Capital Investment in Primary Care—The Funding and Ownership of Primary Care Premises

The authors describe the complexity of the financing arrangements of primary care premises. They explain how the early vision of integrating health and social services within local health centres failed to be realized, with GP-owned practice premises remaining as the dominant model. There was a switch to private finance when the government loan body (General Practice Finance Corporation) was privatized in 1989. Although capital can now be freely raised by the private sector for investment in the National Health Service (NHS), these debts have to be repaid through NHS funds or user charges. The complexity, combined with demographic factors, makes it likely that as GPs opt for the Personal Medical Services (PMS) scheme and a salaried service, the trend towards for-profit corporations owning and buying out GP premises will accelerate.     

Managed Care and Health Care Utilization: Specification of Bivariate Models Using Copulas

This article studies the effect of managed care on health care utilization compared to traditional fee-for-service plans in private health insurance market. To construct our hypothesis, we build a game-theoretic model to study health care utilization under a two-sided moral hazard: of patients and providers. In econometric modeling, we employ a copula regression to jointly examine individuals’ health plan choice and their utilization of medical care services, because of the endogeneity of insurance choice. The dependence parameter in the copula reflects the relation between the two outcomes, based on which the average treatment effects are further derived. We apply the methodology to a survey data set of the U.S. population and consider three types of curative care and three types of preventive care for the measurement of medical care utilization. We find that managed care is in general associated with higher care utilization. Evidence is also found on the underlying incentives of both patients and medical providers.     

Trust and distrust in a network-style organisation: GPs’ experiences and views of a Scottish local healthcare co-operative

This paper considers the conditions needed for an organisation to function as an effective network. In particular, the concepts of trust and distrust are explored. Looking at the new labour reforms of 1997, evidence is presented by means of interview responses from GPs, that this powerful group in primary health care lacked sufficient trust in health care managers. In fact GPs seemed to often distrust them. It is unlikely, therefore, that a Scottish local health care co-operative, created as a result of the 1997 reforms to act as an interface between GPs and health care managers could be effective in allocating health care resources. As a result, the reforms did little to improve primary health care services in Scotland despite the increased funding allocated over recent years to this sector.     

论人人享有基本卫生保健之改革

本文通过分析"看病贵、看病难"原因而导致的阻碍人人享有初级卫生保健的主要因素,提出必须深化卫生体制改革,发展基层社区卫生服务、建立覆盖全民的基本医疗保障制度以及实行均等化的公共卫生服务和基本药物制度,以实现人人享有初级卫生保健的目标。     

美国医疗保险扩面改革之路的里程碑

虽然美国有两大类三大层次的医疗保险体系,但没有实现如其他大多数发达国家那样的全民医保,缺乏一张覆盖全国的社会医疗网络,始终是美国近10年来备受诟病的社会问题.没有医疗保险的问题始终处于社会政策争议的前沿和核心.之前克林顿总统失败的改革方案核心就是实现全民医保,15年后,奥巴马新医改方案又明确将扩大覆盖面作为其改革的重中之重.然而,历经波折得以通过的奥巴马医改法案却依然面临诸多反对和抗议,其中最为核心的是关乎强制参险的条款.2012年6月28日,美国最高法院裁定奥巴马医疗保险改革的大部分条款合乎宪法,最具争议的强制参险也得以保留,这意味着美国在实现全民医保时代的进程中向前迈出了一大步.     

THE IMPACT OF FUNDHOLDING ON PRIMARY HEALTH CARE: ACCOUNTS FROM SCOTTISH GPS

At the inception of the internal market in health care GP fundholding was seen rather as a 'sidesho' to the main reforms. But as the reforms have worked through, GP fundholding has emerged as pivotal to the purchaserlprovider agenda and the changes now associated with GP fundholding will be major issues in directing future health care policy initiatives. Drawing on empirical data from three Scottish regions, this paper argues that fundholding is now significant because GPs perceive benefits for primary health care. The paper uses the data collected from the case studies in the regions to assess these gains on two levels: the 'micro' impact of fundholding on primary health care processes and the 'macro' issues raised for health care policy by involving GPs more closely in resource management. Some GPs wish to use resource management as a vehicle for enhancing equity within the NHS, others are more concerned to manage resources so as to expand their practices into sites which combine primary, secondary and community health care, still others envisage developing the market to include monetary rewards for 'efficient' practices.     

Targeted Interventions in Healthcare: The Role of Facility Placement*

Adequate targeting is a primary concern in the design of any social programme that attempts to reach a specific group in society. This paper studies the targeting of a healthcare‐centre programme aimed at the poor that relies on household self‐selection into the programme at the local level. We find that a key variable in determining utilisation of the health centres is location. Households living near a centre are substantially more likely to use it than households living further away. This points to the importance of facility placement in targeting self‐selected health programmes to the poor.     

Weak Links in the Chain II: A Prescription for Health Policy in Poor Countries

In an earlier article, the authors outline some reasons forthe disappointingly small effects of primary health care programsand identified two weak links standing between spending andincreased health care. The first was the inability to translatepublic expenditure on health care into real services due toinherent difficulties of monitoring and controlling the behaviorof public employees. The second was the "crowding out" of privatemarkets for health care, markets that exist predominantly atthe primary health care level. This article presents an approach to public policy in healththat comes directly from the literature on public economics.It identifies two characteristic market failures in health.The first is the existence of large externalities in the controlof many infectious diseases that are mostly addressed by standardpublic health interventions. The second is the widespread breakdownof insurance markets that leave people exposed to catastrophicfinancial losses. Other essential considerations in settingpriorities in health are the degree to which policies addresspoverty and inequality and the practicality of implementingpolicies given limited administrative capacities. Prioritiesbased on these criteria tend to differ substantially from thosecommonly prescribed by the international community.      

城乡居民医保逆选择的破解——一个基于不同人口年龄需求的设计

逆选择困扰了我国城乡居民医保事业的可持续发展.在原有的大病和重病保障之外,基于不同人口年龄需求设计一个有条件、有限度和有年龄差别的特殊医保待遇方案,让参保者在没有享受到大病重病医保待遇的情况下,也可获得一些与年龄相称的医保待遇.这一设计除了能增加参保的弹性,让各年龄群体都自愿积极参保,还可增强居民的健康意识,提高居民的健康水平,减少居民和医保的医药开支.此外,它还能促进基层医疗服务业的发展.     

A vision for Nicaragua : Health services in the new century

Nicaragua is facing a crisis in health and health care, and a health futures programme has been initiated to focus concern and mobilize key actors. Two national scenario workshops have been held at which participants constructed several scenarios describing alternative health futures for the country, with particular emphasis on the organization of health services. One or these, a scenario of profound change, was selected by the participants as their vision of the preferred future. It involves more emphasis on health promotion, decentralization of health-care services, broader participation in health matters, improved training for health professionals, and a stronger role for universities and other educational and research centres. Implications of the selected scenario regarding health policies and actions have been identified, among them being the adoption and implementation of the Ottawa Charter on Health Promotion, the organization of local health service networks, and the more active involvement of health professionals in the designing of health systems.     

The medical home bends cost curve

While the Affordable Care Act is trying to manage health insurance, as well as mandating coverage, a number of projects around the country are trying to manage the underlying cost of health care. By bringing back the concept of a true primary care physician, who provides 90% of your care and coordinates with your specialists, these programs are bending the curve of health care cost trends. Most are seeing a reduction in emergency room visits and hospital days in the double digits. Others that are taking fee-for-service insurance out of the picture altogether are experiencing even higher reduction rates. The goal is to increase patient health, which includes the patient having an active role in understanding his or her condition, treatment options and self-care strategies. It is estimated that if all Americans had access to a medical home, our nation could save $37 billion annually.     

FINANCING SATELLITE OUTPATIENT CARE IN RURAL HOSPITALS

Providing health care to low income or elderly residents of rural areas remains a serious national health care problem in the United States. This case study evaluates an intervention for primary outpatient care to a particular class of patients – veterans – and shows how it can benefit them. Locating the outpatient clinic in a struggling rural hospital makes an outreach by the urban veterans hospital financially feasible and is profitable for the rural hospital.     

Managed care: the strategic future for education in quality

This paper discusses the needs for future education in quality assurance, assessment and improvement, particularly in relation to managed care. The pressures for increased education about quality are derived from different components of the health care system; e.g., regulatory and governmental agencies, purchasers of care, and competitors of health institutions. The content of future education in health care quality is defined in six areas: (1) organization and management; (2) health systems; (3) quality theory and methods; (4) management information systems and research; (5) governmental policy; and (6) economics and finance. Education in health care quality in these content areas is delivered at both the primary and continuing education levels by universities, professional associations and private training and development corporations. Future oriented, strategic thinking education in health care quality is needed. The pressures for education about quality, including traditional concepts of quality assurance, methodologies for quality assessment and the newer approaches to continuing quality improvement, are clearly growing stronger. This article discusses the need for education in health care quality, the content areas and levels of education and the delivery system.     

Weak Links in the Chain: A Diagnosis of Health Policy in Poor Countries

Recent empirical and theoretical literature sheds light on thedisappointing experience with implementation of primary healthcare programs in developing countries. This article focuseson the evidence showing two weak links in the chain betweengovernment spending for services to improve health and actualimprovements in health status. First, institutional capacityis a vital ingredient in providing effective services. Whenthis capacity is inadequate, health spending, even on the rightservices, may lead to little actual provision of services. Second,the net effect of government health services depends on theseverity of market failures—the more severe the marketfailures, the greater the potential for government servicesto have an impact. Evidence suggests that market failures arethe least severe for relatively inexpensive curative services,which often absorb the bulk of primary health care budgets.A companion paper, available from the authors (seep. 219), offersa perspective on how government funds can best be used to improvehealth and well-being in developing countries. It gives an alternativeview of appropriate public health policy, one that focuses onmitigating the characteristic market failures of the sectorand tailoring public health activities to the government's abilityto deliver various services.      

Tax‐Aided Financial Services Companies and the Cost of Capital

Over the past two decades, the governments of several European countries have implemented special tax devices to attract the finance centres of multinational companies. This paper determines how the cost of capital for investments made by multinationals is affected by the tax regimes, bringing into play the Irish financial services company, the Belgian co‐ordination centre, the Dutch finance company and the Luxemburg company coupled with a Swiss finance branch. It gives evidence that intermediation of a tax‐aided services company in the financing scheme of a foreign subsidiary provides an important tax saving. However, the home and source countries' tax regimes influence the hierarchy of the less heavily taxed treasury and finance centres. The methodology relies on the marginal effective tax rates theory and consists of an extension of Alworth's (1988) model to include treasury centres.     

EVALUATING THE EFFICIENCY OF NONPROFIT ORGANIZATIONS: AN APPLICATION OF DATA ENVELOPMENT ANALYSIS TO THE PUBLIC HEALTH SERVICE

In this paper we have tried to evaluate the usefulness of the DEA model as a management tool when applied to the measurement of the efficiency of health centres. We have chosen the DEA model because it does not need prior specifications. This could be very useful when we lack data on costs. The overall evaluation of a number of health centres provides information on the distinctive features and comparative advantages of the most efficient ones. The information gathered could also be of great use in the selection of those centres in which operational audits should be carried out.     

Beitragsentwicklung und Verteilungseffekte der RfB in PKV-Beständen

The possibility of adjusting premiums is a characteristic feature of the german Private Health Insurance (PKV), which is even required by german law. The main reason for increasing premiums lies in the rise of claims and corresponding compensations. Therefore, the time development of health care costs is of primary importance for the PKV. In the present article, various models for the future evolution of age-specific health care expenditure are studied with respect to their effects on the premiums’ dynamic and policyholder participation. In particular, it is analysed how the age-specific cohorts participate in the benefits.     

Went Fundholding, Going Commissioning? Some Evidence-Based Reflections on the Prospects for Primary Care Groups

Following the publication of the White Paper, 'The New NHS: Modern, Dependable' (Cm 3807), the Labour Government has abolished GP fundholding. Family doctors retain a lead role for primary care in planning health care with the creation of Primary Care Groups (PCGs). In due course, it is expected that health authorities will relinquish direct commissioning of care to PCGs. Although fundholding is ending, its operation provides useful evidence about how GPs approach participation in the planning of health care. This article reflects on the prospects for PCGs, drawing on original research into the reasons why practices volunteered to 'go fundholding' and how those practices selected their 'lead' partner, on whom much of the fundholding burden fell.