40 percent of selected surgical procedures were performed with no clinical basis. Other results, such as those showing that a physician's experience was a stronger factor in determining whether a caesarean section would be performed than a baby's or mother's medical condition, support the belief that a large amount of variability in medical care results from particular practice patterns. Managed care also maintains that high cost does not necessarily correlate with high quality; costs for treating the same disorder can vary by a factor of up to 2,000 percent within the same city. Managed care assumes that the behavior of the insured will be affected by the availability of covered benefits and supports questioning physicians about recommended treatments. Insurers act as 'purchasing agents' for patients. The managed-care business, which includes health maintenance organizations, preferred provider organizations, or managed fee-for-service arrangements, represents nearly 60 percent of commercial insurers' group business. This has necessitated the expansion of the insurers' businesses to include medical professionals and data-collection systems. Programs to contain costs for treating high-cost cases are attractive, since 10 percent of the population currently accounts for 75 percent of medical care costs. Costs of managed care may ultimately rise less rapidly than those of non-managed care. Some factors influencing health care are outside the control of any care program, such as the malpractice situation and the need for physicians to satisfy the consumer. Overall, the goal of managed care is the delivery of high-quality care in a cost-effective manner. (Consumer Summary produced by Reliance Medical Information, Inc.)

Innovations, Health care industry

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Administrative medicine

Article Abstract:

Between 1978 and 1988, the number of physicians serving as 'administrative MDs' rose from 11,858 to 14,536. This trend will continue as enrollment rises in managed-care organizations, such as health maintenance organizations, preferred provider plans, and managed fee-for-service arrangements. One motivation for physicians to act in administrative capacities is to ensure appropriate medical care within the context of accountability to an organization's needs. Three assumptions regarding medical care during the 1990s can be made: costs will continue to rise at the same rate; a government-managed health care system will not develop in this country; and the economy can be expected, on the whole, to remain stable. Trends already in effect will continue, with more people enrolling in managed care and complete freedom to select care available only to the most affluent 10 to 20 percent of the population. Greater control will be exercised over recipients of government programs such as Medicare, while employee groups will also face increased constraints. One organizational response to these trends will be the development of regionally based, vertically integrated systems to manage primary, specialty, and hospital care. Physicians must be capable of taking active management roles in these contexts. Genuine quality control will be in effect. Employers and insurance companies can be expected to become more involved in designing benefit programs. Hospitals will be cost centers, not profit centers. Salaries of non-physician members of the health care team need to be reassessed in light of changing views of patients' needs. The task of striking a balance between the needs of business and community needs is not an easy one. Providers must be willing to admit the present system's shortcomings and to correct their somewhat tarnished image of indifference to public concerns. If change does not come from within the health care system, change will be forced upon it from outside. (Consumer Summary produced by Reliance Medical Information, Inc.)

Supply and demand, Health services administrators

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Applying brakes to the runaway American health care system: a proposed agenda

Article Abstract:

The cost of health care within the United States is out of control. In order for the current system to survive, its costs must be restricted so that it does not grow beyond the 11 percent of the gross national product that it currently consumes. This can only be achieved by rationing the availability of health care based on data which has and will continue to be developed through health services research. Over time a national guideline for quality care will be developed. What is lost to the physician in terms of clinical freedom will be compensated by increased savings, and generally better and more universally available health care for the American people. The authors believe that President Bush should convene a national commission to study this process. Medical organizations and other self-interested parties can not undertake this process without questions of propriety being raised. Areas of concern which should be included in the agenda are: the role of technology and its control, system for reimbursing health care providers, issues of medical ethics arising from new technologies, malpractice reform, universal medical coverage, health research and priorities, the number and distribution of health care facilities, the supply and distribution of physicians, and the means of educating the public to good health practices. Many of the country's internists feel the need to boldly establish new health priorities which would tend to equalize injustices that are built-in to the current delivery system. Health care costs must be reduced if the health professions are to serve the entire nation. This can only be achieved by a realistic rationing of health care which is not based on the patients' ability to pay for service.

Planning, Evaluation, Laws, regulations and rules, Health facilities, Medical care, Cost of, Health care costs, Health services administration

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